development and assessment of a computer-based preanesthetic patient evaluation system for...

8/13/2019 Development and Assessment of a Computer-based Preanesthetic Patient Evaluation System for Obstetrical Anest

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/111erM1icMI Je> . fUlf /Clinical M1.mitc>ri111 111111 Computing 00: I ~ . 1998. 1998 Kl,,,wtr At: '1tt1tlc Pll/>li htr.t. Printed in the Nrthcrlondt. l

Development and assessment of a computer .based preanesthetic patientevaluation system for obstetrical anesthesiaDaniel J. Essirt 12, Raffi Dishakjian1, Vincent L. deCuitiis1, Cecelia D. Essin4

)C.. Stephen N. S t e e n1 Department o Anesthesiology, Martin Luther King Hospital, Drew Universiry, and Departmants o/2 Informaticsand 3 A.nt.Tth11siology, LAC+USC Medical Center, Los Angeles, CA, 4 Magan Medi.cal Clinic, Covina, CA., USA

PU: ~ I fh(Received ..... : Accepted in tlntll form .....) t rKey words: computer, preanesthetic evaluation, obstetrical anesthesja ~ J . ~ r - - : . . . . .

h-.J . ~ . . 1; _AbstractComputeriz.'ltion of the medical record in various outpatient settings has been sue' ~ ~ t t fi{ ~ r , ~t k ~ J ~ . : - - ~ )the prtopet ative visit differs significantly. This study implemented a computerized version of a sttuctured preanesthetic evaluation question.naire that we had previously developed and which provided a starting point fordeveloping a suitable vocabulary and workflow. Using the computerized versiOll, pre.anesthetic evaluations weroperformed on 26 obstetric patients ovel a 20-week period. The introductionof a computer into the physician-patientrelationshipdid not disrupt the examination. It markedly reduced time-consuming tasks (such as dictation), cap t ufar more detail than found in our previous dictated and handwritten notes and provjdes immediately available ofdata for quality assurance activities.IntroductionThe preanesthetic evaluation of the patient pro'/idesvital infonnation that influences the selection of anesthetic agents and technique as well as identifyingpatients that may require special precautions ejtherpre. intra or post-operatively. The importance of thisexamination is underscored by its frequent use a a quality or accreditation indicator. Perfonning and documenting a thorough evaluation is especially chaJleng.ing in the obstetric setting. The situation is frequentlyemergent, increasing the likelihood that the examiner will fail to as k all pertinent que tions and/or willfail to include sufficient details potentially resulting inambiguo\ls information.Even if the appropriate information is elicited, timepressure contributes t0 illegible and incomplete exam.ination records. When coupled with the well-knownproblems of retrieving medical records in general, clinicians are frequently forced to rely on memory or to

m a n a ~ e the patient in an information vacuum. Absenceof complete documentation may compromise I.he abil

ity of other members of the medical team to properlyinterpret the condition should complications develop.It is our hypothesis that Jack o structure, both ofthe infonnation to be gathered and in its storage, isthe cause of the current state of infonnation qualityand availability. Although it is :nee4SSuy to indlvidwualize each e ~ a m i n a t i o n , there arc many elements ofinformalion that are 'requited' to be collected. eitherbecause of a medico.legal documentation requirement.an institutional policy or quality wurance activity orbecause it represents the 'standard of care.' Typically,the practitioner is ex.peeled to remember, and faithfullycomply with, numerous documentation requirements.This is the origin of the hondreds ofpaper fonns foundat most institutions. Havi.n; recorded the informationon pa.ptr, it immediately becomes inaccessible \lnlessone can obtain the chart and read and reinterpret thematerial contained within itComputerization offers an obvious opportunity toadd additional structure to the information creationprocess [l] as well as tl1e information s t 0 r a g ~ process.It ~ h o u l d be possible to use structured infonnation toguide the encounter as well as improve the legibH-


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2T a b l ~ I CQmposition of OS PrcOp Exam Notes by CategoryCase Age ASA # ASSESS COMP CONS GEN HX LAS NEWS NPO PHYSICAL PLAN REASON REV SOCIAL SURG

Pacts (DX) SURV RES STAT EXA. vt FOR ANES OF HX /ANESSYS HX

246 27 2 116 4 41 8 40 4 9 8253 32 2 49 20 20 2 j 3255 34 2 55 2 3 23 20 2 3 I260 :Zl 2 61 2 3 20 4 2 18 2 3 3 4261 26 2 62 2 3 26 21 2 3 3 1264 28 2 62 2 3 24 2 21 2 3 3265 20 2 66 2 3 25 2 21 2 3 3 4266 21 2 58 2 2 22 2 1 21 2 3 3268 39 3E 137 4 2 58 2 2 51 4 6 6 22 6 ~ 27 2 61 2 3 21 4 18 2 3 3 4271 2S 2 73 2 6 l3 9 10 > 5 21274 34 2 145 3 l 8 20 30 26 3 10 39:Z?S 58 na 103 2 5 8 16 13 27 s 5 17 5277 20 .,. 74 2 2 26 3 26 3 3 7278 19 2 65 2 3 5 2 24 3 3 I279 28 na 63 2 3 24 23 2 3 .. 3 I280 32 na 63 2 3 24 2 19 . 3 3 4ZS 20 ti.ii SS 2 3 23 2 18 2 3 3 I282 34 2 61 2 3 :.:6 2 19 I 3 3 I283 38 2 67 2 3 26 2 21 2 3 3 4284 32 na 6S 2 3 24 3 20 2 3 3 43S 30 2 63 2 3 22 2 18 2 3 3 7

Case lmern:ill y i l i i ~ i g o e d ID LAB RES of Lab r e s u l t ~ nolt'dAge Patieot's Age in year; NEWB # of Eotrie$ about babyASA ASA Classification assigned NPOSTAT of Plan items about(na not available) oral in1;.JceFacu To lll number of infonnatio1' PHYSICAl., SXAJvt # of Pliysical Findiagsclements induded in noteASSESS(DX) of C tltnes lh:it assen a diag losis PLAN # of treatment plan itemsor a..-.. IC . s the patient's conditionCOMP of enlrics doc\lmcnti.ng a REASON 'FOR ANES o entries describingc..omplkation the patienfs r c a . ~ o n fofrequiring anest Jcsia servicesCONS # of Clltrics making up the REV OF SYS # of enlries comprising theconsent Review of SysiemsGENSURV of cntr:ics aoout patient's SOCIALHX # of entries descriNng thegeneral health a.nd habits p;\tient's social historyHX II of 01111cs about the paoent's SURO/ANES KX II of n i r i e s detailing patient's

i m m c r l ~ e m e , 1 , , ~ ~ history prior ~ u r g c f i c s and ancsU ctJcsLegend: Ddi.nition of r i p t i v c statistics and the major subject headings of the examination

1ty and retnevability of tl1e records. Othei; potentialuses of infonnation structure in this way are l) prov1de reminders to clinicians about relevant details, 2)standardize the mforrnanon collected and 3) pmvideexpanded access tc_i lhc information when the chart isnot readily accessible.

Since our hypothesis involves the interactionbetween infonnation systems and people, it cannotbe tested in a theoretical setting and several additional q\lestions arise. C;JJ'l a computer be introduced intothe physician-patient interaction without disnipting theexammation? ls it possible to customize a computerized patient record system to the special nc.eds


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(Figure 1 - Sample Computer Generated RecordPATIENT IDENTlFICATlON 285. 06/15/96@ 10:29INDICATION FOR ANSTHESIA CONSULTATION: CESAREAN sgcTION.DATE OF PROCEDURE: 0 6 1 1 ~ l 996INDICATION FOR C-SECTION: PRIOR CESAREAN SECTION /DECREASED AFIHISTORYPAST OB - EGA 41 WEEKS BY DATES. PRENATAL CARE SOURCE: HUBERT HUI\1PHRY.GRA \ IDA l, PARA 1, ABORTIONS 0, STILLBIRTHS 0. PRIOR C-SECTIONS l.CURRENT OB - NOT IN LABOR PRESENTATION, VERTEX. GESTATION, SINGLETON.MECONIUM, NONE. MiNIONITIS, NO. AMNIOINFUSION, NOPAST MEDlCAL BJSTORY - HEART DISEASE, NEG. MORBID OBESITY, POS. HYPERTENSION,NEG. DIABETES M'.ELLlTUS, NEG. NEUROLOGIC DISEASE , NEG. RENAL DISESE, NEG.BLEEDING DISORDER, NEG.

CURRENT MEDS NARCOTIC USED: NONE.ALLERGY BX - NO KNOWN DROG OR FOOD ALLERGIES.SU.R.GICALJANESTHETIC HISTORYLAST REGIONAL ANESTHETIC - SURG CAL PROCEDURE C/S FOR MACROSOMlA, 1994.COMPLICATION, NONE.LAST GENERAL. SURGICAL PROCEDURE OR.IF RLE, 1991. COMPLICATION, NONE.SOCIAL HISTORY - TOBACCO SMOKING, NO. ALCOHOL, NO. ILLEGAL DRUG USE, NO.

LAB RESULTSHCT, 37.2 %. PLATELETS, 149 X 1000/L.

l BYSICAL EXAMGENERAL- ALERT. ORIENTED. COOPERATIVE. AWAKE. HYDRATION: FAIR. RESPIRATORYDISTRESS: NONE.VITAL SIGNS - WEIGHT, 98 KG. HEIGHT, 152 CM. BP, l 14172 ?\1M HG BY CUFF. PULSE, 87 MIN.BREATHJNO RATE, 18 IMJN. TEMP, 98.9 FARENHEIT ORAL.AIRWAY ASSESSMENT MALLAMPATr CLASSIFICATION CLASS II, UVULA PARTIALLYVISUALIZEO. NECK MOBILITY FAill.. MANDIBULAR SPACE GOOD. MOUTH OPENING 3FINGERBREADTH TEETii PARTIAL UPPER DENTURES AND MULTIPLE MISSING CHIPPED.NECK - SUPPLE, WITH FULL RANGE OF MOTION. NO TIIYRO:MECALY, PALPABLE MASSESS, TVOOR TRACHEAL DEVIATION.LUNGS - Clear breath sounds in all areas. moving air well without retraction or increased respiratory effort.}HEART - Regular cardiac rate and rhythm. Quiet precordium. Normal S1/S2, No murmurs, 1luills or gallops.ABDOMEN Soft, gravid, without guarding or tenderness. No organomcgaly or Ina$ses. No epigastiictenderness Soft, nondistended, without gutnsat.ion in all c:->lremities. Cranial nerves II-XUgrossly intact, without focal neuroloi;ical signs.NPO STATUS- LAST PO INTAKE MORE THAN 8 HRS AGO.ASSESSMENT - ASA STATI.JS II. SECO:NDARY TO DELAYED GASTRIC EMPTYING MORBID

OBESln .PLANANESTHETIC PLANNED: SPINAL.POST-OPERATIVEPAIN MANAGEMENT: SPINAL DURAMORPH.CONSENT - FOR REGIONAL ANESTIIESIA Wlni GA BACKUP. PATIENT AW A.RE OF POSSIBLE COMPLlCA"flONS fNCLUDING, BUT NOT LIMITED TO, HYPOTENSION, H/A, SEIZURES, PARESIBESIA,TEMPORARY NmABNESS, FAILED ANESTHET1C, RESPIRATOJW /CARDIO-VASCULAR. COLLAPSEAND DEATH. CONSENT OBTAINED THROUGH INTERPRETER. THE PATIENT UNDERSTANDSTHE RISKS vs. BENEFITS OF nm ANESTHETIC AND CONSENTS FREELY.

Frgwe I ~ m p l c c o n 1 p \ l t ~ r gcncra.1co record.

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4the obstetric pre:mesthctic setting? Wlll the output beacceptable for inclusion in the medic:al record? Clinicalexperience in various outpatient ambulatory settingshas been positive (2, 3] but the natme of the work doneby anesthesiologists and the details of the preoperativeclinical setting differ significantly from that found madoctor's office or clinic.

The Martin Luther King/Drew University MedicalCenter Department of Anesthesia, as part of ts ongoingquality improvemem activities [4], decided to explorethe feasibility of introducing a computerized p1eanes-thetic evaluation into its Obstetric Anesthesia Service.This study attempted to answer three questions: l)could the computer program be customized for useby anesthesiologists without requiring programmjngor an extcm;ive technical background, 2) could theprogram produce relevant clinical notes, and 3) wouldt.he process of inte.rncting wit11 a computer during thecourse of the examination be acceptable to the physician both in terms of the time requirement and thea c c t ~ p t a b i l i l y to the patient?

Materials and methodsA preliminary c o n ~ i d e r a t i o n of these questions suggested that a computer prograrn would have to be extensively customizable, be capable of running on lightweight ponable equipment, able to function without akeyboard and to produce printed output acceptable tothe Medical Records Department. In order to conducta clinical trial to test these concepts, we stlected acommercially available electronic medical record pro-gram (01arlWarc, ChartWare, Inc., Rohnert Park,CA) and a self-contained pen-based computer weighmg Jess than 5 pounds (Toshiba T200, Toshiba Ame.ricaCorp., Irvine, CA).if s euc of us ( ~ D ) had previously preprued a struc( < i i o tured (paper) preanc lthctic questionnaire. This foml' , served as the starting point for developing the vocabulary that was used in the computer program. Aftereach iteration of the vocabulary development process,the resulting program was used in several cases. Thisactivity served to demonstrate that using the application during a patie.nt encounter was acceptable to boththe patient and the physician. 1'he preliminary experience wa.


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100go

J 80c: 7060-;; Q4()i 30100

Cumulatlvo Fl'QQllOny Dlotr1butlon ofChal'tlng O\lratfon

n 11 6353, moclo 3.1, mvdlan 4.3, mean= 5.7

_. . ....

// -

j0 25

--

Figur z Data on 6353 consecutive. computcr-charo:d primaty careencounters (ti - 6353, mode - 3.1, median mean - 5.7).

scnted in Table 2. The printed output from the programhas beeo approved by the Medic.il Records Department for inclusion i.n the patient s permanent chart. Asample of tl1e content included in a typical record ispresented in Figure l.

Discus.4lionEarly in the :>tudy, substantial time was required tocomplete a note as the investigator was spending timeto learn tht process, evaluate and revise the structure ofthe vocabulary and devise a workftow that could incorporate the computer interaction. The time required tocomplete the final 8 cases averaged 12.0 minutes. TI1istime included entering rhe patient demographic information, examining the patient, and interacting with theprogram. Other data indicate that with additional experience most notes can be compleced in under 5 minutes(Figure 2).In an institutional setting, the time and workrequired by the physician could be reduced further1f the patients identifying information were obtainc.dfrom a pre-existing. registration or billing system. Similarly, any requests for lab work or radiological studiescould be extracted dh ectly from the physicians notesand tn111smitted to the appropriate ancillary department, eliminating the need to 1nake duplicate entrieson order sheets. Such an approiich would also decreasethe time required to initiate the required studies anddecrease the possibility of clerical transcription errors.We observed several points with regard to the.amount of time and effort required on the part of the

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aJ1C thi:siologist. First, most practitioners require theexperience of doing 50-..75 notes before proficiencydevelops and the average time drops to the 3-5 min11terange (Essin D: Pcrsunal Communication; August1996]. Second, part of the time used to complete thenote was used to create the treaunent plan (orders) andto obtain and document the patient s consent. In traditional settings, such as those in which physician notesare dictated, these time consuming tasks are frequentlynot factored into the estimate of physician effort. Thecomputer program provides a painless and automatedway to insure that these tasks are completed. Third,in the experience of the authors, the amount of detailcaptured in these notes far exceeds that of the typicalhandwritten or dictated preop note at our institution.We also note that in our institution there tendsto be abundance of automated monitoring equipmentavailable in the critical ca.re areas. For this reason, inrecent years, the availability of adequate recordsof thephysiological status of the patient during surgery hasimproved significantly. This aspect ofpatient care documentation continue.s to attract considerable attentionand funding and the capabilities will only increase inthe furore. The one component of care that has defiedautomation has been the capture and storage, in rcaltime, of the observations and evaluation of the patientmade by the physician. Even otherwise sophisticatedsignal processing applications [SJ, for the lack of anautomated capture process for physician bservations,are frequently reduced to employing hand copying ofhandwritten notes in order to capture the clinical background material necessary for proper interpretation ofthe biophysical signals and measurements.

Conclu5ionsWe have been able to introduce a computer into thephysician-patient interaction without disrupting theexamination and were able to customize a c;omputerized patient-record system to the special needs of theobstetric pre-anesthetic sccting. The output is acceptable for inclusion in the medical rec;ord.The hypotheses that were being t e ~ t e in this tudywere formulated on the ba5is of successful applicationof this approach to charting in other clinical specialties.We were able to confirm that they are equally applicable to the area of obstetric anesthesia. The program, asconfigured, is vers;itiJe, inexpensive, reliable and easyto use. It provides a mechanism for introducing guidelines mto the evaluation process and insures that the


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6infonnation that is collected will be standardized. Thiswill aid in our future Quality Assurance and QualityImprovement activities.

On the basis of these results. we are conducting asimilar exercise in the gene.ral preoperative clinic. ItIs our long-range objective to compile a record of ourpatient care activities that spans temporal and organizational boundaries that are now common in our institution. We would like the records generated in the preoperative and pain clinics and the initial evaluationsperformed in the trauma center, the pen-operative dataand physician obser;ationsand followup examinationsaud treatment to all be stored in a similar format andaccessible both for patient care and research. It seemsinevitable that each of these settings will employ different types of critical care and rnonitori.ng equipment.We would prefer to treat the monitoring signals. imagesand other mechanically acquired data to be adjuncl.;;or addenda to the longitudinal comprehensive medical record rather that the cum:nt situation where eachpie.ce of specialty equipment duplicates i t ~ own smallpiece of the medical record leaving it to the physician tolocate, retrieve and integrate the infonnahon necessaryto care for the patient.

AcknowledgementsTI1is study was partly supporled by a gram from theS.M.A.R.T. Foundation.

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ReferencesI. Essin DJ. Intelligent l ' r o c c ~ 1 n g of o o ~ c l y s i : n 1 ~ n 1 r e < i d o c u 1 1 1 ~ n 1 . sas a strategy for orsanuing c:lrx:trortlc health care records. Methods of Infonnation in Medicine, 1993: 3 2 ~ 6 ~ 82. Essirl DJ. Introducing a genetalil.:ed multiple-choice q11estion

~ o r i t h m into adatllbase u:;cr-intrrface. in software engint.t ringin medical infonnatics. IMJA International Medical Informatics Association) series on Mwical Informatics. Elsevier, 19923. Essin DJ, Lincoln TI... Implementing a low-c.os1 computtrbased~ t i c n t record; A controlled VOC

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