Anesthesia Record Keeping Needs to Change Healthcare Informatics is a growing field (Ben-assuli, 2015). Because electronic record keeping has been shown to improve quality, decrease medical errors, improve documentation and decrease cost, there has been a large amount of encouragement toward the adaptation of electronic health records (EHR) (Bloomfield & Feinglass, 2008). In 2003, the Institute of Medicine published a report that defined the core functions necessary in all electronic health record systems (IOM, 2003). The United States Government developed an Office of Health Information Technology to help support the implementation of healthcare technologies (Bloomfield & Feinglass, 2008). The Centers for Medicare and Medicaid established incentive programs for EHRs that include all of the Meaningful Use criteria in order to help increase the number of providers who use healthcare information technologies (CMS, 2013). Because of this, the number of EHRs are growing (Ozair, Jamshed, Sharma & Aggarwal, 2015).

Anesthesia documentation differs from other specialties in the medical field (Kadry, Feaster, Marcario & Ehrenfeld, 2012). Anesthesia providers monitor minute-to-minute physiological data, attend to surgical events and needs, as well as administer medication; all while documenting the anesthesia record (Kadry, Feaster, Marcario & Ehrenfeld, 2012 and Peterson, White, Westra, & Monsen, 2014). The anesthesia record contains documentation of the events that occurred throughout the anesthesia case (Wilbanks, Moss, & Berner, 2013). It needs to be an accurate display of the patient's responses to anesthesia and surgery, medications, and surgical events (Kadry, Feaster, Macario, & Ehrenfeld, 2012). It is vital that the anesthesia record be complete and accurate for billing and legal purposes (Avidan & Weissman, 2012). Historically, this record has been created by hand in hard copy, but there are limitations to documenting in this way (Wilbanks, Moss & Berner, 2013). Anesthesia providers can have recall bias because they are not charting at the same time as delivering patient care, and their records can be incomplete, illegible, lost, or difficult to use for extrapolating data (Kadry, Feaster, Macario & Ehrenfeld, 2012). Inaccurate or illegible charting can lead to decreased revenue (Wilbanks, Moss & Berner, 2013). Also, the need for manual recording of information has been thought to decrease the anesthesia provider's vigilance by diverting attention away from the patient (Bloomfield & Feinglass, 2008). Therefore, it is encouraged to use electronic anesthesia record keeping and Anesthesia Information Management Systems (AIMS) instead of hard copy documentation (Peterson, White, Westra & Monsen, 2014). In this paper, we will discuss the advantages and disadvantages of AIMS and reasons why adopting them into every anesthesia practice is necessary.

AIMS are electronic health records specialized for use in anesthesia (Ehrenfeld, 2009). AIMS differ from other electronic health records because the format is specific and more relevant to anesthesia (Lees & Hall, 2011). They allow for automated collection and storage of accurate information throughout the perioperative period (Ehrenfeld, 2009). AIMS specifically extract patient data, use algorithms to identify information beyond the normal range, communicate with the patient database (EHR), and create a storable record (Bloomfield & Feinglass, 2008). Along with automated data from machines, data can also be input manually with the help of touch screen features to allow faster documentation, and barcode scanning is used for medication documentation (Lees & Hall, 2011). Also, AIMS can interface with other software and EHRs, which allow for data previously entered to automatically be incorporated into the AIMS (Willbanks, Moss & Berner, 2013). All of these methods create the anesthesia record and information that can be used for other purposes such as research and billing (Peterson, White, Westra & Monsen, 2014).

The advantages of AIMS are vast. Kadry, Feaster, Macario and Ehrenfeld (2012) listed the benefits of AIMS to include "improved documentation, safety, quality of care, reimbursement, operations management, cost containment and research" (p. 157). AIMS are also superior to hand-written records because they capture data in real time as well as alert anesthesia providers to information outside set limits (Bloomfield & Feinglass, 2008). They also allow for information to be gathered from a number of patient databases, which leads to a more complete knowledge of the patient (Bloomfield & Feinglass, 2008). AIMS produce a clear and concise record and the automaticity of data collection allows for the provider to be more vigilant while administering anesthesia (Kadry, Feaster, Macario & Ehrenfeld, 2012). This leads to improved documentation, patient safety, and quality of care. There is a reduction of time spent charting and increased quality of the information recorded (Peterson, White, Westra and Monsen, 2014).

Patient safety...

These include "drug-dose calculations, drug-drug interaction checking, drug allergy checking and re-dosing reminders" (Ehrenfeld, 2009, p. 4). AIMS allow for templates, which are standardized documentation text blocks that "improve for application of best practices" and also enhances patient safety (Willbanks, Moss & Berner, 2013, p. 360). Real-time visual alerts can help remind anesthesia providers of important surgical details, such as antibiotic administration and tourniquet times (Peterson, White, Westra & Monsen, 2014). This helps improve patient safety and quality of care.
Most AIMS allow users to access information for research, management, and quality assurance purposes (Ehrenfeld, 2009). Because retrospective analysis of data can be performed with AIMS, quality improvement becomes easier, even allowing for feedback of the anesthetic (Hyun et al., 2012). Because AIMS automatically record information when adverse events occur, they are superior in helping to determine the cause of adverse events (Bloomfield & Feinglass, 2008). Bloomfield and Glass (2008) found that 18.7% of adverse events were documented with AIMS vs. only 5.7% when documented manually. AIMS have the ability to take large amounts of data and use research to validate it (Kadry, Feaster, Macario & Ehrenfeld, 2012). This is time consuming to do with hand-written records.

Although AIMS have existed since the 1980s and the benefits are clearly documented, the majority of anesthesia documentation continues to be performed by hand (Less & Hall, 2011, and Peterson, White, Westra & Monsen, 2014). Cost is one of the reasons for the slow transition to AIMS. The cost of purchasing and maintaining AIMS can be equal to 20-30% of purchasing new anesthesia machines per operating room (Less & Hall, 2011). According to Ehrenfeld, in 2009 the upfront cost for AIMS was $4,000-$9,000 per operating room plus $15,000-$40,000 for the AIMS server. Many hospitals and anesthesia providers do not believe there will be a return on their investment (ROI) by purchasing AIMS. In smaller practices, the ROI may not be recovered quickly enough (Lees & Hall, 2011 & Ehrenfeld, 2009). Because the cost of purchasing and maintaining AIMS is high in an already expensive healthcare setting, many hospitals have not started the implementation process.

Although upfront cost is a significant concern for many providers, ROI does occur and therefore, AIMS can help save money. The ROI can be retrieved through reduced drug costs, better scheduling processes, improved billing and reimbursement (Ehrenfeld, 2009). Bloomfield and Feinglass (2008) describe how many departments "reported cost-efficiencies that resulted from electronic data collection and the use of a simulation model" (p. 405). Because the cost can be recovered, AIMS are, in fact, cost-effective.

Acceptance is also a documented obstacle to AIMS (Bloomfield & Feinglass, 2008). Because anesthesia documentation has been created in hard copy for years, some anesthesia providers do not see value in AIMS (Lees & Hall, 2011). Documenting on paper is easy, and a usability gap is possible where AIMS are concerned (Kadry, Feaster, Macario & Ehrenfeld, 2012). There have been documented fears and discomfort about adopting new technology (Hyun et al., 2012). Lack of demonstration of quality improvement is also another reason anesthesia providers are reluctant to accept AIMS in their work setting (Bloomfield & Feinglass, 2008). Wacker et al. (2015) found that factors such as lack of use of the data and its relevance, as well as working conditions during data entry were barriers to the acceptance of AIMS. Although acceptance is a concern, Jin et al., (2012) found that satisfaction with AIMS improved within one year.

Concern for data integrity is another documented implementation barrier to AIMS (Peterson, White, Westra, & Monsen, 2014). Although AIMS automatically record information from monitors, anesthesia machines and infusion pumps, the information may not be accurate (Wilbanks, Moss & Berner, 2013). Data can be missing, time stamping can be inaccurate, and artifact can also be recorded on the anesthesia record (Peterson, White, Westra & Monsen, 2014). Wilbanks, Moss and Berner (2013) observed that there were inaccuracies in the anesthesia record with the use of AIMS. The inaccuracies were related to gas flow rates, where documentation of oxygen, air, and nitrous oxide were documented with an inaccuracy rate of up to 45%. There were also inaccuracies with regard to medication administration times, failure to change automated templates, and documentation of erroneous data (artifact) (Wilbanks, Moss, & Berner, 2013). Therefore, the anesthesia provider has to take time at the end of the case to review the record to ensure data integrity (Peterson, White, Westra & Monsen, 2014).

Even though there are some inaccuracies with AIMS, many studies have shown that documentation with AIMS produces more accurate…