Chapter 28

Data Management Systems

Progress i n moni tori ng i nstrumentat i on has l argel y outpaced met hods used to
record and manage the expandi ng body of cl i ni cal data (1). Whi le many anesthesi a
departments conti nue to use the tradi ti onal method of recordi ng i nf ormati on
manual l y, el ect ronic data management systems are gai ni ng i n popul ari t y. The
Anesthesi a Pati ent Saf et y Foundat ion and the Soci ety f or Technol ogy i n Anesthesi a
have endorsed computeri zed anesthesi a records (2,3, 4).
Definitions
Anesthesi a Informat ion Syst em (AIS or AIMS): A system that manages i nf ormat i on
t hroughout the peri operati ve peri od.
Appl i cat i ons: Comput er programs, usual l y of a si mi l ar t ype.
Anal og Data: Conti nuous data t hat can, wi thin l imi ts, assume any val ue. An analog
computer cannot handl e al phanumeric data (l et ters and numbers) but can process
waveforms. Anal og i s the opposi t e of di gi t al .
Arti fact : Data t hat is not a true representat ion of a condi t ion.
Aut omat ed Anesthesi a Record Keeper (AARK): Devi ce t hat col l ects, di spl ays, and
records i ntraoperati ve data f rom a vari et y of moni tors and other sources.
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Cl osed Archi t ecture or System: Equi pment desi gned t o work onl y wi t h accessori es
made by one company.
Database: A col l ect i on of data, of ten i n storage f or l ater access.
Data Management Syst em: System that records data relati ng t o the pat i ent 's care
t hroughout the peri operati ve peri od and i ntegrates wi t h other medi cal data systems
t o gai n or share data.
Decision Support: Any method that t akes i nput i nformat ion about a cl i ni cal si tuati on
and produces i nf erences t hat can assist pract i ti oners i n deci si on maki ng.
Di gi tal : A way of stori ng informati on usi ng numbers. Digi tal i s the opposi t e of
analog.
Edi t ing: The process of changing a recorded value, comment, annotat i on, or event
af ter i t has been made part of t he record.
Fi le: A col l ect ion of inf ormat ion i n a format desi gned f or comput er use.
Fi leserver (Server): The master computer i nto whi ch al l the other comput ers on a
net work are connected. The f i leserver st ores programs, processes and stores dat a
i n a database, and runs t he net work operati ng syst em.
Hardware: The physical part s of a computer. Exampl es incl ude the pri nter, screen,
keyboard, and el ect ronic components.
I nput Devi ce: A means to manual l y enter dat a or cont rol a computer. Exampl es
i ncl ude a keyboard, mouse, trackbal l , l i ght pen, bar code scanner, touch screen,
voice recogni ti on device, and pen pad.
I nterf ace: The common boundary between computers, between computers and t hei r
peri pheral devi ces, or between two peri pheral devi ces.
Local Area Network (LAN): A net work t hat is l i mi t ed to a l ocal area such as a
department . A LAN can be i ntegrated into a l arger net work. Devices connected by a
net work are ref erred t o as modul es.
Macro: A tool used to automate tasks or procedures wi t hi n a program. Exampl es
are pretyped notes or check-of f boxes.
Network: A group of computers connected together.
Open Archi t ecture: The pract i ce of making the design and computer engi neeri ng or
programs publ i c knowl edge.
Operat ing System: Sof t ware t hat cont rols how a comput er performs i ts f unct i ons.
Out put Devi ce: A devi ce that presents i nf ormati on f rom a computer system t o a
user for vi ewi ng or storage. Exampl es i ncl ude pri nt ers, screens, f l oppy di sks, and
t ape drives.
Peri pheral : A general t erm f or any of the devi ces by which a computer gathers i ts
i nput and di ssemi nates i ts output .
Sof tware: Programs that cont rol the hardware and det ermi ne t he functi ons
perf ormed by a computer.
Elements of the Data Management System
A typical anesthesia data management system i s shown i n Figure 28.1. The data
management system consi sts of one or more central f i leservers and a net work
connecti ng the components. Each computer recei ves dat a and sends i t to the
server. I n a properl y desi gned system, if an i ndividual comput er f ai ls, i t wi l l not
di sable t he ent i re system but wi l l af f ect onl y t hose functi ons that the part i cul ar
computer was perf ormi ng.
A data management system may be cl osed or open. A closed system hel ps to
ensure t hat al l components work together and all ows the insti t uti on t o deal wi t h a
si ngl e vendor. A closed system may not wor k wel l wi th components f rom other
manuf acturers. Because of the great vari et y of sources used t o capt ure dat a,
cl osed systems are not f requentl y used.
I n an open system, components f rom vari ous vendors are used. This enabl es each
department to choose t he best devices for i t s needs whi l e st i l l al l owi ng the
i nformati on to be accessed by ot her systems. Insti tuti ons selecti ng an open system
must make cert ai n that new components wi l l i nterface wi t h thei r network.
A data management system may be cent ral i zed or di stri buted. If t he data are copi ed
i nto a central reposi tory (server), t he system i s cent ral i zed. If the data resi des at or
near the poi nt of care, the system is di st ri buted. Even i n the distributed system, a
net work connect i on is necessary to st ore t he data af ter i t has been col l ected. The
di st ri buted system may be more rel i abl e than the cent ral i zed system because i t
of fers redundancy (5). Expandi ng a di st ri buted system i s strai ghtforward, as i t
usual l y requi res si mply addi ng another computer or peri pheral devi ce to t he
net work and updat ing t he system's sof t ware.
Fileserver
The f i l eserver processes and st ores data and programs i n a database and runs the
net work operati ng system. There may be one or more f i l eservers, dependi ng on the
si ze of t he system.
Input Sources
Electronic Anesthesia Record
The el ectroni c anesthesi a record col l ects i nf ormati on f rom various sources,
processes the dat a, presents sel ected values and trends on a screen (Fig. 28.2),
and t ransports data to other parts of the system. It may perf orm addi ti onal f unct ions
such as i ntegrati ng informat ion and al arms. A choi ce of display conf i gurati on on the
screen i s usual l y avai l able. The el ect roni c anesthesi a record computer and data
screen may be mounted on
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P. 848

t he anesthesi a machi ne, a cart , t he fl oor, or t he ceil i ng. Some are an i ntegral part
of t he anesthesi a workstat ion.

View Figure

Figure 28.1 Typical anesthesia information management
system. Workstations and peripheral devices are physically
connected to each other and to the fileserver by wires or
cables to form a LAN. Part of the network operating system
resides in the fileserver and part at each user workstation.
Applications software that runs the AARKs may reside in
the fileserver but are executed in the AARKs. An AARK
can be located in other places beside the operating room.
AARK, automated anesthesia record keeper; PACU,
postanesthesia care unit.


View Figure

Figure 28.2 Electronic anesthesia record with device for
reading the label on the syringe and plunger movement to
record the amount of drug administered. (Picture courtesy
of DocuSys, Inc.)

The el ectroni c record must provi de a means t o ent er data t hat cannot be
t ransferred automat ical l y (5,6,7,8,9). Handhel d computers of fer a conveni ent way t o
enter data at the bedsi de (10). All input devi ces must be easy t o cl ean t o avoi d
cross i nf ecti on. A seal ed, pl ast i c-covered keyboard may be t he most appropriat e
solut i on.
Manual entry should be as easy as possi bl e. I f i t is di f f i cul t or t akes a l ot of ti me,
t he record wi l l of ten be i ncompl ete or incorrect. Macros that ent er rout ine
i nformati on or user preferences i nto the record make data ent ry easi er and reduce
t he i nformat ion that must be entered manual l y.
Because i t i s not al ways possible t o enter al l i nformat ion at the ti me i t occurred,
t here needs to be a means t o add i t af t er t he fact and to indi cat e when i t took
pl ace. Avai l abl e systems handl e back dati ng di f ferent l y. A common met hod i s to
al l ow t he t i mi ng of an entry in t he past wi t h an i ndi cat ion of when t he ent ry was
made.
I n order to properl y ident if y the responsi bl e cl inici an, there must be a way of endi ng
a record wi t h an elect ronic si gnature.
Inputs from Other Components of the Data Management
System
I nput f rom other computers or servers al l ows the electroni c anest hesi a record to
acqui re i nf ormat i on f rom other areas of t he f aci li t y and to i ntegrate i t i nto the dat a
management system. Demographi c i nf ormati on f rom the admi t ti ng depart ment and
pre- and postoperat ive dat a may be entered i nto the record. There may be
connecti ons to elect ronic l ibrari es, t he pharmacy, or t he I nternet.
Wi rel ess t echnol ogy i s bei ng used more f requent l y (11). Si nce radi o f requency may
i nterf ere wi t h medical devi ces such as i nf usi on pumps or pacemakers, i nf rared i s
t he most usef ul means of t ransmissi on (12). Wi reless technol ogy facil i tat es using
smal l computers for col l ecti ng data (such as preoperati ve assessment ) f rom si tes
away f rom t he operat i ng room. Thi s dat a can subsequent l y be entered i nto the
computer net work (13). A wi rel ess network i s rel ati vel y inexpensive, easy t o i nstall ,
and easi l y expanded.
Printer
I f a pri nt ed (hard) copy of the anest hesi a record or ot her i nf ormati on t hat cannot be
obtai ned f rom the computer net work i s desi red, a devi ce capabl e of pri nti ng both
graphics and text wi l l be needed. Frequent ly, the pri nti ng i s performed i n a l ocati on
such as the postanesthesi a care uni t (PACU) or an of f ice.
An i mportant considerati on i s whether t he pri nt ed record is generated as dat a
becomes avai labl e or at the compl eti on of the case, or both. If t he record can onl y
be printed at the end of the case, data could be l ost i f the dat a management syst em
mal f unct ions. Frequent back-up wi l l l i mi t the l oss. Wi t h a real -ti me copy, the record
can be removed f rom the pri nter and completed by hand i f the automated syst em
f ai l s (14).
Records
Preanesthesia
The data management system has been f ound to be eff i ci ent and eff ect i ve for
preoperat ive evaluati on (15,16,17). Pati ent-compl eted quest ionnai res can be
perf ormed electroni cal l y (18). This coul d be compl eted and submi t t ed through the
I nternet f rom the pati ent ' s home (19) or f rom a physi ci an' s off i ce. Based on t hi s
i nformati on, pati ents who do not present probl ems that requi re a preoperat ive vi si t
can be separated f rom those wi th compl i cated medical hi stori es. Preanesthesi a
consul t ati on using t el emedi ci ne technol ogy of fers t he chance to reduce travel costs
and to ident if y pat ients wi t h problems so that addi t ional workup or consul tati ons
can be perf ormed wi t hout del aying t he surgery (20). Thi s data can al l ow t he
cl i nician t o det ermi ne which pati ents are at ri sk and requi re more t est i ng and
perhaps increased i nvasi ve moni tori ng (21,22). Pati ents who would benef i t f rom
anti bi oti c prophylaxi s can be i dent if i ed (23). Wi th good preoperative dat a, an
associ at i on bet ween the preanesthesi a eval uati on and peri operat ive i ncidents can
be eval uat ed.
Preoperati ve i nformat ion can be obt ai ned f rom the heal th care f aci l i t y' s or
physi ci an' s of fi ce records. This i s usual ly i n the f orm of a hi story and physi cal or
progress notes. In addi ti on, l aboratory resul ts and radiol ogy i nf ormati on shoul d be
avai l able. Whil e l aboratory i nf ormati on may be accept ed by the data management
system, informat ion t hat is i n text st yl e, such as the history and physi cal , may not
l end i tself t o automati c capture by the data management system and may need to
be entered i nto t he system manual l y.
Intraoperative
Patient Variables
The bulk of ent ri es duri ng surgery are objecti ve pati ent vari ables (bl ood pressure,
heart rat e, oxygen saturat i on, i nspi red and exhal ed carbon dioxi de concent rat i ons,
oxygen and anestheti c agent concent rati ons, central and art erial pressures, bl ood
gases, mi xed venous oxygen sat urati on, intracrani al pressure, cardi ac output, t i dal
and mi nute vol umes, respi ratory rate, compl i ance, resistance, temperature,
el ect rocardi ogram, t ourniquet t i mes, el ectroencephal ogram, uri ne output,
P. 849

neuromuscular transmi ssi on data). Most of thi s dat a can be automat i cal l y
t ransferred f rom the moni tors to the i nt raoperat ive record.
Systems edi t automatical l y captured pati ent vari ables dif f erentl y. Some wi l l not
permi t edi ti ng and requi re a note t o explai n an arti f act . There may be macros that
explain common art i facts. Others requi re t he operator t o approve vari ables before
t hey are recorded, of f er a wi ndow of t i me f or edi t ing, or make the vari abl es edi t abl e
at any ti me. One of the advantages of edi t i ng may be al gori t hms to help rej ect
arti f acts.
Workstati on and Monitor I nformation
Much of the i nf ormati on t hat i s generated by moni tors and the anesthesia machi ne,
vapori zers, venti l ators, and associ ated equi pment [f resh gas f low, vapori zer set ti ng,
composi ti on of respi ratory gases, breathi ng system pressures, t idal and mi nute
volumes wi t h cont rol l ed venti l ati on, respi ratory rat e, i nspi ratory:expi ratory (I :E)
rati o, breathi ng system pressures and f lows, end-t i dal concentrat i ons, whether
al arms are ON or OFF and t hei r set t i ngs, drugs administered by i nf usi on pumps]
can be t ransf erred automati cal l y to a data management system total l y or in part .
Wi th some anesthesia machines, gas f l ows and vapori zer sett i ngs can be
t ransferred.
Information from the Anesthesia Provi der
Some i nf ormat i on, i ncluding observat i ons and some i nterventi ons, is avai labl e only
f rom the anesthesi a care provider. This i ncl udes pre- and postoperative diagnoses;
premedi cati ont ype, amount , t i me gi ven, and eff ects; operati on(s) perf ormed;
posi t i on of t racheal tube; di f fi cul t ies encountered wi t h i nt ubati on; heart and l ung
sounds; echocardi ography i nf ormati on; pat ient appearance (e. g., pal e, f lushed,
sweaty, wri nkled); pati ent posi t ion; esti mat ed bl ood loss; uri ne output ; the type of
breat hi ng system; special saf et y precauti ons; and checks of equi pment. The si te,
si ze, and t ype of i nt ravenous catheter(s) and the t ype, amount, and ti me of f luid
admi ni st rati on need to be noted. Rout ine procedures such as posi t i oni ng, paddi ng
pressure points, and eye care need to be i ncl uded. Speci al procedures such as
pl aci ng a central or art eri al l i ne or a regi onal bl ock shoul d be recorded wi th
i nformati on on how i t was performed and any probl ems that occurred. Events t hat
need to be entered (along wi t h the t i me) i ncl ude surgery st art and stop, tourni quet
i nf l at i on and release, cl ampi ng and unclamping of maj or vessel s, and
cardi opul monary bypass begi nni ng and end. I n many cases, thi s i nformat i on can be
i ncorporated i nto macros that can be easil y entered into the record. These ent ri es
shoul d al ways be t ime st amped by t he system.
Most neuromuscul ar st i mulators (Chapter 25) depend on the anesthesia provider to
assess the response, so manual ent ry wi l l be requi red. However, some inst ruments
both st imulat e and assess the response. These can be i nterf aced t o automatic data
recordi ng.
The record shoul d cont ai n the dosages and ti mes of al l medi cat ions admi ni st ered.
Vari ous methods have been used t o at l east part i al l y aut omat e these entri es. The
medi cati on can be sel ect ed f rom a menu and i ts dosage entered. Label s carryi ng
t he drug names and bar code can be at tached to syringes (24). The anesthesi a
provi der can scan the l abel to t he automat ic bar code reader. It i s al so possi bl e to
automati cal l y determi ne the amount of drug admi ni stered f rom a pref i l led syringe
(Fi g. 28.2).
Information Transfer
An i mportant advantage of t he data management system is i ts abi l i ty t o import data
f rom and export dat a to other computer systems i n the heal th care faci l i ty. These
i ncl ude t he laboratory, radi ol ogy, busi ness of f ice, and cri ti cal care.
Laboratory i nformat i on such as hemogl obi n, blood gases, cl ot ti ng values, and
el ect rol ytes are of ten needed duri ng t he course of an anestheti c. I f the dat a
management system i s connected to t he laboratory, i nformati on shoul d be qui ckl y
avai l able. Test resul ts shoul d be entered on t he record i mmedi atel y af ter the data
becomes avai labl e. The t ime that t he resul ts arri ve shoul d be recorded as wel l .
I f the i nf ormati on on a bl ood container can be scanned, thi s can be t ransf erred to
t he record. If the data management system i s i nterfaced t o the bl ood bank, t he
i nformati on on the contai ner can be checked t o det ermi ne i f the blood is bei ng
admi ni stered to t he correct pat i ent .
Pi cture archivi ng and communi cati on systems (PACS) t hat al l ow acqui si ti on,
storage, and retrieval of di gi tal i mages can be i ncl uded i n the inf ormati on system
(25). Thus, an esophageal echocardiograph obtai ned i n the operat i ng room can be
vi ewed by cli ni ci ans i n other areas of the f aci l i t y.
Postanesthesia
The postanesthesi a record can be considered a cont i nuat ion of the i nt raoperat ive
record but usual l y wi t h a dif ferent format . Preoperat i ve pat ient i nformat i on and the
record made duri ng the i nt raoperati ve peri od must be i mmediatel y avai l abl e to the
PACU.
Data is extracted f rom moni tors i n the same manner as duri ng anesthesia. It i s
i mportant that moni tors used in t he PACU be abl e to communi cate wi t h the data
management system. Drugs, l aboratory resul ts, and incidents are recorded, al ong
wi th user not es. Pat ient consci ousness, pain l evel s, and ot her i nf ormati on requi red
by regul atory agencies should be part of the postanesthesi a record. Qual i t y
assurance can be conducted f rom the postanesthesi a record (26).
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Uses for Data Management Systems
I nformat i on f rom a data management system can be used by the anesthesi a
department and ot hers f or a vari et y of tasks. Speci al sof t ware modul es may be
needed f or some of these.
Anesthesia Record Generation
An anest hesi a i nformat ion syst em can provide a ti mel y and accurat e record of
pati ent care t hrough t he ent i re perioperative peri od.
Research
Because a l arge vol ume and vari et y of i nformati on can be col l ected and searched
by procedure, pati ent charact eristi cs, drugs used, and ot her parameters, an
anesthesi a i nf ormat ion management system database can be very useful f or cli ni cal
research (22,27,28, 29,30,31,32). Studi es have shown t hat manual records
f requent l y are not suf f i ci ent l y accurate f or research purposes
(29,33,34, 35, 36,37,38). Large retrospecti ve studi es are dif f i cul t t o handle manual l y
and may ref lect t he bi as of the reviewer. El ectroni c data management makes i t
easier to col l ect and anal yze the vari ables bei ng studi ed. An I nternet websi t e can
be used for data col lecti on f or mul ti center research proj ects (39). Af ter the
database has been establ i shed, t he eff ects of a change i n some aspect of care can
be studi ed.
A necessary f actor t o be abl e t o exami ne data f rom di ff erent i nsti tuti ons i s a
standard anesthesia l exi con. Thi s is being developed by usi ng SNOMED
(systemi zed nomencl at ure of medi ci ne) as a base (40,41,42, 43).
Education
I n a t rai ni ng program, an automated record can be used to revi ew and ref i ne the
t rai nee' s ski ll s. Si nce t rai nees are requi red t o keep a l og of thei r cases, the dat a
management system can be uti l i zed t o furni sh t hat i nf ormati on and t rack each
t rai nee' s experi ence (44).
As departments i nsti t ute various practi ce gui del i nes, t he avai l abi l i t y of these on l i ne
may i mprove and si mpl if y thei r i mpl ementati on. Compl iance wi t h these gui deli nes
can also be determi ned.
Billing
I nformat i on necessary for bi l l i ng includes pati ent characteristi cs, case-speci fi c
data, and concurrency (t he number of anestheti cs supervised at one t i me). A data
management system can be used t o assi gn t he proper bi l l i ng codes (45). Proper
data can i ncrease bil l abl e di agnoses, hel p t he f aci l i t y increase reimbursement , and
decrease the ti me bet ween t he event and payment (15).
I f the record i s i ncompl et e or does not conform to Heal th Care Fi nance
Admi ni st rat i on rul es, the bi l l may be disall owed or reduced. Even worse, the
i nst i tut ion may be accused of and f i ned f or f raudul ent bi l l ing. A program can be set
up to i mprove documentati on by cal l i ng att ent ion to requi red entri es.
Administrative Functions
Si nce al l the funct ions i n an operati ng room envi ronment are i nterrel at ed, i t makes
sense that t hey shoul d be i ntegrated i nto t he data management system. These
i ncl ude pati ent t racki ng, nursi ng, radi ol ogy, schedul i ng, room ut il i zat ion, cl eaning,
i nst rument care and pref erences, t ransport , and the li ke. If a probl em develops, i t i s
i mportant to determi ne what occurred and to devel op a st rategy t o prevent i ts
reoccurrence. An i ntegrated data management system may help wi th t hi s.
The data management system can provide i nf ormati on on ut i li zati on of f aci l i t ies,
personnel , equi pment , and suppl ies. I t may be used to f aci li t ate scheduli ng (46,47).
Surgi cal del ays can be anal yzed and the probl ems corrected.
The i nf ormati on management system can be used to obtai n summari es of an
anesthesi a provi der' s or a group' s practi ce patterns, f or exampl e, t he number of
cases of a part icul ar type done i n a gi ven peri od of ti me. In a group pract ice,
questi ons of t en ari se as to how t he work is di vi ded, ti me of f , call , and number of
ni ghts and hours worked. The i nf ormati on management system can be used to t rack
t hese events.
Quality Assurance
Data gathered el ect ronical l y i s rel ati vel y easy to anal yze f or qual i t y assurance
purposes. Wi th manual charti ng, there may be a consi derabl e def ici t i n
documenti ng adverse events (27,48,49,50, 51, 52,53,54, 55,56). When an i nci dent
occurs, the rel at i onships to drugs or procedures may be determined more
accuratel y f rom t he data management system t han f rom the wri t ten record. I n one
reported case, i t woul d not have been possi bl e to determi ne t he cause of a cri ti cal
i nci dent f rom the manual record, but the data management system i ndicated the
source of the problem (57).
A registry of anesthesi a-relat ed probl ems can be compi led (58, 59,60,61). Events
such as mal ignant hypert hermi a, suspect ed l atex al l ergy, atypical
pseudochol i nesterase, and di ff i cul t i ntubat ion that woul d be of i mportance to
subsequent anesthesi a providers can be sent to a data bank t hat i nsti tuti ons and
anesthesi a personnel can access el ect roni cal l y.
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Advantages
Accuracy, Completeness, and Legibility
The accuracy, completeness, and l egi bi l i ty of handwri tt en records of ten l eave much
t o be desi red (6, 29,33,34, 35,36,62,63,64). There i s a bi as toward recordi ng more
normal val ues (37,38,65, 66).
St udi es show t hat a high number of errors are made when bl ood gas anal ysi s
resul ts are telephoned to t he operat ing room (67). Elect ronic t ransf er of l aboratory
i nformati on shoul d be more accurate.
Cl inici ans are not al ways able to make ti mel y notati ons i n t he wri tt en record whi l e
respondi ng to emergenci es, and thei r memori es are not compl et el y rel i able when
recordi ng data af ter an i ncident . The resul t i s of ten an i ncomplete record duri ng
peri ods of si gnif i cant and rapi d changes when i ncreased physical and
pharmacol ogi c mani pul at ions occur. Wi th el ectroni c data transf er, recordi ng wi l l
conti nue duri ng t hese t i mes.
New vi ews of data are avail abl e wi th el ect roni c records (25). Dat a that woul d be
spread among many pages or reports in a paper record can be f ormat t ed to a si ngl e
page or moni tor screen, al lowi ng the cl i nician to revi ew l ongi tudi nal inf ormat ion at a
gl ance.
Decreased Paper Use
Decreased paper use i s a goal of data management systems. It is possi bl e t hat in
t he fut ure a paper pri nt out wi l l be unnecessary, as i t wi l l be possi bl e to cal l up al l
records f rom the electroni c dat abase.
Accessibility
Anesthesi a provi ders need access to previ ous anesthetic records, especi al l y i f
t here was an adverse reacti on, dif f i cul t i ntubati on, unexplained problem, or nausea
and vomi t i ng. In the past , this necessi tat ed having someone l ocate the ol d chart.
Thi s can be t i me consuming and may not be possi bl e during evening or nightt i me
hours. Many ol d chart s are stored at an of f -si te l ocati on. If the record is stored
el ect roni cal l y, i t should be readi l y avai l abl e at any t i me at al l locat i ons where
access i s needed. I n the f ut ure, i t may be possi ble to transfer records between
i nst i tut ions by usi ng the Internet or other secure means.
Integrating Monitored Variables and Alarms
The operati ng room i s an i nf ormat i on-i ntensi ve locat ion wi t h data provided by a
heterogeneous mi x of i ndependent devi ces. It may be dif f icul t to compare vari abl es
and determi ne the rel at ionshi p bet ween t hem. A dat a management system may
make i t easi er to present data i n a f ormat t hat al l ows rapid and accurate
recogni t i on of devel opi ng pat t erns and exami nati on of the relati onshi p between
vari ous i ntervent ions and responses.
Another probl em i n the operat ing room is that several dif f erent al arms of ten occur
si mul taneousl y. Thi s may resul t i n conf usi on as to the source and si gni f icance of
t he al arms. An i ntegrated system can generat e more speci f i c and descri pti ve al arm
messages. I deal l y, al l al arms woul d be di spl ayed on one cent ral panel desi gned f or
maxi mal visibil i ty and readabi l i t y, and the al arms on the pri mary moni tors coul d be
t urned OFF. This would ai d i n recogni zi ng what condi ti on(s) requi re at tenti on. The
el ect roni c dat a system coul d then anal yze the data and suggest di agnoses and,
possi bl y, t reatments. See Smart Al arms i n Chapter 26.
Legal Protection for Anesthesia Providers
Every anesthet ic record has t he potent i al to become a l egal document
(68,69,70, 71, 72,73,74). No case wi l l come to tri al or sett l ement wi t hout a detail ed
analysi s of the anesthesi a and perioperative care records. Manual records of ten
l ack i nf ormat i on that could be essenti al i f l egal acti on occurred. Incomplete or
i l l egi bl e medi cal records create t he impressi on that care was carel ess, superf i ci al ,
or subst andardeven i f , i n truth, i t was good. Cl ear, complete, and ti mel y
anesthesi a records wi l l almost al ways help t o def end a case that was properl y
managed, al t hough i t wi l l not hel p wi t h one t hat was poorl y handl ed.
A data management system can f aci li t ate documenti ng protect ive acti vi ti es by
presenti ng the cl inici an wi th a checkl i st of rel evant safety i tems. Data management
systems can be used to det ermi ne popul at i on-based normal l i mi ts f or vi tal si gns
duri ng anesthesi a (75). These may pl ay a role i n professi onal li abi l i t y cases.
The medicol egal signi f i cance of t he dat a management system has yet to be
determined, as there have not been a l arge number of l egal proceedi ngs in which
t hey were invol ved. One large survey determi ned that there were no report ed cases
i n which the data management system hi ndered t he def ense process (76). However,
si nce then, a case has been report ed where a data t ransmi ssi on fail ure was not
noti ced, and the plainti ff ' s att orney suggested that t he absence of data was
evidence that the st andard of care was not met (77).
Beneficial Effects on the Anesthesia Provider's Time
St udi es have shown t hat 20% of total anesthesi a t i me i s used for manual
documentat i on (78). St udi es al so have shown t hat chart i ng t ime i s modestl y less
wi th a data management system (63,79,80).
P. 852


Automated Therapy
El ect roni c data i nf ormati on of f ers t he pot ent i al for i nformat i on i ntegrat ion.
I nformat i on such as blood pressure, pulse rat e, and neuromuscul ar bl ockade coul d
t hen be al l owed to cont rol the admini st rati on of vol ati l e and i ntravenous drugs and
agents (81).
Decision Support Capability
The data management system shoul d be abl e to access vari ous sources of
i nformati on. These can i nclude the pharmacy for i nformati on about drugs and thei r
i nteracti on wi th ot her medi cati ons as wel l as calculati ons and drug costs. Other
sources could i ncl ude text books and j ournal s. The speed, breadt h, and consistency
of a computer deci sion support system f ar exceed those of even the most dedi cated
and expert cl i nician.
Problems
Artifacts
A common concern wi th data management systems i s that arti facts wi l l be used
against the anesthesi a provi der i f there i s an untoward occurrence
(82,83,84, 85, 86,87). Arti facts may be caused by mechani cal or el ect ri cal
di sturbances (e. g. , external pressure on the blood pressure cuf f ; el ect rosurgical
i nterf erence on t he ECG, oxygen moni tor, or pulse oxi meter; mal posi t i on, ambi ent
l i ght, or mot ion on the pul se oximeter sensor; l i ne f l ushing or sampli ng on i nvasive
pressure l i nes; and a pl ugged gas sampl i ng l i ne). Another source of art i facts i s
l oggi ng errors by t he anesthesi a provi der.
Unf ortunatel y, arti fact recogni t i on is not an exact science. Notes that are made to
explain an art i f act may be ret rospecti ve and i n error. Of ten, the data management
system makes i t di ff icul t to di st ingui sh an arti f act f rom a true value (82,88).
Arti facts can be reduced by usi ng moni tors wi th resi stance to interf erence and
arti f act rej ecti on capabil i ty. Another method i s to uti l i ze the dat a compari son or
arti f act rej ecti on capabil i ti es of the data management system. For exampl e, heart
rate i s commonl y measured by several di f f erent moni tors. The comput er coul d
compare these measurements and rej ect one that does not match the others.
When an erroneous val ue is not f i l tered, manual not es can be used t o expl ai n the
questi onabl e readi ng. Many art if acts can be addressed by usi ng prewri t ten notes
f rom a l i st of common causes of arti facts (e. g. , saturati on of peri pheral oxygen
(SpO
2
) aff ect ed by el ectrosurgery).
I ncomplet e dat a ent ry can occur wi t h el ect ronic records, especi al l y when they rel y
on f ree text ent ri es or i t i s t i me consuming and di ff icul t to enter coded events (89).
Physical Layout
Contemporary operat i ng rooms are of ten crowded, so the bulk of the el ectroni c data
system may cause probl ems. Careful consi derati on shoul d be gi ven to where the
system and the necessary cabl es are pl aced. It shoul d be i n a l ocati on t hat i s
ergonomical l y pract i cal but does not i nt erf ere wi t h other equipment . In one case,
t he dat a management computer shif ted i n i ts mount and compressed t he transf er
t ubi ng bet ween t he adj ustable pressure l i mi t i ng (APL) val ve and t he scavengi ng
i nterf ace, bl ocki ng gas f l ow.
Interfacing
Al l of the devices that are connected to t he data management system must be abl e
t o communi cate wi th t hat system. An i nterf aci ng device i s needed to perf orm thi s
f uncti on. I t i s i mport ant t hat i f a moni tor f ai l s to f uncti on, anot her moni t or can be
at tached t o the syst em wi t hout havi ng t o reboot or reconf igure t he system.
I nterf aci ng some equi pment to the data management system can be di ff icul t. Some
devices must be modi f i ed, and unl ess thi s is done correctl y, they may be rendered
unsaf e. Al so, t he warranty may become void. A customi zed i nterf ace may make i t
di ff i cul t to exchange moni tors.
Adverse Effects on Operator Vigilance
Another worry about t he data management systems is that the cl i ni ci an wi l l not look
at t he moni tors si nce there i s no need to record the val ues shown on t hem (90).
The reasoni ng is that the process of enteri ng data on the record causes t he
anesthesi a provi der t o mental l y absorb and evaluate t hat i nf ormati on (91). Studi es
have found that vi gi lance i s not adversel y af f ected by usi ng a data management
system (79, 80, 92).
User Attitude and Acceptance
User atti tude can make or break a system. An anest hesi a provi der who f i nds
computers i nt imi dat i ng or who has t he percepti on that automated records i nvi te
l awsui ts may be rel uctant to i nvest the ti me and energy necessary to l earn to use
an i nf ormat i on system. Since the data management system i s cont i nual l y bei ng
i mproved, there wi l l be f requent upgrades, whi ch can be a source of i rri tati on and
confusi on.
For a system to be successf ul , i t needs to be user-f riendl y and dependable.
I nvol vi ng t he users in choosi ng and conf i guri ng the system wi l l hel p to wi n support .
A team t o carry out dat a management system i mpl ementat i on should be put
t ogether pri or t o i ts introducti on (53).
P. 853

Detai led educati on i n bot h the reasons for the conversi on and the actual system
operati on wi l l be necessary.
The i nt roducti on method wi l l af f ect acceptance. Experi ence suggests that i n most
cases, i t i s best is to make a qui ck, cl ean break wi th t he ol d system and requi re al l
provi ders to use the new one (93). Af ter the system has been in use for an
extended peri od, user acceptance is usual l y high, provi ded t hat t here are not
f requent malf uncti ons (94,95).
Security
Securi t y concerns have become very i mportant for all medi cal records. There needs
t o be a means to guard agai nst unauthori zed personnel maki ng ent ri es or gai ni ng
access to the system as wel l as a means of i denti f yi ng personnel who l og on to the
system.
Confidentiality
I nformat i on can be t ransferred bet ween i nsti tut i ons by way of the Internet
(8,70,96,97). A maj or problem i n elect ronic medi cal record t ransf er i s protecti ng
pati ent pri vacy (98). The syst em must provide tool s to safeguard dat a
confi denti al i t y yet make i t easi l y ret ri evabl e f or sel ected users. The anesthesi a
record wi l l be used by other anesthesia and heal th care provi ders, incl udi ng
admi ni st rators, nurses, t echni ci ans, pharmaci sts, bi l li ng personnel , pharmacy, and
peer revi ew personnel . All of these i ndivi dual s need certai n inf ormat ion but not
necessari l y al l the i nf ormati on i n the record. I t may be advantageous t o make the
record avai l abl e in di f f erent formats that i ncl ude onl y the i nf ormati on needed f or
speci f i c purposes.
Training
I mpl ement ing a data management system requi res an i ni ti al invest ment of t ime for
user educat ion. I nadequate trai ni ng can l ead to resi stance to usi ng the system. An
i nadequatel y prepared provi der can cause records to be i naccurate, lost, or
unusable. Trai ni ng cannot be hi t or mi ss. Al l provi ders must recei ve adequate
i nst ructi on before usi ng t he data management system. Thi s can be dif f i cul t ,
especi al l y i f there are provi ders who work onl y occasi onal l y at t he faci l i ty.
Af ter users are t rained on the data management system, the compl iance l evel
needs to be moni tored and t he cause of any decreased compl i ance determi ned.
Cri t eri a f or det ermi ni ng user compl i ance have been devel oped (99). A decrease i n
compl i ance can si gni f y that the user i s unwi l l i ng to perf orm wi thin set cri teri a or
t hat there is a probl em in t he system that can be corrected.
Mechanical Problems
The operati ng room can be a hosti le envi ronment f or computers. Damage may be
caused by other equi pment or user abuse. Cl eanl i ness can be a probl em. Bl oody
gl oves may be used t o make ent ri es. Li qui ds may f i nd thei r way i nto the mouse or
keyboard.
The system should not be af f ected by power f l uctuat ions, a brownout, or a bl ackout.
Preventi ve measures include an uni nterrupti bl e power suppl y (UPS) and a l i ne
condi ti oner to prevent vol tage f luctuat ions.
Probl ems are i nherent i n any computer system. There wi l l be t i mes when
i nformati on is sl ow i n comi ng or t he computer i s down. Looki ng up informat i on may
be too ti me consumi ng in emergency si tuations. If the server where al l the dat a
eventual l y ends up i s not f unct i oni ng, the data needs to be retained in the bedsi de
computer unti l the server i s abl e to recei ve t hat i nf ormati on.
I nformat i on in t he data management system needs t o be backed up at f requent
i ntervals and stored i n a manner that wi l l ensure that i t wi l l not be lost . There needs
t o be a means to record data if the computer f ail s.
Inability to Deal with Certain Information
No devices are avai labl e f or quant if yi ng or measuri ng physiol ogic si gns such as
pupil l ary si ze and react ivi ty, sweati ng, or bl ood l oss. Thi s t ype of i nf ormati on needs
t o be manual l y entered i nt o the computer.
Difficulty Adapting to Special Situations
I n t he operati ng room, the equi pment is l ocated i n one or t wo l ocat ions. This means
t hat connecti ons between moni tors and the data management system and between
t he dat a management syst em and the network do not need t o be al tered f requent l y.
When anesthesia i s admi nistered i n a remote area, the moni tors i n t hat locat ion
may not be abl e to i nt erf ace wi t h t he data management system. This wi l l
necessi tat e taking t he ent i re anest hesi a machine wi t h i t s moni tors and data
management system t o the l ocat i on. Si nce a connecti on to t he server may not be
avai l able i n t hese areas, the i nformat i on wi l l need to be stored i n the computer unt i l
i t can be connected to the network and the i nf ormati on downl oaded f or storage and
pri nti ng. Wi reless communicati on f rom the moni tors in t he l ocat i on where the
procedures occur may overcome some probl ems.
El ect roconvul sive therapy poses another probl em f or t he dat a management system
(100). I n t hi s si tuati on, several pat ients can be l i ned up and anesthesi a
admi ni stered in a rapi d manner. Thi s i s usual l y performed i n a psychiat ry sui te or
PACU. The total ti me per pati ent i s onl y several mi nutes, and an anesthesi a
machi ne i s usual l y not used. To use a data management
P. 854

system f or t hese cases, moni t ors would need to be connected and di sconnected
every f ew mi nutes and the record rest arted and demographi c i nformat i on added f or
each pat ient. Al l of this would great l y extend t he ti me requi red to perf orm thi s
procedure.
Lack of Information Standardization
I t i s i mportant that data f rom other si tes be i ntegrated. Hori zontal i ntegrati on shoul d
i ncl ude connecti ons between the areas such as the pharmacy, l aboratory, and
radi ol ogy. I f these areas use a di ff erent f ormat, i t may not be easy t o add thi s
i nformati on el ect ronicall y.
Long-term Manufacturer Stability
Some earl y hardware and sof tware provi ders went out of busi ness, so t hei r systems
t hat had been i nstal led became obsol et e. As the technol ogy matures and becomes
more popul ar, i t is expected t hat the compani es t hat mai ntai n the systems wi l l
become more stabl e, and this problem wi l l dimi ni sh. A vendor' s long-t erm viabil i ty
shoul d be consi dered when purchasing a system.
Financial Considerations
The drugs and equi pment used i n anest hesi a contribute t o the cost of the
anesthet ic. The abil i t y to t rack drugs and moni t oring procedures al lows thei r cost
and eff ectiveness to be assessed. The data management system can be used to
determine t he ef fect of a drug or moni tor on overal l outcome and costs and whether
an expensive drug coul d be replaced by one of less cost wi t hout a decrease in t he
quali t y of care (72).
Costs
The i ni ti al cost of a dat a management system i s hi gh and depends on the number of
operati ng rooms, what equipment and i nf rastructure is al ready i n place, t he wi ri ng
requi rements and abi l i t y of existi ng moni tors, and ot her equi pment t o i nterf ace wi th
t he system.
There are costs i nvol ved i n trai ni ng users and support personnel . These wi l l be
repeated each ti me there i s a revi si on i n the program and each ti me a new user or
servi ce person is added.
Af ter purchase and instal l at i on, ongoi ng costs i ncl ude hardware and sof tware
mai ntenance, upgrades, and support personnel . Ot her costs to be consi dered
i ncl ude paper, printer cart ri dges, pref i l l ed syri nges, and addi ng bar codes. There
must be techni cal backup avail abl e to sol ve problems and to keep the syst em
f uncti onal . If the system is di f f i cul t to operat e, mi stakes may resul t i n lost bi l li ngs.
Savings
Data management systems may reduce l osses f rom charges not capt ured and
i naccurate codi ng or t ime bi l l i ng (101,102). The costs of di ff erent t echni ques can be
compared. Af ter each case, the anesthesia provi der can be presented wi t h the
costs of drugs and other i tems used. These can t hen be examined to determi ne if
t hey were trul y necessary and i f ot her l ess cost l y ones could be used (103).
Savings can be achi eved by reduci ng last-mi nute delays and surgery cancel l at ions;
i mproved staf f i ng; bet ter i nventory cont rol ; and reduct ions in admini st rati ve and
overhead costs such as bi l l i ng, medical records, qual i ty assurance, and compl iance
wi th t he Joi nt Commi ssi on on Accredi tati on of Heal t hcare Organi zati ons and other
regul at ory bodi es.
Savings can be achi eved i f data management systems ai d anesthesi a provi ders and
i nst i tut ions in prof essional l i abi l i ty l i ti gati on. One i nsurance company of fered a
di scount f or using data management systems (71). Some problems that resul t in
l awsui ts, such as i nject ing t he wrong drug, may be avoi ded.
I f central t rendi ng and al arm f unct i ons are assumed by the automated record
system, i t may be possible to use moni tors wi thout t hese f eatures and t hat cost less
t han the top-of -t he-l ine model s (104).
Whether data management systems wi l l be cost ef f ect ive remai ns t o be
demonst rated. Whi l e some centers have reported savi ngs (105), i t is di f fi cul t t o
document that dat a management syst ems save enough to j usti f y the hi gh i ni ti al and
mai ntenance costs.
I n summary, t he data management system of f ers many advant ages as wel l as a
number of disadvantages. Some i nsti t uti ons have used one f or a ti me and then
stopped because the work of supporti ng i t was too demanding or the system was
f lawed (106). Syst ems presentl y avai l abl e are sti l l el ement ary i n relat i on to thei r
potenti al , but they are becomi ng more powerf ul and easier t o use. Many of t he
potenti al f eatures di scussed i n thi s chapter are t heoreti cal , whi l e many of the
potenti al f eatures di scussed have yet t o be i mplement ed. Despi te t he f act t hat t here
are l i ttl e hard data t o support t he superi ori ty of data management systems, i t seems
l ikel y that in the fut ure, most medi cal records wi l l be computeri zed and i ntegrat ed
i nto a f aci l i t y-wi de data management system.
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Questions
For the f ol lowing quest ion, sel ect the correct answer
1. Whi ch of the fol l owing defi niti ons is i ncorrect?
A. Anal og data i s conti nuous data that can, wi thi n l i mi ts, assume any val ue.
B. Cl osed archi tecture ref ers to equi pment desi gned t o work onl y wi t h accessori es
made by one company.
C. Analog i s a way of stori ng inf ormat ion usi ng numbers.
D. Peri pheral i s a general term for any of the devices by whi ch a computer gathers
i ts i nput and dessi mi nates i ts output .
E. A macro is a tool used t o automate tasks or procedures wi t hi n a program.
Vi ew AnswerFor the fol l owing quest i ons, answer
i f A, B, and C are correct
i f A and C are correct
i f B and D are correct
i f D i s correct
i f A, B, C, and D are correct .
2. Uses of a data management system in anesthesi a include
A. Educat i on
B. Quali t y assurance
C. Research
D. Bi l l i ng
Vi ew Answer3. Proven benefits of automated records i ncl ude
A. Legal prot ecti on for the anesthesia provider
B. Fi nanci al savi ngs
C. Maj or benef i ci al ef fect on the anesthesi a provi der' s t ime
D. Accuracy
Vi ew Answer