Jeffrey Plagenhoef, M.D., is president of Anesthesia Consultants Medical Group, the anesthesiology group affiliated with Southeast Alabama Medical Center, a 400-bed tertiary care center in Dothan, Ala. He has been a practicing anesthesiologist for two decades. Plagenhoef has been the designated physician champion for the anesthesia information system implementation at Alabama Medical Center. He is the immediate past chair of the American Society of Anesthesiologists’ Committee on the Anesthesia Care Team, and is chairman of the board of directors of the Anesthesia Quality Institute (both the ASA and AQI are based in Park Ridge, Ill.) He spoke recently with HCI Editor-in-Chief Mark Hagland regarding his perspectives on anesthesia information systems.
Healthcare Informatics: What are the critical success factors in anesthesia management systems, from the anesthesiologist point of view?
Jeffrey Plagenhoef, M.D.: The critical success factors have changed over the past five years. But the CIO must understand that he or she has to have a physician champion; there are places where the CIO has tried to drive this, and it doesn’t work very well. The people in IS/IT don’t know what makes a good AIMS [anesthesia information management system]. So my first directive would be to find a clinical champion and ask him. But basically, they need a system that’s embraced by the anesthesia community. And the IS people are sometimes guilty of forcing a system upon the anesthesiologists, because it will be a fully integrated system. And the reason that some areas of the hospital have been later adopters of electronic health records has had to do with specific needs in the cath lab or NICU [neonatal intensive care unit], or anesthesia department. We need a system that does not cause any delay in workflow; and it has to fit into the unique workflow at every site. And you can’t force a unique workflow just because it fits into some vendor’s system. So from my perspective, best-of-breed trumps integrated systems that are integrated just to be integrated.
Jeffrey Plagenhoef, M.D.
And some systems capture the digital data from the monitors and put that data into the electronic medical record, and the top seven or eight vendors all have that integration with the physiological systems. But the best systems have clinical decision support. You should have an electronic pre-anesthesia evaluation that’s well thought out and doable in terms of efficient care delivery, and so you have to have an evaluation that can’t take forever to accomplish the interview and enter the data. And that pre-anesthesia evaluation needs to be fully integrated with the interoperative record. Another example is a drug safety system; the [Indianapolis-based] Anesthesia Patient Safety Foundation has taken a strong stance that it is now time that we as a specialty address safety or lack thereof within the systems we use to administer IV medications. Some systems have a drug safety component, and others don’t have them. And that was a driving element for us here, in terms of the solution we chose. We knew we could get the electronic data entry of the physiologic system, but we wanted and needed the drug safety component. But the drug safety component doesn’t work if you don’t have an integrated pre-anesthesia evaluation. Because a good drug safety system will also tell you if the patient is allergic, if the drug is contra-indicated based on a drug the patient already takes, or is contra-indicated based on the pre-anesthesia evaluation program.
And if there’s a bad outcome, you need to know what drug was given for sure according to a barcode, to know for sure that the right dose was documented, and that the timing of the drug administration was accurate. And that’s not always the case. And barcoding in the operating room is different from barcoding on the nursing floor. Other elements include clinical decision support for compliance with all the quality and safety initiatives, all the care paths we’re supposed to be effectively implementing, for instance DVT prophylaxis reminders; some systems have blood sugar/diabetes management prompts in them, to make sure a patient on an insulin drip is getting regular monitoring of their insulin so they don’t get hypoglycemia while they’re under sedation.
HCI: Which system did you end up choosing?
Plagenhoef: We chose DocuSys [from the Chicago-based Merge Healthcare]. We really dug into the market well and looked at all vendors. And because we were focused on trying to do more than just an electronic record, it worked well for us. It was a company that started out in the drug safety area; so the company’s focus from the very beginning was on safety in the operating room, and philosophically, that is significantly different. Sometimes, physicians and nurses feel they’re forced to use a record to generate more data for administrative people to use, but that slows them down and doesn’t provide them with as much end-user benefit. So for us, the patient safety aspect was so important.
The record should start before the patient gets to the receiving room, with the first set of vital signs; then the receiving room, pre-op, the OR, and the PACU [post-anesthesia care unit]. And our PACU record had not been fully integrated with our anesthesia record; that integration is now in place. We also have a tool that is turbo-charged, and that has a turn-mount on it for rapid scrolling through pick lists. It facilitates data input for those things that do have to be manually entered into the record. So the solution we chose brings several elements that are important.
HCI: When did you go live?
Plagenhoef: Back in 2005.
HCI: And it’s worked out well?
Plagenhoef: Yes. We actually gave the whole department the opportunity, twice, at six-month intervals after go-live, to choose to go back to the market and make another choice, and our 35 nurse anesthetists and 20 anesthesiologists voted unanimously to keep this.
HCI: Will enough vendors produce enough rich systems for anesthesiologists and nurse anesthetists, and anesthesiologist assistants?
Plagenhoef: Yes, and one reason is that CMS [the Centers for Medicare and Medicaid Services] is going to penalize organizations for not using systems that help them qualify for meaningful use. Our hospital-based specialties were left out of the meaningful use equation a few years ago, and there’s been a strong reaction to that, and we’re working with CMS so that we can officially qualify as eligible providers. And there’s a strong case for us being included in meaningful use. We’re also working internally in Washington, D.C., to create the key elements of meaningful-use-based AIMS. And the House of Delegates supported a resolution for the ASA [the Park Ridge, Ill.-based American Society of Anesthesiologists] to become involved to start providing help for its members to start tackling some of the more challenging elements of going electronic, to make product evaluation easier for me and my department when we started evaluating products in 2003 and 2004, and to make sure we can become meaningful users.
And the other big factor is that the [Park Ridge, Ill.-based] Anesthesia Quality Institute is going to make a huge difference to our specialty in impacting quality of care and patient safety, in providing usable, rich and valid data via electronic use. So there will be the incentive from CMS and from the AQI side of things. And at the local level, we’ll probably be developing an accountable care organization soon, and it’s just going to be hard to participate in an accountable care organization without easily accurately reported data measures on quality and patient safety, and the use of comparative effectiveness data to stand up to the competitors. So yes, there will be a ramp-up in AIMS adoption.