Technology, Social Engineering, and Clinical Anesthesiology

This issue of Anesthesia & Analgesia features 3 reviews focusing on current technologies in clinical anesthesiology. In this editorial, we will review the 3 papers and discuss the potential use of anesthesia technology in the next decade. The review by Epstein et al.1 explores the ability of anesthesia information management systems (AIMS) to influence anesthesia providers using near real-time alerts and post hoc reports. The paper reviews recent publications about feedback from AIMS systems to providers: improved protocol adherence, improved capture of billing elements, and increased compliance to required documentation and regulatory elements. The authors look at how these systems have influenced provider behaviors and how we might better go about designing these systems to cause the desired provider response. This aspect of AIMS will grow tremendously. AIMS began as little more than computer-based storage of what had previously been handwritten charts. Digitized storage of case records led to improvements in reporting and data analysis.2,3 In the last 10 years AIMS started providing physicians with direct feedback.4,5 As of 7 years ago, according to a study published in Anesthesia & Analgesia,6 only about half of academic practices even had AIMS installed. Today, immediate feedback in the form of decision support is increasingly commonplace.7,8 However, we have far to go to realize the potential of AIMS to improve patient care, provide better documentation, and support operating room management and perioperative quality improvement. AIMS will blossom from information storage systems into true information management systems. Epstein et al. nicely present the state of the art. The article by Galvez et al.9 reviews Meaningful Use (MU) of AIMS. MU is a government program to improve health care delivery through certification of electronic medical records (EMRs) systems. The MU program was not designed for anesthesiology. The authors discuss whether it is possible for AIMS to comply with the MU program in different settings. This is particularly timely since as of January 1, 2015, full payment is only possible to providers and hospitals that are in compliance. This is likely the first of many such regulatory challenges for AIMS. As governments become active managers of health care delivery, regulation of EMRs and AIMS will increase as well. We should be prepared to comply with new regulations. We should also endeavor to help regulatory agencies craft standards appropriate to the needs of perioperative care. The review by Prahl et al.10 explores the potential benefits of prompt asynchronous written communications (e-mails) as a communication channel between a decision maker (manager) and an expert advisor. On a very basic level, the authors are seeking to scientifically answer the question “Is e-mail appropriate for perioperative group management?” It would be easy to dismiss this question based on our gut response to e-mail (Love it? Hate it? Both?). However, new technologies are expanding so quickly that we are presented with new communication options almost monthly (see whatever social networking site is hot this month as an example). With so many options, we are going to have to challenge our existing assumptions from time to time about the technologies we’re using and whether or not they still make sense. What changes will computer technology bring to clinical anesthesiology? The topic of the future of our specialty has been the subject of considerable debate.11–13 There is significant support for the expansion of our clinical footprint beyond the operating rooms. We submit that this expansion to the preoperative and postoperative periods (and even through to the recovery of the patient at home) will rapidly reshape the way perioperative technologies are developed, adopted, and used. In addition, we believe that what Peter Pronovost14 calls the perioperative “technological ecosystem” will change substantially. Major companies such as Apple, Google, Microsoft, and others are preparing to invest in the health care market. Dr. Michael O’Reilly, an anesthesiologist previously at the University of Michigan, at the University of California Irvine, and currently at Stanford, is now Vice President of Medical Technologies at Apple. It is likely Dr. O’Reilly is one of many anesthesiologists who will play a significant role in bringing advanced computing technology to our workplace. As our specialty shifts focus from a purely intraoperative setting to the overall perioperative environment, the new Perioperative Surgical Home (PSH) model of care may soon become a new reality for all of us practicing anesthesiology.15,16 As defined by the American Society of Anesthesiologists, the PSH is “a patient-centered, physician-led multidisciplinary, and team-based system of coordinated care. One of the central tenets of the PSH is to guide the patient through the whole perioperative experience from the day the surgery is decided until 30 days after discharge from the hospital.”16 This guidance is based on evidence-based care plans and development of clinical pathways. Although autonomy in decision making for the practitioner and his/her patients will always be respected, the use of pathways will decrease ambiguity among patients and providers, improve outcomes, decrease costs, and improve patient and provider satisfaction.16 These clinical pathways are holistically mapped out by the medical professionals from the surgeons to the anesthesiologists to the nurses to the medical device specialists to the rehabilitation therapists, providing complete continuity of care and standardization of practices to enhance patient safety. Once developed, newly developed pathways and order sets will be programmed into existing EMRs and AIMS to provide guidance for the health care providers. The implementation of this new clinical delivery model will probably require the use of social engineering tools such as LEAN six sigma17,18 or others. Today, process and outcome metrics are not accessible in a single repository, precluding access in real time by stakeholders involved in perioperative care. The PSH will likely facilitate implementation of a “data mart” to continuously collect process and outcome metrics from multiple electronic sources, including scheduling, admissions, AIMS, EMRs, clinic and hospital records, laboratory, radiology, and billing during all phases of patient care. Only a few academic departments that have already invested significant time, energy, and money in EMR, AIMS, and other electronic data recording and integration systems research have access to this information in real time today. Information in the data mart would be used for many purposes. A patient-tracking board would display current PSH patients from postanesthesia care unit until discharge from the hospital. This goal-directed dashboard would be updated in real time, immediately presenting factors that could cause the patient to deviate from the optimized clinical pathway (e.g., poorly controlled pain, inability to tolerate the planned diet progression, continued presence of a urinary catheter increasing the risk of infection, side effects such as constipation, deviations from the planned anticoagulation management, inability to reach physical activity goals, and abnormal vital signs or laboratory values). These technologies have already been developed and implemented in some form in our institution. Looking forward, the data mart will facilitate computers moving beyond data capture, storage, and communications to becoming active participants in our cognitive processes as well, as they will assist in identifying, designing, and implementing optimal patient care pathways. Our specialty has dedicated the last 30 years to improving patient safety through systems-based solutions and new information technologies. The next decade will see this trend continue with the added attention to incorporating social engineering in perioperative care. The result will be technologies that make the entire perioperative period from scheduling to returning to daily activity at home and beyond as safe and controlled as we have made the operating room. RECUSE NOTE Dr. Maxime Cannesson is the Section Editor for Technology, Computing, and Simulation for Anesthesia & Analgesia. This manuscript was handled by Dr. Steven L. Shafer, Editor-in-Chief, and Dr. Cannesson was not involved in any way with the editorial process or decision. DISCLOSURES Name: Maxime Cannesson, MD, PhD. Contribution: This author helped write the manuscript. Attestation: Maxime Cannesson approved the final manuscript. Conflicts of Interest: Maxime Cannesson has equity interest in Sironis, received honoraria from Edwards Lifesciences, consulted for Edwards Lifesciences, received research funding from Edwards Lifesciences, received honoraria from Masimo Corp., consulted for Masimo Corp., received research funding from Masimo Corp., consulted for Covidien, and consulted for Gauss Surgical. Name: Howard Schwid, MD. Contribution: This author helped write the manuscript. Attestation: Howard Schwid approved the final manuscript. Conflicts of Interest: This author has no conflicts of interest to declare. Name: Joseph Rinehart, MD. Contribution: This author helped write the manuscript. Attestation: Joseph Rinehart approved the final manuscript. Conflicts of Interest: Joseph Rinehart has equity interest in Sironis and consulted for Edwards Lifesciences. Name: Zeev Kain, MD, MBA. Contribution: This author helped write the manuscript. Attestation: Zeev Kain approved the final manuscript. Conflicts of Interest: Zeev Kain consulted for Merck.