The Intra-Operative Anesthesia Record

Sachin Kheterpal, MD, MBA

Historically, anesthesia information systems have focused upon the most acute portion of the perioperative care process—the intra-operative episode. Any observer of a paper-based intra-operative record marvels at the volume of data that is transcribed from physiologic monitoring equipment onto the paper record. The tedious process of copying information from one location—the monitor, gas analyzer, ventilator, IV infusion or pump, EEG, etc.—to another immediately attracted the attention of the pioneers in perioperative digitization. As a result, the first generation of information systems in the operating room were categorized as "record keepers" that monitored automated data sources and collected and combined their output with manually entered information such as medication type and dose. The result was a complete intra-operative record.

Traditionally, intra-operative record keeping systems have been deployed at medium to large surgical centers or hospitals with the necessary information technology infrastructure such as reliable networks, computer help staff, and the resources required to purchase and maintain a point-of-care information system. As the cost of computing devices decreases and other information system projects build the necessary infrastructure, the cost of deploying a perioperative information system in the operating room has actually decreased over time. This increased availability and access to clinical information systems is a crucial step forward as the health care industry attempts to improve the quality of health care across the spectrum of its services.

The unique ergonomics of the anesthesia cockpit pose challenges to the implementation of an intra-operative information capture system. An already crowded area, the space around the anesthesia machine must be used very carefully. Each additional device or cable must provide enough value to justify its potentially disruptive influence. Various implementations are possible, but most involve a separate and distinct computer installed on or near each anesthesia machine. A computer screen is attached, with an optional keyboard or mouse depending on the system’s alternative means of input. Touch-screens, light pens, on-screen keyboards, barcode scanners, and voice recognition represent user interface variations attempting to simplify the task of manual data entry while also delivering clinical care.

Given that anesthesiologists continue to spend the majority of their clinical time in the operating room, intra-operative record keeping remains a focus of perioperative clinical information systems. The table below describes the various types of information that can comprise an intra-operative record and the sources of that information.

Aggregation of the various information types described in the table above is essential to create not only a usable medical record document, but also to create a data set that can be used to analyze provider care patterns, patient outcomes, patient satisfaction, and compare each of these metrics against other clinicians’ practice patterns. The existing focus on perioperative processes by the Joint Commission on Accreditation of Hospital Organizations demonstrates that perioperative care can have a major impact on a patient’s care experience and satisfaction—positive or negative. Increasingly, the goal of intra-operative data collection is to ensure that the best possible outcomes are achieved while effectively using the scarce anesthesia resources—be it facilities, devices, or clinical personnel. Analysis of historical care patterns and outcomes is the first basic step necessary to achieve improvements in care delivery. To that end, intra-operative data collection must be performed at a discrete level that enables subsequent analysis. For example, if an institution wishes to review its rate of difficult intubation, unanticipated reintubation, or dental injury, these elements must each be documented in separate data fields in a discrete, codified format. A prose, manually typed field that contains multiple observations and interventions does not permit facile extraction of these specific elements. Furthermore, discrete data entry permits the use of consistent terminology, another requirement for effective data analysis. This patient safety analysis function of the intra-operative record demands that basic preoperative assessment data be included in order correctly to segment the patient population into appropriate categories.

The next step in an effective intra-operative record management system is actually impacting the care delivered in the operating room. A controversial topic within the medical community, the concept of patient care pathways and patient care protocols has recently gained favor as medical errors have received increasing scrutiny from the popular media. In order to improve the quality of anesthesia care, an intra-operative record and data set must build on historical analysis, which will enable clinical leaders to determine preferred care practices. Documentation templates, intra-operative dose calculations, and automatic display of drug-drug interactions are illustrations of these potential advanced techniques. A future further extension is the so-called "smart alarm" that can recognize a pattern in the captured monitoring data (e.g. suddenly falling BP with suddenly rising HR) and offer a differential diagnosis (e.g. hypovolemia, blood loss, excessive vasodilation from medication, etc.) and even suggest therapies. Though they may seem intrusive, these features of an intra-operative record allow health systems to move forward from the days of posting warnings on bulletin boards to actually changing the quality of care and resulting patient satisfaction.

Clearly, the automation of the intra-operative clinical record is an essential element of a robust perioperative clinical information system. The pressures to be efficient, parsimonious, and yet deliver care of high quality drive the evolution of the intra-operative record. It must change from a "record keeper" to an information system. When integrated with comprehensive preoperative and postoperative information, the intra-operative record will make anesthesia safer and contribute to patient satisfaction.

Dr. Kheterpal is General Manager, Global Marketing, Clinical Information Systems, GE Medical Systems Information Technologies.

Elements of an Automated Intra-Operative Record
Information Type Sources Comments
Patient demographics

•Carried forward from hospital information system

•Carried forward from OR scheduling system

•Manually entered in the OR

Basic elements such as name, DOB, record number, must be captured correctly to allow downstream consumption of information
Patient history, anesthetic plan

•Carried forward from online preoperative assessment

•Carried forward from OR scheduling system

•Carried forward from previous intra-operative episodes

•Manually entered in OR

Provides crucial context for intra-operative care plan
Device data

•Physiologic monitor

•Capnograph/Agent analyzer

•Ventilator

•Infusions and IV pumps

•Twitch monitor

•Cardiac bypass machines

Varying levels of automatic integration, depending upon output capabilities of device and import capabilities of vendor software
Provider interventions, assessments, and patient responses

•Some device integration in cases of infusion pumps and IV drug pumps

•Manually entered in OR

Includes description of induction, medications given, procedures done, emergence, and transport to postoperative area. Various user interfaces have been developed to improve usability, ranging from documentation templates, barcode scanning, hand-typed entries, graphical user interface
Quality assurance and patient safety information

•Automatically derived from provider assessments, interventions, and device integration

•Manually entered in OR

Very fruitful area of development. Non-device data are often the basis for quality assurance analysis and quality improvement efforts. As vendors apply increasing focus to user interface and computers become more usable, patient safety data will be collected more reliably and consistently.
Facility/professional fee charge capture

•Pre-populated from OR scheduling system

•Manually entered in OR by provider

•Manually abstracted by coder or biller after episode of care

As reimbursement processes become more complex and onerous, charge capture often serves as the "hook" that gets providers to use information system