Anesthesia and Technology - A Practioners Perspective

After lamenting my lack of input in my hospital's decision to transition to digital anesthesia records I was encouraged by a couple of the comments by CRNAs who were actively involved in the process when their facility made the leap a few years back. I have had some follow up communications with Shannon Scaturro who has agreed to share his experience over the past 10 years.

Shannon, you are about to upgrade the AIMS you have been using for the past 10 years, can you walk us through some of the stages you have passed through over the past decade ? (like anger, bargaining, acceptance, etc)

Our hospital was chosen as a beta site to implement Docusys, an anesthesia information management system (AIMS) nearly a decade ago.  The journey from implementation to the present day has been anything but a relaxing Sunday afternoon drive.  Most anesthesia providers settle into their practice and abhor change.  Our practice was no different.  We liked our paper records and saw no reason to fix something that wasn’t broken.  Change did not come easy.

Our system was developed by a local anesthesiologist and our hospital was a natural choice to serve as a beta site.  Serving as a beta site, however, meant we had the misfortune of “guinea pig” status.  I really think this was a major source of the lengthy adoption.  When the product was launched, as with any new product, it needed de-bugging and tweaks.  There were product specialists on site and immediately available for months.  Some would accompany you throughout the anesthetic.  They lived among us during this stage to constantly refine the system, work out bugs, solicit provider feedback on ways to enhance the system, and roll out updates.  As is also true with most CRNAs, everyone spoke their mind with complete, uncensored candor.  I think a few feelings were hurt during this time.  Most of the providers openly disliked having to accept a system they did not request, tend to a computer during a case rather than giving full attention to the patient, have product specialists pepper them with questions about improvements, and weave this new tool into their already comfortable practice.  In short, it was not welcomed with traditional Southern hospitality.

Dennis, I would describe the next stage of the journey like an arranged marriage.  The CRNAs knew the system was here to stay and they realized they needed to find a way to make it work.  While they realized the system was not going anywhere, a lingering discontent carried for a while until the two (Docusys and the CRNAs) got to know each other better.  Over the next couple years, the difficulties experienced during the beta launch and implementation gradually subsided and the psyche of the CRNAs improved.   Some had even begun admitting that they could see the benefit of an AIMS and preferred using our product over paper documentation.  The two were finally getting to know one another.

I cannot say that the journey from the staged marriage to present has been that coveted easy Sunday drive.  It could be better described as a Sunday drive with occasional pot holes.  However, the system has been fully accepted by the group.  It has become an essential tool in our practice and a data source for billing, compliance, quality initiatives, archiving, medication charging, documentation improvement, and chart reviews.  Everyone has fully adopted it into their practice, and now I get tantrums when the system is down.  For some reason, it is now difficult for a CRNA to do a case on paper rather than electronic.  Who would have envisioned this nearly 10 years earlier?

"Super users" is a term I'm hearing as we begin planning our transition. Can you explain what a super user is and what should be considered before committing to this new role ?

Personally, I still have mixed emotions about assigning “super user” status to any clinician- CRNA or anesthesiologist.  Again, these are my personal feelings, but anesthesia providers should be focused on patient care, not trouble shooting computer software or hardware issues.  In my pea sized brain, I cannot remove the notion that a vendor or hospital IT designee should resolve these issues, not us.  Having aired out my bias, there is a need for a few people in the department to have specialized knowledge of the AIMS.  Pot holes will show up from time to time, and having someone in the department who can rapidly fix an issue- while the other provider continues to deliver care- is reasonable and prudent.  Furthermore, when the system acts up at 0200 during your bring back CABG, you will have a hard time reaching the vendor’s clinical support line or the hospital IT department.

Now to answer your question:  A super user is a designee within the department who receives significantly more vendor training and use of the system than others.  The super user is the first person called when a system issue arises and can typically perform simple trouble shooting tasks.

If you are evaluating a system, insist that the hospital IT department have assigned super users as well.  They should be the first line of defense, not clinicians.

You are upgrading - what are you seeing being offered by the upgrades as an improvement over the original product ?

Much of the upgrade offerings have focused on functionality, integration, and intuitive work flow.  Given my limited experience, earlier AIMS products seemed to remain key stroke heavy, bog down users in manual entry, and drag a user through its designed flow.  Newer products seem to do a better job removing manual inputs, offer practical standardized documentation, and are designed more to follow the provider through their workflow.

Integration was a large part of our upgrade requirements also.  Like many hospitals, there are several different information systems throughout the building.  Anesthesia touches many departments in a hospital.   Having the ability to interface with lab, pharmacy, radiology, medical records, and other departments was crucial.  Any upgrade considered had to adequately address integration with these departments.

Any other pearls or words of advice to those of us about to begin the transition ?

While not complete, we are near the end of our evaluation process.  I replied previously to your article, “Digital Anesthesia Records- Will you have a seat at the table?”  It may benefit others for me to cross post my comments.

    ‘As part of the evaluation process, administration formed a cross-functional team consisting of CRNAs and reps from pharmacy, surgery, finance, administration, IT, and legal. Since anesthesia touches so many departments, we set out establishing priorities from the various functional groups and categorized those priorities into six groups: Integration, Accessibility/Availability, Longitudinal Data, Compliance, Support/Training, and Functionality.

Within these categories, we prioritized needs vs. wants. Of course, this is where the interdepartmental debates ensued. Our HIS is largely McKesson, our pharmacy IS is largely Pyxis, our radiology IS is largely Emageon PACS, our lab a different vendor, and our billing is handled with custom built software. Integration with the various departments was critical, and this rose to the top for everyone.

After establishing our priorities, we used the KLAS report, The Growing Market for Anesthesia Software: Liability, Integration and the Benefits of Adoption, to preliminarily evaluate vendors. An RFI was sent, and the dog and pony show followed. Product demos were done on site, with Q & A sessions following. As of now, we have narrowed our search to two vendors- McKesson and Merge. We are formalizing an RFP and hope to make a decision within the next several months. The process has been educational and enlightening, and as Dennis has asked, at least we have had a seat at the table.’

I’ll just close by emphasizing my last point- be at the table.  Every practice is different and every practice location is unique.  The hospital IT department will tell you how many terabytes of data the system can compute, medical records will tell you how great the system will archive your records, pharmacy will tell you how the system can eliminate lost charges, and the vendor will tell you whatever you want to hear, but only you- the anesthesia provider- can speak to the utility of it in your practice.  Engage in the process, accept its arrival, realize the benefits it offers your practice, and enjoy your Sunday drive.

Thank you for sharing your insights Shannon.