Automated anaesthesia record system - Expensive toy or a change whose time has come?

The first paper records in anaesthesiology were developed in the 1890s, and remain little changed.[1] The anaesthesia record is designed to document not only what was done to a patient during the surgical experience, but also how the patient responded. The patient record is extremely important and must be carefully chronicled with every anaesthetic procedure. The anaesthetic record is used for patient care during anaesthesia administration and in the post anaesthesia care unit (PACU), the intensive care unit (ICU) and the postsurgical ward. The recorded information is used for billing, tabulating patient statistics, and reviewing previous anaesthetic procedures. Finally, advances in quality improvement methods assist in peer review and legal defence.[2] As the anaesthesia record has evolved, it has become a significant document on a number of levels.[3] Initially designed as a medical record and communication tool, it has now become a medical-legal document that may be used to demonstrate that standards of care were met in the care of patients who may have had adverse outcomes.[4]

The practice of anaesthesia requires a medical record system that can capture patient's data in real time from the devices in the operating room. Traditionally, it has been done manually by the attending anaesthesiologist. Observer bias, missed readings, and errors of memory which affect manual anaesthetic records may cause significant inaccuracy and may be avoided by using automated records generated by information management systems.[5]

The concept of automating the anaesthesia record has intrigued academicians for decades. The first known example of an automated anaesthesia recordkeeping device dates to 1929. An electronic medical records system integrates clear and concise information across the entire hospital system. This can help improve quality of care, reduce errors, decrease risks, and improve revenue capture.

The advantages of an Anaesthesia record system are as follows:

Capturing high quality data in real time

Alerting the anaesthesia provider of deviations from preset physiologic limits

Communicating with various patient databases

Generating an accurate, understandable record at the end of the procedure, and

Reduction in the workload of the anaesthesiologist

Generation of large databases to help audit and research.

The disadvantages of automated anaesthesia record systems are as follows:

Vital information may be lost when the data are recorded fully automatically-without active involvement on the part of the anaesthetist which may lead to loss of vigilance

Repeated training of the staff is required as it involves change from manual to automatic data recording

The software needs to be tailor made for each hospital according to the need

These systems are expensive and need constant updating which may lead to recurrent expenditure.

In this issue of the IJA, Palaniswamy et al. publish their findings after 1000 neurosurgical cases, and the results are in tune with the other findings in literature.[6] It is easy to fathom that junior anaesthesiologists were completing the records better than the seniors as they are supervised and more technologically savvy than the seniors. Similarly, more incomplete records were seen in emergency cases, perhaps because the attention of the anaesthesiologist was more towards the clinical requirement in the emergency cases. The second case of the day showed more incomplete entries. In the institute where I work, we had a similar experience. The reluctance to change from manual to automated systems was seen more with seniors, the reasons being computer phobia, personal biases and fear of litigation due to artifact inclusion in the records. Till date, the available literature does not show any evidence of litigation against anaesthesiologist due to artifacts in records.

There is no denial that more and more hospitals are adapting to the change and implementing the automated anaesthesia records. As the banks adapted the automation and did away with teller-based transactions, in the future, there will be residents who have graduated without writing the anaesthesia records!

There is no question that these systems provide more detailed access to patient's medical history and previous anaesthesia records. But when it comes to billing the patient it relies heavily on the manual override function in the software. No software can guarantee complete capture of every detail needed for the accuracy of the billing.

The real question that needs to be answered is, have these automated systems impacted the quality of care provided to the patient? There is no doubt that they reduce the workload of the anaesthesiologist and capture a far more and detailed, concise data. But having this data in possession does it necessarily mean we are giving better care to the patient? As these systems are expensive does the expense really justify its usage? Or is it adding one more layer of expenses to an already expensive system?

Unless these questions are answered by more conclusive evidence which is lacking at this point in time these systems will remain expensive toys in the hands of a select few instead of a change whose time has come, especially so in a resource limited country like India!

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Conflicts of interest

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