Chapter 3 - Anesthesia and Health Information Technology

Abstract

Anesthesia providers routinely produce and record large amounts of physiologic, pharmacologic, and patient care management data and information. There has been a shift from recording data on paper to anesthesia information management systems (AIMS), and electronic health record (EHR) systems. The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 and Centers for Medicare & Medicaid Services’ (CMS) payments for fulfilling “Meaningful Use” of EHRs have fueled the current widespread adoption of overall health information technology (health IT). Health IT should support the clinical needs of providers and patients, as well as the quality, financial, and management needs of the organization. Health IT can generate large datasets to feed clinical and quality “big data” warehouses or multiorganizational data registries such as those of the Anesthesia Quality Institute (AQI), the Multicenter Perioperative Outcomes Group (MPOG), and the Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) projects. Intelligently designed health IT can produce a user interface that improves clinical documentation, but complex clinical decision support (CDS) provides health IT users with knowledge and specific information, presented at appropriate times, to enhance evidenced-based care. Poorly designed and implemented health IT, on the other hand, can be a distraction for clinicians and patients. Attention to the concepts of “usability,” computer-human interaction, user-centered design, and “human factors” should support clinical situational awareness and teamwork. Many tasks, considerations, and potential pitfalls surround the planning and implementation of an AIMS or EHR system. Implementing an EHR is a daunting initial experience, but the work of ongoing EHR maintenance and advancements continues forever.