Anesthesia Information Management Systems for the Office Practitioner
Keith J Ruskin, MD
Anesthesia information management systems (AIMS) offer the same benefits to an anesthesiologist who practices in an office setting as they do to those managing inpatients undergoing complex surgical procedures. An electronic workflow allows the anesthesiologist to focus on patient care while facilitating tasks such as quality assurance and submission of health insurance claims. AIMS systems have the potential to improve patient care because they deliver a customized, easy to read anesthesia record while storing the patient’s physiologic data in a database that can easily be searched. This information can be used for quality assurance, to search for and track specific events and their outcomes, and to provide benchmarking for individual providers.
Anesthesiologists have been among the first to develop technology for keeping electronic health records and work with medical device manufacturers and standards organizations to create new devices that can communicate with AIMS systems. In one recent study, 44% of all academic anesthesiology practices had adopted AIMS systems.  This ability to collect, store, and organize large amounts of data makes AIMS systems ideal for quality assurance and clinical research. Although most office anesthesia practices still rely on paper records, these practitioners may soon begin to adopt electronic health records.
An electronic health record can facilitate preoperative screening and may ultimately decrease the number of procedures that are deferred in patients undergoing outpatient surgery. A preoperative evaluation module makes the patient’s history, physical examination, and pertinent laboratory data easily accessible to the anesthesiologist who will care for that patient. A survey of anesthesiologists attending a large meeting revealed that missing information commonly caused cancellations on the day of surgery.  The ability to access an EHR with the patient’s medical information, including the anesthesia record from prior surgeries, can help to prevent the cancellation of a procedure simply because the needed information was unavailable. This improves both patient and surgeon satisfaction while maximizing the use of valuable resources, making an EHR with a preoperative evaluation module a desirable component of an AIMS system even if it will be used in an office setting.
In one example of how AIMS can improve patient care, Nair et al recently reported that including real-time alerts for prophylactic antibiotic administration increased the rate of timely administration by over nine percent. The study concluded that a decision support system that includes real-time guidance and alerts could improve compliance with guidelines.  The American Society of Anesthesiologists has created the Anesthesia Quality Institute, a nonprofit foundation that maintains a national clinical outcomes registry (NACOR). It is hoped that widespread use of information that NACOR can produce will help anesthesiologists to improve their practice. The AQI is working with both AIMS vendors and practice groups to develop methods for transmitting anesthesia records to its database.
The development of widely used data transmission standards has made it possible to connect medical equipment together and to transmit medical information through existing networks to desktop computers, servers, or monitoring stations. Wireless Ethernet (Wi-Fi) networks are inexpensive to set up and maintain, and are highly versatile. The end result is that a core communication infrastructure is likely to be compatible with new devices and can be installed using commercially available equipment, even in an outpatient or office setting. These advantages, combined with the low cost and wide availability of Wi-Fi equipment, make this technology well suited for many healthcare applications. Most monitors are now capable of transmitting numbers and waveforms (e.g., an electrocardiogram or a blood pressure tracing) to another monitor or to a computer at a remote location, making this critical information immediately available to the clinician. A portable device capable of displaying this critical information allows a physician to be immediately available in the event of a sudden change in the patient’s condition. [4,5] For example, an anesthesiologist can care for a patient in the operating room while being able to observe the vital signs of a patient who is in the recovery area.
Choosing a System
When choosing an AIMS system for an office-based practice, the questions that should be considered are fundamentally the same as those of a large, hospital-based practice. The practitioner should choose a system that allows him or her to provide high-quality perioperative care while keeping a comprehensive record that meets third-party payer and regulatory requirements. Evaluating a system on its return on investment (ROI) may not be productive because an AIMS system may never pay for itself by increasing profits. Instead, the provider should do a cost-benefit analysis that includes such intangible benefits as reduced medication errors, improved resource utilization, and more rapid patient turnover.
Specific characteristics that should be evaluated before purchasing a system include compatibility issues, ability to access old records, safety and data security features, and usability. Whenever possible, a system that is compatible with existing EHR should be chosen. This will allow the anesthesia record to be incorporated into the remainder of the patient record. This also improves patient flow, since pertinent preoperative information may be available to the anesthesiologist. The system should also be able to display critical information such as patient demographics and drug allergies. The ability to extract information for quality assurance will help the provider to improve patient care as well as meet some state and third-party payer requirements. A system that captures co-morbidities and billing modifiers will help to improve revenue by charging for services that otherwise might have been missed by a billing service. All patient information must be stored securely to prevent data breaches, and the system should maintain an audit trail that indicates who modified a record and what modifications were made. Most importantly, the system must be easy to use. A system that is not compatible with physiologic monitors, for example, and requires manual entry of vital signs will rapidly fall into disuse. Lastly, the vendor should have a solid record of successful installations in practices that are similar to those of its intended use. It is important to make several site visits to see the system in actual use, to speak with the anesthesia providers who are using it, and to see the printed reports that the system generates.
Barriers to Implementation
Despite the obvious advantages of electronic health records, however, their complexity and perceived costs have prevented many providers, particularly those working in small hospitals or in rural practices, from adopting this important technology. Most office-based anesthesiologists rely on the surgeon’s medical records, and at the present time, none of the systems that are commonly used in offices are designed to include an anesthesia record. As a result, few anesthesiologists who practice in an office setting will have the resources to adopt a comprehensive AIMS system. AIMS systems can, however, provide a return on investment by ensuring compliance with PQRI guidelines and CMS documentation requirements. AIMS have also been shown to increase scheduling efficiency, decrease drug costs, and provide better charge capture and diagnosis and procedure coding.  The American Recovery and Reinvestment Act established programs to distribute approximately $19 billion to eligible health care professionals who participate in Medicare and adopt practices that make “meaningful use” of EHRs. Although most hospital-based anesthesiologists are specifically excluded from these incentives, office-based anesthesiologists or others who bill primarily under ambulatory service codes might be eligible for these payments. It is currently unknown, however, whether the Centers for Medicare and Medicaid Services will consider offering incentives to office-based anesthesiologists who provide evidence of “meaningful use.”
Although implementing an AIMS system is initially time-consuming and requires substantial resources, several studies have identified predictors of user satisfaction. At least one study has shown that physicians who have been using an EHR for at least two years are more likely to be satisfied or very satisfied with the system. This study, which focused on primary care physicians, also revealed that clinical notes, an easily accessible diagnosis, and off-site login capabilities were also important. Although anesthesiologists have different information needs, these predictors would seem to be important to any user of an AIMS system. 
Perhaps the most significant difficulty in upgrading an AIMS system occurs if it is necessary to migrate from one system to another that is provided by a different vendor. Although most systems store information in commercially available databases (e.g., Microsoft SQL Server), it may be very difficult to move a large number of patient records into a completely new system. It is, therefore, important to choose a system that can grow and adapt to a changing practice, and that will be usable for the foreseeable future. It is also important to carefully explore problems related to data migration before migrating to a new system.
Electronic generation, transmission, and storage of health data has transformed patient care by making it easy to acquire, search, manipulate, and distribute large amounts of information. Information in the health record is also used for purposes not directly related to patient care, including insurance qualification, law enforcement, and litigation. Health information may also be used for clinical research and for projects that improve public health. Unintentional release of information about disease processes, medication use, or visits to health care providers can result in stigmatization, difficulty in obtaining credit or employment, or disruption of friendships or family relationships. Most importantly, unintended release of information can result in a breach of trust between patient and physician. Patients and physicians are aware of how health information may be used and have legitimate concerns about how their information will be used and expect their healthcare providers to protecting health information from unauthorized use.
Government regulations as well as ethical obligations require that patients’ health information be protected. Most of the requirements for storage and transmission of medical records are covered under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). These requirements extend beyond health professionals who collect information. Any provider of services to a health care organization that handles “protected health information” is bound by HIPAA to defend the security of medical records. Any practice contemplating the implementation of an AIMS system should develop a comprehensive information security plan that encompasses physical protection of hardware, access control, data storage, and encryption of sensitive information. 
The United States Health Insurance Portability and Accountability Act of 1996 (HIPAA) includes specific requirements for privacy and security of electronic medical records systems. The primary impact of the Privacy Rule on the development of pre-anesthetic evaluation systems was to require user identification and authentication and log every access to the electronic health record in order to allow the patient to have access a list of all personnel who had accessed the record. Under HIPAA, health care organizations face a series of regulations that dictate how protected health information must be stored, distributed, and used. These regulations apply not only to practitioners who collect the information, but also to their business associates. If, for example, a physician in solo practice collects information that is then forwarded to a billing service, that billing service must comply with HIPAA privacy rules. Patients must give consent to the use of protected health information, although HIPAA consents can be interpreted broadly. Compliance with HIPAA regulations will ultimately benefit health care providers, by preventing or limiting disclosure or damage to protected health information.  The Health Information Technology for Economic and Clinical Health act was enacted as part of the American Recovery and Reinvestment act of 2009, and is intended to promote the adoption and meaningful use of health information technology. HITECH included $20 billion in funding for health information, and extends the privacy and data security regulations enacted as part of HIPAA. The Act also includes provisions for the development of health information standards as well as even stronger privacy and security regulations. As interoperable electronic health records become commonplace, however, it may ultimately be possible for the health care provider or the patient to determine how confidential information is used. 
Attacks on personal computers in the form of viruses, keystroke loggers, and “phishing” attacks are a growing threat and have the potential to interfere with patient care. Hundreds of viruses are released every day. Many health care applications rely on Intel-based computers running the Microsoft Windows operating system. As a result, they are vulnerable to the same kinds of viruses that affect home and office computers. In addition to rendering a computer unreliable, viruses and worms can compromise or destroy health information. Because office-based AIMS systems may be readily accessible to a variety of staff, it is important to limit the number of programs installed on the computers that run patient care applications. Office staff should be educated as to the critical nature of these computers and the impact on patient care should the computer become unusable because of a virus infection.
Fortunately, a few simple precautions, combined with common sense, can minimize the risk of information theft or damage. Ideally, protection of computers on a network should involve a comprehensive approach that includes both hardware and software firewalls, antivirus software, and frequent security analyses. All access to sensitive information must be protected by a carefully chosen password, which should ideally consist of a series of letters, numerals, and punctuation marks. Remote access to hospital information systems from home computers, that may not have the latest security updates, should be allowed only when necessary, and these computers should have security software installed by the hospital IT department.
Firewalls determine information traveling across a network should be allowed to continue. Software firewalls prevent unauthorized programs from using an Internet connection. Specific programs, such as a Web client, are permitted to send information to a location on the Internet. If an unknown program attempts to establish a connection, a software firewall blocks the connection until the user grants access. By limiting the programs that can send information to external computers, software firewalls prevent information from being stolen by spyware or adware. A hardware firewall is a piece of equipment that is installed between a home or office network and a cable or DSL modem and helps to protect against attacks from outside computers. Hardware firewalls guard an entire network against an outside attack, but usually permit any computer on the local network to establish an outbound connection. As a result, hardware firewalls do not protect against programs that harvest information.
In conclusion, anesthesia information management system offer a variety of benefits to any anesthesia provider, including those who practice in an office setting. The increasing requirement for anesthesia services in locations such as interventional radiology or endoscopy suites underscores the need for efficient, reliable anesthesia information management systems. Modern systems offer a sophisticated user interface allows multiple features to be accessed at the touch of a button. Online help systems can allow the clinician to find the particular feature that he or she was looking for, and newer systems are far more intuitive and easy to use. AIMS systems can improve operating room efficiency, decrease the number of cancelled or deferred procedures, and provide important information that can be used for quality assurance and regulatory compliance. A variety of factors must be considered before purchasing an AIMS system, including compatibility with existing EHRs and monitors, data security and integrity, and usability. If chosen carefully and implemented as part of a comprehensive information technology solution, AIMS systems can be successfully adopted by the office-based anesthesiologist.
1. Halbeis CBE, Epstin RH, Macario A, Pearl RG, Grunwald Z. Adoption of Anesthesia Information Management Systems by Academic Departments in the United States. Anesth Analg. 2008;107:1323-9.
2. Holt NF, Silverman DG, Prasad R, Dziura J, Ruskin KJ. Preanesthesia clinics, information management, and operating room delays: results of a survey of practicing anesthesiologists. Anesth Analg. 2007 Mar;104(3):615-8.
3. Nair BG, Newman SF, Peterson GN, Wu WY, Schwid HA. Feedback mechanisms including real-time electronic alerts to achieve near 100% timely prophylactic antibiotic administration in surgical cases. Anesth Analg. 2010 Nov;111(5):1293-300.
4. Cermak M. Monitoring and telemedicine support in remote environments and in human space flight. Br J Anaesth. 2006 Jul;97(1):107-14.
5. Kyriacou E, Pavlopoulos S, Berler A, et al. Multi-purpose HealthCare Telemedicine Systems with mobile communication link support. Biomed Eng Online. 2003 Mar 24;2:7.
6. Sandberg WS, Sandberg EH, Seim AR, Anupama S, Ehrenfeld JM, Spring SF, Walsh JL. Real-time checking of electronic anesthesia records for documentation errors and automatically text messaging clinicians improves quality of documentation. Anesth Analg. 2008 Jan;106(1):192-201.
7. Menachemi N, Powers T, Au DW, Brooks RG. Predictors of physician satisfaction among electronic health record system users. J Healthc Qual. 2010 Jan-Feb;32(1):35-41.
8. Agrawal R, Johnson C: Securing electronic health records without impeding the flow of information. Int J Med Inform. 2007 May-Jun;76(5-6):471-9.
9. Gostin LO: National health information privacy: regulations under the Health