Clinical and practical requirements of online software for anesthesia documentation—an experience report
Introduction
As early as 1895, a formal documentation of an anesthesia procedure was made [1]. Since then, anesthesia documentation has been developed continuously and is now an integral part of anesthesiology.
At present, the documentation is mainly done on paper. Computer entry of this data is supported by machine-readable forms and/or done manually after the anesthesia. These methods are very time-consuming [2] and do not meet increasing quality requirements [3], [4], [5], [6], [7].
Another, presently less-used method of documentation, is automated online recording during anesthesia, including automatic data transfer from patient monitoring systems and connection to the hospital information system (HIS).
For effective use, an anesthesia documentation software should provide user-friendly, ergonomic interfaces for data entry and extensive evaluation of data. The criteria of the German society for Anesthesiology and Intensive Care Medicine (DGAI) [5], [8], [9] must be met. Also, safety against failure and the administration of the system during the hospital routine working hours must be ensured.
In 1994, the Department of Anesthesiology and Intensive Care Medicine at the Justus-Liebig University, Giessen, decided to implement an anesthesia information management system (AIMS). The requirements for such documentation software were put down in a developer’s document. At that time, no adequate commercial product was available to fulfil the high performance requirements, so we signed a co-operation contract with a software company for the development of the program for clinical routine use. Now, after 4 years of experience with the system, the time has come for a critical review and evaluation of the extent of our attaining the objectives.
Section snippets
The last version
The version NarkoData 3.0 of the anesthesia documentation software, installed in 1995, had initially been developed by the Department of Anesthesiology, Intensive Care Medicine and Analgesia at the University of Bochum (Klinik Bergmannsheil, Head of Department: Professor Dr M. Zenz) in co-operation with the company ProLogic GmbH (Erkrath, Germany) [10]. The original program recorded medical data during anesthesia and ran as a local application at the workstation. The software was disk-based and
Requirements
After a thorough check of the options provided by the initial version of the system, a set of requirements was set up for further development. Of particular value was the experience of daily administration and data management gained from the existing patient data management system (PDMS) Emtek 2000 (Siemens AG, Munich, Germany) at our operative intensive care unit (ICU).
In a brief abstract of the 150 page requirement document, the main demands are highlighted: The three most important aspects
Adaptation to anesthesia working procedures
The main function expansions of Version 4 are listed in Table 2. For more flexibility, this version is available for MacOS and MS-Windows based PCs.
The worksheet with its graphic user interface (Fig. 1) corresponds to the conventional paper report. It offers a permanently visible documentation of the complete procedure including the recovery room. Differences in color guarantee clear recognition.
The ergonomic and intuitive entry of data during the procedure, e.g. vital data, drugs given and
Routine use
On January 1, 1997, NarkoData 4 was implemented hospital wide. The change from version 3.0 to version 4.0 during routine clinical work did not cause any difficulties thanks to already established software architecture. From 1997 to 1999, 66 764 anesthesia procedures at 115 workstations were recorded with the new version (1997, 21 133; 1998, 21 216; 1999, 22 284; values refer to the database inventory on February 8, 2000).
Despite doubts and somewhat reserved attitudes of some staff members
Manual versus automated anesthesia documentation
Increasing requirements for performance and quality assurance predetermine future problems with ordinary paper documentation. This method will no longer be sufficient to record all relevant data. A large proportion of manually recorded data is full of mistakes, the quality is poor [12] and direct evaluation is impossible or very time consuming and requires manual search of the records.
With an automated online recording system and connection to the HIS, the presented documentation system is able
Conclusion
The joint cooperation of an anesthesiological department at a university hospital and a software company proved to be a suitable way to design an online documentation system. The realization of the main points of the requirement document enabled us to develop an anesthesia documentation system that supplies an exact, comprehensive and legible anesthesia record, along with an ergonomic data presentation for statistical use and an economical archive access.
References (25)
- et al.
Computerized patient anesthesia records: less time and better quality than manually produced anesthesia records
J. Clin. Anaesth.
(1993) - et al.
Effect of automatic record keeping on vigilance and record keeping time
Br. J. Anesth.
(1995) - et al.
Challenges and opportunities for computerizing the anesthesia record
J. Clin. Anesth.
(1994) - et al.
Harvey Cushing: his contribution to anaesthesia
Anaesth. Analg.
(1986) - et al.
Ergebnisse zur Verfahrensentwicklung und zum personellen Aufwand im Zusammenhang mit der Einführung qualitätssichernder Maßnahmen
Anästh. Intensivmed.
(1994) Empfehlungen der DGAI zur Qualitätssicherung: Kerndatensatz Anästhesie
Anästh. Intensivmed.
(1993)- et al.
konomische Aspekte in der Anästhesie
Anästhesiol. Intensivmed. Notfallmed. Schmerzther.
(1998) Qualitätssicherung und Datenverarbeitung in der Anästhesie: Kerndatensatz Qualitätssicherung in der Anästhesie
Anästh. Intensivmed.
(1993)- et al.
Eine Empfehlung zur einheitlichen Protokollierung von Anästhesieverfahren
Anästh. Intensivmed.
(1989) Form und Inhalt eines EDV-gerechten Anästhesieprotokolls
Anästh. Intensivmed.
(1993)