Electronic health records (EHRs) are essentially digital versions of a patient’s paper medical chart. By means of their organization and functionality, EHRs can be powerful clinical and administrative tools. Ideally, an EHR is a dynamic, comprehensive representation of a patient’s health. The EHR consolidates medical history, diagnoses, medications, immunization dates, allergies, images, as well as laboratory results. The information captured by an EHR is stored in a relational database with archival and backup capabilities, which supports simultaneous multiuser access. The electronic format is more organized and accurate compared to its paper counterpart resulting in a more efficient delivery of health services. In addition, EHRs offer evidence-based decision support tools for providers that can improve clinical outcomes and patient safety.
The implementation of EHRs in the United States has long been impeded by cost, lack of standardization among vendors, and issues of security and privacy. However, in 2009, the Federal Government began offering incentives to providers to encourage implementation of EHRs. The incentives are in the form of rebates or reimbursements based on a set of criteria called “Meaningful Use.” Under Meaningful Use, the Federal Government has defined a complete EHR system as containing four basic functionalities: computerized orders for prescriptions, computerized orders for tests, reporting of test results, and physician notes.
ANESTHESIA INFORMATION MANAGEMENT SYSTEMS
Anesthesia Information Management Systems (AIMS) is a component of the EHR designed to record the entire clinical encounter in both an efficient and comprehensive manner. As technology evolves outside of health care, the AIMS is better able to capture the tremendous amount of physiologic and pharmacological data generated during anesthesia. Multitouch interfaces, faster data retrieval, and intuitive design allow the AIMS to represent the data in a way that facilitate diagnostic and treatment decisions without compromising the anesthesiologists workflow. An AIMS is built within the EHR and synthesizes anesthesia-relevant data pulled from disparate systems, such as laboratory, billing, imaging, communication, pharmacy, and scheduling. The more complete and less biased documentation facilitates both clinical and management research. Realization of value from the AIMS requires additional expenditures of resources to adapt the system to meet specific institutional requirements.
Although financial benefits are the most attractive to the anesthesia department, there are many other facets of AIMS that can influence the bottom line of a medical system. In terms of actual monetary savings, three important areas of focus are reimbursement, operations management, and cost containment. By utilizing an AIMS the anesthesia department can capture more billable actions, including time units, line placement, and blocks. A more comprehensive billing system can lead to increased charges as well as decreasing the workload on the billing department, resulting in additional savings. By merging operational and clinical systems within a hospital, both staffing and resource management can be optimized. Features such as a real-time whiteboard can help reduce turnover time and predictive algorithms can maximize operating room utilization. Finally, ...