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|Year : 2007
: 10 | Issue : 1 | Page
|IT empowered anaesthesiologist
Department of Anaesthesiology, Escorts Heart Institute and Research Centre, New Delhi, India
Click here for correspondence address and
|How to cite this article:|
Karlekar A. IT empowered anaesthesiologist. Ann Card Anaesth 2007;10:13-8
| Year 1977: 'Finger on pulse monitoring era'|| |
Mr. ABC, 46 years old man was advised surgical repair of right inguinal hernia. During preanaesthetic evaluation, he was found to be a known asthmatic and had suffered an uncomplicated myocardial infarction few months back. The surgery was planned under regional block. Intraoperatively, the only monitoring he had was anaesthesiologist's finger on his pulse and periodic blood pressure measurements.
During the course of surgery, he developed hypotension, and required a vasopressor, which worsened the existing tachycardia. His condition deteriorated over next 30 minutes despite further medications including a beta-blocker. He became breathless and required assisted ventilation, not to forget the difficult endotracheal intubation that cost him one tooth, hoarseness and a sore throat that lasted several days. He had to be transferred to ICU following surgery, and was eventually diagnosed as having suffered another myocardial infarction. His hospital stay had to be extended by 2 weeks.
| Year 1988: ' Multi-channel graphic display monitoring era'|| |
Mr. ABC reports to Emergency room with chest pain and breathlessness. He goes through cardiac work-up, and remembers that he felt sick during angiography and was told by the doctor that he was probably allergic to the dye. He was advised surgical revascularisation. Coronary artery bypass grafting (CABG) was performed successfully though not uneventfully. The event happened to be the difficult endotracheal intubation again, since neither the earlier discharge summary nor Mr ABC himself had warned the anaesthesiologist in advance about the history of difficult intubation .
The intraoperative monitoring appeared to be a quantum jump from what it was 10 years ago. A sleek monitor with bright display of continuous electrocardiogram (ECG), direct arterial blood pressure and pulmonary artery waveforms in different colours along with numerical values and selective audiovisual alarms for different parameters, seemed to successfully keep the concerned personnel 'well informed' and on alert in the operating room (OR).
Mr. ABC had frequent ventricular ectopics after being weaned off the heart lung machine. He developed severe bronchospasm following a small dose of beta-blocker that necessitated postopective ventilation for 48 hours. He was put on steroids besides bronchodilators and nebulisers. The antibiotics were continued for 3 additional days and he was finally discharged on 14th postoperative day instead of expected 10th day.
| Year 1999: 'Arrival of Electronic Patient Records'|| |
Mr. ABC reports for his routine follow-up. He did, however, notice that this time history taking appeared little more detailed and that his replies were being keyed into a laptop that the doctor was carrying. The doctor also clicked a photograph from a small camera attached to his laptop. Mr. ABC was given a plastic card with his photograph, demographic details, blood group and even a small strip of latest ECG. A bar-coded registration number was meant to be read quickly for connecting to the server.
The difference was that papers were being replaced with electronic records. Actually the doctor created an electronic folder for Mr. ABC on the computer network this time: an Electronic Patient Record (EPR), thanks to a Hospital Information System (HIS) that the hospital had acquired. The opening screen of EPR had demographic details of Mr ABC, his photograph, list of diagnoses and a not to be missed section marked "ALERTS" that prominently displayed in red:
- Allergic to radio-opaque dye.
- Metallic implant in the right femur.
- Asthmatic: avoid beta blockers.
- Difficult endotracheal intubation.
Another section on one side of the screen had a 'menu', which basically provided hyperlinks to other details. Some of the options were:
The advantages of the electronic folder couldn't have been missed by any one. One look at the summary would simply outline patients' clinical condition at the last visit. The details could be found under relevant sections. The lab results were all there in chronological sequence, and could be seen as cumulative graphics as well. Medications advised to the patient were all neatly and legibly displayed with details like the date of starting and discontinuing, if applicable. The folder was accessible across the hospital network as well as on the Internet, if so desired and consented by the patient. In addition, it could be copied on a portable storage device as well, and could be carried on person, particularly when travelling outstation. He was very happy to learn that efforts were on to make all this information available on his 'smart plastic card'.
| Year 2003: 'The era of Artificial Intelligence and Decision Support Systems'|| |
Mr. ABC noticed that off late he was having pain in legs on walking, and one night he just fainted. His family members rang up the hospital, the doctor in emergency asked for the registration number. On entering the number, patient's EPR was just a click away. The doctor incidentally had attended to him during his previous visit and recognized him straight away as he saw Mr. ABC's photograph on the screen. The doctor wasted no time in advising the family to transfer Mr. ABC to the hospital.
The doctor alerted the critical care unit and cardiac catheterisation laboratory. By the time patient arrived, the doctor had reviewed his history, X-rays, and 'the moving images' of echocardiograms and angiogram by navigating through the hyperlinks on his EPR. The image viewing was possible with the help of PACS (Picture Archiving and Communication System). On arrival, he was rushed to the emergency room, where this time his son just flashed the plastic card. On previous occasions they had to lug around disorderly heap of worn out papers like discharge summaries, out patient department (OPD) prescriptions and X-rays, that had changed colours in last 25 years, and would usually take hours to lay them in some intelligent sequence to make any sense out of them. The ER reception just punched his ID, and all his clinical details appeared on the screen, including alerts.
Eventually, he had to go through another workup but he noticed that 'things were moving more smoothly' and there were hardly any papers being carried around. He wore the ID card around his neck, and whichever laboratory or station he was ushered in, a sensor attached to the local computer identified him instantly, obviating the need for him to even tell his name. His wristband also had his unique number printed on it, in case he had to remove the ID card like in X-rays or OR complex. While initially he thought all this automation was going a bit too far, it was actually an anaesthesiologist who explained how this system would ensure that, even anaesthetized patients with identical names, would never get mixed up, like it had happened to a celebrity's mother in a reputed hospital. He didn't have to wait too long outside the laboratory, since he was called only 10 minutes before the procedure, thanks to 'electronic queuing and communication'. He had reluctantly agreed for the angiography but did not experience any discomfort this time. He could see that the computer screen did have a blinking message "Allergic to dye" and doctors used an alternative. When he was taken for imaging studies, he noticed a different message 'metallic implant in the right femur' was flashing on the screen. He undoubtedly felt more reassured.
He was told he had blockages in the blood vessels to his brain and legs and that he would need surgery. While the memories of a tube in his trachea on the earlier occasion and extended stay in the lonely recovery room during last surgery did send shivers down his spine, the visit of the anaesthesiologist made quite a difference. In the first place, the anaesthesiologist appeared well informed. The anaesthesiologist seemed aware of Mr. ABC's past illnesses and complications including difficult airway management. The anaesthesiologist was also entering the data into his laptop. As soon as he selected "carotid endarterectomy (CEA)" as the proposed surgery, the screen flashed a message "isolated or combined". When the doctor selected "isolated"; the screen asked another query "consider regional analgesia?" The doctor once again clicked "yes", which was followed by a checklist that helped him examine and discuss the feasibility of a regional analgesic technique. It prompted him to do a sensitivity test for the anaesthetic agent. Before leaving, he wrote "prepare for CEA under regional block", which triggered a set of instructions for the nurses, including application of a gel on the site under occlusive dressing about 45 minutes before scheduled time of transfer to OR. Preset clinical pathways ensured that no detail, howsoever minor, was ever missed.
On the day of surgery, as soon as the sister incharge assigned the OR for him, the thermostat got reset to warmer temperature since the procedure was to be performed under regional technique. The special trolley for 'Difficult Endotracheal Intubation' was kept in readiness and an experienced anaesthesiologist was assigned the case. In the OR, the anaesthesiologist set up continuous ECG and direct arterial pressure monitoring, and hooked the patient monitoring system to the computer. The computer screen was showing electronic anaesthesia record,  where the output from the monitor was on display and being saved real time. Occasionally if the values were outside a specific range, the screen would prompt the doctor to validate the data before saving it. The induction time, incision time, clamp time, shunt time and other events were appearing one after another on the screen. The doctor had to just touch the screen to accept that, or he could write with a special writing device on the 'tablet', a computer, which accepts, inputs directly. The record keeping appeared more authentic yet simple to chart, thanks to it being intuitive and user friendly.
As the operation progressed, Mr. ABC did not feel pain but he felt suffocated and gradually became more and more restless. The monitor recorded an increase in heart rate and blood pressure. Apart from usual audio alarm, the pathways flashed:
- Rate pressure product nearing threshold for ischaemia
Mild sedation failed to calm him down. It was then the anaesthesiologist decided to start propofol infusion. He selected the labelled mount fixed on an infusion pump. When he loaded the pre-filled labelled syringe, he had to swipe the barcode of the label and match it with barcode of the mount to start the pump. This ensured that the drug was identified before it was administered to the patient rather than recorded in to the system post administration.  The infusion rate too was calculated by the system based on the weight, which had been entered in the EPR. The anaesthesiologist of course had the option to accept or alter the rate suggested.
On one occasion, the ST segment analysis detected elevation, "suggested pathways" automatically offered options, after an alert "Patient known case of ischaemic heart disease":
- Sedate, reassure
- Raise blood pressure
- Sublingual nitrates
- Start nitroglycerin
- Lower heart rate
- Do not use beta blockers: known asthmatic
- ? Intra-aortic baloon pump: Peripheral vascular disease
Similar checks were in place to cross check the blood bags before transfusion by barcode matching on the patient wristband and on blood bag fixed by the blood bank.
Incidentally this narration is not from a book on medical fiction. All this and more is not only possible but is actually happening. Human brain has always been at it, trying relentlessly to convert dreams into reality. Last three decades or so have seen some spectacular achievements in the field of medicine. The largest share of contribution for such seemingly impossible feats has been thanks to some rearranged atoms of sand and few other trace elements put together and called a silicon chip! The power and reach of this technology has revolutionized our working and thinking as well!
| What is IT ?|| |
"Information Technology" or IT as it is called, is a combination of software, hardware and mindware. Hardware is the physical form of machinery, or the computer, software are the programs, which run on the computers and mindware is actually the driving force, the vision that propels the technology to achieve the goals.
The bedside patient monitors churn out loads of data in bits and bytes; it is IT, which converts it into 'information'. The information can be pieced together to build 'knowledge', that can be used for 'decision making' ,, and minimize errors. Thus the journey that starts from data collection goes through storage, sharing, distribution, communication and intelligent analysis to convert it to information and knowledge. The success of these efforts largely depends on proper design, development, installation, implementation and finally 'continuous evolution' of the applications. IT based applications promise overall better quality of healthcare ensuring greater safety, high precision, decision support and automation.  IT applications have also helped in the development of technology that is more precise and less invasive.
As is apparent in the story of Mr. ABC above, many of the IT applications in healthcare have already taken off from the 'mind space to the realm of reality'. The progress in terms of IT' s possible reach and canvas of seemingly never-ending horizons is simply mind-boggling.
The 'digitization revolution' is set to empower anaesthesiologists too, like a few examples that are listed in the story. Though not directly involved in conventional prescription writing, the anaesthesiologists order and administer a vast range of medicines to their patients in the OR as well in critical care. According to 'Institute of Medicine' reports (1999 and 2006), medication errors leading to morbidity and mortality are common and every day happening across hospitals in the USA.  The shocking revelation has forced policy makers to look for practical yet reliable tools to tackle the problems of an inadequately informed physician (not fully aware of patient's condition/ diagnoses, allergies, other medications that patient may be taking, latest laboratory results and drug updates), miscommunication (illegible hand, similar sounding drugs, wrong units), and miscalculations. 'Electronic Prescription' holds promise by incorporating drug formulary into the order entry pathway known as CPOE (Computer Physician Order Entry) of the EPR. , It must be mentioned that some studies have reported new set of medication errors even through the CPOE route. ,
The incorporation of digital drug formulary to the EPR and Electronic Anaesthesia record 1 , if used effectively, will not only enhance safety for the patients, but would be a great help to the physician as well. Following are but a few examples of what a ready access to electronic drug formulary can possibly do:
- The prescriptions will be legible and complete. Pharmacists/nurses would not have to 'guess' as to what the physician may have meant before administering a drug prescribed by the doctor in the 'copyright' illegible hand. The physician while writing prescription will be forced to complete the details like strength, form, frequency and duration since all such fields would have been marked mandatory.
- It is humanly impossible for a physician to know all possible drug interactions while writing prescriptions. How many amongst us really know that amiodarone reduces clearance of digoxin, warfarin and metoprolol but not atenolol? And that one-half the normal lidocaine dose should be administered if cimetidine is being administered too, since the latter reduces the metabolism of former by 50%? We do commit such mistakes and society in general and patient in particular do pay a heavy price for such innumerable 'overlooks'. IT empowerment if used effectively may change all this. Whenever a physician is writing a prescription, if two or more drugs with known interactions appear together, the system will throw up a warning and thus avoid, may be a major mishap! It is imperative that physician should not only accept their own limitations against the power of computer, but adopt computer aided prescription writing even if it means deviation from an age old practice, some inconvenience and of course that little extra effort.
- The physician may not be aware or may not remember each time he writes a prescription, of special instructions that may have to be communicated to the nurse/patient for executing the order. How often a doctor actually remembers to tell his patient that allendronate has to be taken empty stomach with full glass of water and that he/she should remain upright for next 30 minutes, or that calcium supplements should not be ingested with fibre-rich meals. The application, by default, may give a print out of such instructions that must be followed, which not only enhance patient safety and improve outcomes but also help reduce costs.
- An anaesthesiologist during a preanaesthetic evaluation may come across unfamiliar drug names that patient may be taking. With the help of electronic drug formulary available on his laptop/local area network computer, he can instantly find all that he needs to know about the drug and plan the anaesthetic accordingly.
- With ever-increasing list of trade names, many physicians in the OPD do encounter medicines prescribed elsewhere that they may have never heard of. Empowered with ready reference to drugs and their trade names on his desktop, he doesn't have to feel embarrassed anymore trying to find out the composition.
- A ready reference to drug dosage and inbuilt calculator can eliminate simple errors of arithmetic, of decimals and zeroes, not uncommon in clinical practice.
- Checks can be built within the system, which do not allow over-dosage or wrong route of entry, as only the correct options would be available in the 'pull down menu' for the physician to select from.
- Cross checks within the EPR and prescription module can help avoid many clinical errors. If a patient's EPR has entries such as history of asthma and allergy to penicillin in relevant sections, whenever a physician inadvertently prescribes betablocker or penicillin, the system may not allow him to do so. It is believed that there are over 600 drugs that require adjustments of doses in the event of renal dysfunction. A case report published in this issue of the Annals of Cardiac Anaesthesia by Tiwari and colleagues highlights how rofecoxib when inadvertently prescribed to a diabetic patient already on acenocoumarin and metformin following valve replacement led to unacceptably high prothrombin time and lactic acidosis.  Agreeably all possible interactions between drugs may not be listed, but data collected when such an incident happens first time will eventually build the knowledge base and can be used to forewarn subsequent user.
- Attempts have been made to build IT based 'Intelligent Delivery Systems.  Entire patient related information from EPR can be fed to the delivery system that will then ensure through barcode readers and other monitors that the intended drug in correct dose, form, route and frequency is delivered to the patients. The 'program' can be further modified to work on feedback from the monitors about the intended response or lack of it.
- Recently O'Reilly and colleagues have reported effective use of information system to improve timely and appropriate administration of prophylactic antibiotics to patients in the ORs. 
- Systems have been built that also verify blood products cross matching information fed by blood bank with that of recipient's before transfusion can be unlocked and initiated.
The big question remains: are we ready for all this and more?
There are two-fold reasons for such applications not becoming commonplace. The first and foremost undoubtedly is the prohibitive cost. The industry must do a serious introspection and take measures to make such technology affordable. Bigger volumes do bring down the cost, and the industry must take the first step forward. Secondly, the doctors, too, generally resist any change in their work practices, more so when it demands of them to switch over to technology driven applications. Unless the initial inputs are entered correctly, the 'logic' based system will fail to perform. Whether it is techno- phobia or sheer inertia, doctors must conquer it and adopt the new technology, for that alone will deliver the cherished benefits to their patients and they shouldn't forget, to themselves. The technology has kept its promise of becoming user-friendly over last decade and a half, now it is up to us to exploit it fully and ensure timely healthcare delivery to our patients in a safe environment.
| References|| |
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|5.||Institute of Medicine: Reports 'To err is human': Nov.1, 1999 'Preventing Medical errors': Quality chasm series. July 20, 2006 http://www.iom.edu/CMS 2955.aspx . |
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|8.||The U.S. Pharmacopeia's 5th annual report. Dec 2004. |
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|10.||Tewari P, Nath SS, Mazumdar G. Increased prothrombin time and lactic acidosis: Rofecoxib drug interaction with acenocoumarin and metformin. Annals of Cardiac Anaesthesia 2007; 10: 58-60. |
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Department of Anaesthesiology, Escorts Heart Institute and Research Centre, New Delhi
Source of Support: None, Conflict of Interest: None