DEC 30 '97 0?

:51AM SMART FOUNDATION P,1/6

/111erM1icMI Je>,.,,fUlf <>/Clinical M1.mitc>ri111 111111 Computing 00: 1998.
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Development and assessment of a computer .. based preanesthetic patient
evaluation system for obstetrical anesthesia
Daniel J. Essirt
1

2
, Raffi Dishakjian
1
, Vincent L. deCuitiis
1
, Cecelia D. Essin
4
&
)C.. Stephen N.

1 Department of Anesthesiology, Martin Luther King Hospital, Drew Universiry, and Departmants o/
2
Informatics
and
3
A.nt.Tth11siology, LAC+USC Medical Center, Los Angeles, CA,
4
Magan Medi.cal Clinic, Covina, CA., USA
PU:-- "fh
(Received ..... : Accepted in tlntll form ..... ) Lt r
Key words: computer, preanesthetic evaluation, obstetrical anesthesja
h-.J'. . . 1;._
Abstract
Computeriz.'ltion of the medical record in various outpatient settings has been sue'
t>fi{
tJ (
the prtopet"ative visit differs significantly. This study implemented a computerized version of a sttuctured pre-
anesthetic evaluation question.naire that we had previously developed and which provided a starting point for
developing a suitable vocabulary and workflow. Using the computerized versiOll, pre.anesthetic evaluations wero
performed on 26 obstetric patients ovel" a 20-week period. The introduction of a computer into the physician-patient
relationship did not disrupt the examination. It markedly reduced time-consuming tasks (such as dictation), captu. J.
far more detail than found in our previous dictated and handwritten notes and provjdes immediately available of
data for quality assurance activities.
Introduction
The preanesthetic evaluation of the patient pro'/ides
vital infonnation that influences the selection of anes-
thetic agents and technique as well as identifying
patients that may require special precautions ejther
pre. intra or post-operatively. The importance of this
examination is underscored by its frequent use a a qual-
ity or accreditation indicator. Perfonning and docu
menting a thorough evaluation is especially chaJleng.
ing in the obstetric setting. The situation is frequently
emergent, increasing the likelihood that the examin-
er will fail to as"k all pertinent que$tions and/or will
fail to include sufficient details potentially resulting in
ambiguo\ls information.
Even if the appropriate information is elicited, time
pressure contributes t0 illegible and incomplete exam.
ination records. When coupled with the well-known
problems of retrieving medical records in general, clin-
icians are frequently forced to rely on memory or to
the patient in an information vacuum. Absence
of complete documentation may compromise I.he abil
ity of other members of the medical team to properly
interpret the condition should complications develop.
It is our hypothesis that Jack of structure, both of
the inf onnation to be gathered and in its storage, is
the cause of the current state of infonnation quality
and availability. Although it is :nee4SSuy to indlvidw
ualize each there arc many elements of
inf ormalion that are 'requited' to be collected. either
because of a medico.legal documentation requirement.
an institutional policy or quality wurance activity or
because it represents the 'standard of care.' Typically,
the practitioner is ex.peeled to remember, and faithfully
comply with, numerous documentation requirements.
This is the origin of the hondreds of paper fonns found
at most institutions. Havi.n; recorded the information
on pa.ptr, it immediately becomes inaccessible \lnless
one can obtain the chart and read and reinterpret the
material contained within it
Computerization offers an obvious opportunity to
add additional structure to the information creation
process [l] as well as tl1e information process.
It be possible to use structured infonnation to
guide the encounter as well as improve the legibH-
DEC 30 '97 07: 52AM :3MART rn'l
P.2/6
2
I. CQmposition of OS PrcOp Exam Notes by Category
Case 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 /ANES
SYS HX
246 27 2 116 4 41 8 40 4 9 8
253 32 2 49 20 20 2
j 3
255 34 2 55 2 3 23 20 2 3 I
260 :Zl 2 61 2 3 20 4 2 18 2 3 3 4
261 26 2 62 2 3 26 21 2 3 3 1
264 28 2 62 2 3 24 2 21 2 3 3
265 20 2 66
2 3 25 2 21 2 3 3 4
266 21 2 58 2 2 22 2 1 21 2 3 3
268 39 3E 137 4 2 58 2 2 51 4 6 6 2
27 2 61 2 3 21 4 18 2 3 3 4
271 2S 2 73 2 6 l3 9 10 (>
5 21
274 34 2 145 3 l 8 20 30 26 3 10 39 5
:Z?S 58 na 103 2 5 8 16 13 27 s 5
17 5
277 20
.,
. 74 2 2 26 3 26 3 3 7
278 19 2 65 2 3 25 2 24 3 3 I
279 28 na 63 2 3 24 23 2 3
.. 3 I
280 32 na 63 2 3 24 2 19
,.,
3 3 4 ..
ZS! 20 ti.ii SS 2 3 23 2 18 2 3 3 I
282 34 2 61 2 3 :.:6 2 19 I 3 3 I
283 38 2 67 2 3 26 2 21 2 3 3 4
284 32 na 6S 2 3 24 3 20 2 3 3 4
23S 30 2 63 2 3 22 2 18 2 3 3 7
Case# lmern:ill y ID LAB RES #of Lab nolt'd
Age Patieot's Age in year; NEWB # of Eotrie$ about baby
ASA ASA Classification assigned NPOSTAT #of Plan items about
(na not available) oral in1;.Jce
# Facu To!lll number of infonnatio1' PHYSIC Al., SXAJvt # of Pliysical Findiags
clements induded in note
ASSESS(DX) #of C!tltnes lh:it assen a diag!losis PLAN # of treatment plan items
or a..-..'IC'.'s the patient's condition
COMP #of enlrics doc\lmcnti.ng a REASON 'FOR ANES # o( entries describing
c..omplkation the patienfs fof
requiring anest!Jcsia services
CONS # of Clltrics making up the REV OF SYS # of enlries comprising the
consent Review of Sysiems
GENSURV #of cntr:ics aoout patient's SOCIALHX # of entries descriNng the
general health a.nd habits p;\tient's social history
HX II of 01111cs about the paoent's SURO/ANES KX II of detailing patient's
history prior and ancsU!ctJcs
Legend: Ddi.nition of statistics and the major subject headings of the examination
1ty and retnevability of tl1e records. Othei; potential
uses of infonnation structure in this way are l) pro
v1de reminders to clinicians about relevant details, 2)
standardize the mforrnanon collected and 3) pmvide
expanded access tc_i lhc information when the chart is
not readily accessible.
Since our hypothesis involves the interaction
between infonnation systems and people, it cannot
be tested in a theoretical setting and several addition-
al q\lestions arise. C;JJ'l a computer be introduced into
the physician-patient interaction without disnipting the
exammation? ls it possible to customize a comput
erized patient record system to the special nc.eds <)f
DEC 30 ''37 137: 52AM =.;MART FOUf'lDATI mj P.3/6
(Figure 1 - Sample Computer Generated Record
PATIENT IDENTlFICATlON 285. 06/15/96@ 10:29
INDICATION FOR ANSTHESIA CONSULTATION: CESAREAN sgcTION.
DATE OF PROCEDURE: 996
INDICATION FOR C-SECTION: PRIOR CESAREAN SECTION /DECREASED AFI
HISTORY
PAST 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, NO
PAST 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 HISTORY
LAST 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 RESULTS
HCT, 37.2 %. PLATELETS, 149 X 1000/L.
l'BYSICAL EXAM
GENERAL- ALERT. ORIENTED. COOPERATIVE. AWAKE. HYDRATION: FAIR. RESPIRATORY
DISTRESS: 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 MALLAMP A Tr CLASSIFICATION CLASS II, UVULA PARTIALLY
VISUALIZEO. NECK MOBILITY FAill.. MANDIBULAR SPACE GOOD. MOUTH OPENING 3
FINGERBREADTH TEETii PARTIAL UPPER DENTURES AND MULTIPLE MISSING CHIPPED.
NECK - SUPPLE, WITH FULL RANGE OF MOTION. NO TIIYRO:MECAL Y, PALPABLE MASSESS, .TVO
OR 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 S 1/S2, No murmurs, 1luills or gallops.
ABDOMEN Soft, gravid, without guarding or tenderness. No organomcgaly or Ina$ses. No epigastiic
tenderness Soft, nondistended, without gu<lrding or tendemcss. No organomegaly or masses.
EXTREMITIES - Wann, well perfused, without clubbing, cyanosis, or non-dependent edema.
NEUROLOGIC Normal tone, reflexes, strength and :>tnsat.ion in all c:->lremities. Cranial nerves II-XU
grossly intact, without focal neuroloi;ical signs.
NPO STATUS- LAST PO INTAKE MORE THAN 8 HRS AGO.
ASSESSMENT - ASA STA TI.JS II. SECO:NDARY TO DELAYED GASTRIC EMPTYING I MORBID
OBESln'.
PLAN
ANESTHETIC PLANNED: SPINAL.
POST-OPERATIVE PAIN MANAGEMENT: SPINAL DURAMORPH.
CONSENT - FOR REGIONAL ANESTIIESIA Wlni GA BACKUP. PATIENT AW A.RE OF POSSIBLE COM-
PLlCA "flONS fNCLUDING, BUT NOT LIMITED TO, HYPOTENSION, H/A, SEIZURES, PARESIBESIA,
TEMPORARY NmABNESS, FAILED ANESTHET1C, RESPIRATOJW /CARDIO-VASCULAR. COLLAPSE
AND DEA TH. CONSENT OBTAINED THROUGH INTERPRETER. THE PATIENT UNDERSTANDS
THE RISKS vs. BENEFITS OF nm ANESTHETIC AND CONSENTS FREELY.
Frgwe I, gcncra.1co record.
3
DEC 31J '37 IJ7: 53RM FOUt-mRT rm1
4
the obstetric pre:mesthctic setting? Wlll the output be
acceptable for inclusion in the medic: al record? Clinical
experience in various outpatient ambulatory settings
has been positive (2, 3] but the natme of the work done
by anesthesiologists and the details of the preoperative
clinical setting differ significantly from that found ma
doctor's office or clinic.
The Martin Luther King/Drew University Medical
Center Department of Anesthesia, as part of its ongoing
quality improvemem activities [4], decided to explore
the 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 use
by anesthesiologists without requiring programmjng
or an extcm;ive technical background, 2) could the
program produce relevant clinical notes, and 3) would
t.he process of inte.rncting wit11 a computer during the
course of the examination be acceptable to the physi-
cian both in terms of the time requirement and the
to the patient?
Materials and methods
A preliminary of these questions sug-
gested that a computer prograrn would have to be exten-
sively customizable, be capable of running on light-
weight ponable equipment, able to function without a
keyboard and to produce printed output acceptable to
the Medical Records Department. In order to conduct
a clinical trial to test these concepts, we stlected a
commercially available electronic medical record pro-
gram (01arlWarc, ChartWare, Inc., Rohnert Park,
CA) and a self-contained pen-based computer weigh
mg Jess than 5 pounds (Toshiba T200, Toshiba Ame.rica
Corp., Irvine, CA).
.if. "s euc of us had previously preprued a struc-
( o) tured (paper) preanc!lthctic questionnaire. This foml
' , served as the starting point for developing the vocab-
ulary that was used in the computer program. After
each iteration of the vocabulary development process,
the resulting program was used in several cases. This
activity served to demonstrate that using the applica-
tion during a patie.nt encounter was acceptable to both
the patient and the physician. 1'he preliminary expe-
rience wa.<; used to refine the vocabulary. After four
iterations it was kit that that the vocabulary was com-
plete and the program was used in M additional 8 cases
\ for confirmation.
'
.< to
. J
F'.4/b
Table i. /l.fajor struLtural componc:nts of the preanesthellC
exam
Category
Reason for
History
Social history
Lab results
cum
NPO

Plan
Consent
Con1plications
Newborn outc-omc
Topics

Cw-rent Ob
Past medical hhtory
CuTTent meds
Allergy Hx
re;ional ancslhctic
Last general
Other
General
Vital signs
Airway

Lunp

Abdomen
fatrc:midcs
Neurologic
Preanesthetic evaluations were performed on 26 obstet-
ric patients over a 20 week period. The patients ranged
in age from 19 to S8 years. None of the patients had
signi!icant anesthetic risk factors. Seventeen (77.3%)
of the patients were assessed to be ASA class II,
five (22.7%) had no numerical score assigned but had
entries indicating lhat the patient was class II and one
(0.5%) patient was class m. The number of infom1a-
t1onal items includcc.l in the examination record ranged
from 46 to 142 with a mean of 73. The m:tJor compo-
nents of the template that was used to guide the doc-
ument creation process appears in Table 1. A detailed
breakdown of U1c t:omposition of each exam note indi
eating which sections of the template were relevant and
how ma.ny facts were collected in each section are pre-
DEC 3D 97 D7: '53RM '=;MART FOUrmRTI ON
100
go
:J
80
c:
70
..
..
60 w
-;;
$Q
~ 4()
i
30
~
~ o
10
0
Cumulatlvo Fl'QQllOny Dlotr1butlon of
Chal'tlng O\lratfon
n 11 6353, moclo" 3.1, mvdlan "4.3, mean= 5.7
~
_.,.,,....
/
/
-
I
I
I
I
..
__ I
j
0 25
--
Figur( z. Data on 6353 consecutive. computcr-charo:d primaty care
encounters (ti - 6353, mode - 3.1, median ~ mean - 5.7).
scnted in Table 2. The printed output from the program
has beeo approved by the Medic.il Records Depart
ment for inclusion i.n the patient's permanent chart. A
sample of tl1e content included in a typical record is
presented in Figure l.
Discus.4lion
Early in the :>tudy, substantial time was required to
complete a note as the investigator was spending time
to learn tht process, evaluate and revise the structure of
the vocabulary and devise a workftow that could incor-
porate the computer interaction. The time required to
complete the final 8 cases averaged 12.0 minutes. TI1is
time included entering rhe patient demographic infor
mation, examining the patient, and interacting with the
program. Other data indicate that with additional expe-
rience most notes can be compleced in under 5 minutes
(Figure 2).
In an institutional setting, the time and work
required by the physician could be reduced further
1f the patients' identifying information were obtainc.d
from a pre-existing. registration or billing system. Sim-
ilarly, any requests for lab work or radiological studies
could be extracted dh'ectly from the physicians' notes
and tn111smitted to the appropriate ancillary depart
ment, eliminating the need to 1nake duplicate entries
on order sheets. Such an approiich would also decrease
the time required to initiate the required studies and
decrease the possibility of clerical transcription errors.
We observed several points with regard to the.
amount of time and effort required on the part of the
F'.5/o
5
aJ1C$thi:siologist. First, most practitioners require the
experience of doing 50-.. 75 notes before proficiency
develops and the average time drops to the 3-5 min11te
range (Essin D: Pcrsunal Communication; August
1996]. Second, part of the time used to complete the
note was used to create the treaunent plan (orders) and
to obtain and document the patient's consent. In tradi
tional settings, such as those in which physician notes
are dictated, these time consuming tasks are frequently
not factored into the estimate of physician effort. The
computer program provides a painless and automated
way to insure that these tasks are completed. Third,
in the experience of the authors, the amount of detail
captured in these notes far exceeds that of the typical
handwritten or dictated preop note at our institution.
We also note that in our institution there tends
to be abundance of automated monitoring equipment
available in the critical ca.re areas. For this reason, in
recent years, the availability of adequate records of the
physiological status of the patient during surgery has
improved significantly. This aspect of patient care doc-
umentation continue.s to attract considerable attention
and funding and the capabilities will only increase in
the furore. The one component of care that has defied
automation has been the capture and storage, in rcal-
time, of the observations and evaluation of the patient
made by the physician. Even otherwise sophisticated
signal processing applications [SJ, for the lack of an
automated capture process for physician ''bservations,
are frequently reduced to employing hand copying of
handwritten notes in order to capture the clinical back-
ground material necessary for proper interpretation of
the biophysical signals and measurements.
Conclu5ions
We have been able to introduce a computer into the
physician-patient interaction without disrupting the
examination and were able to customize a c;omput-
erized patient-record system to the special needs of the
obstetric pre-anesthetic sccting. The output is accept
able for inclusion in the medical rec;ord.
The hypotheses that were being t e ~ t e d in this $tudy
were formulated on the ba5is of successful application
of this approach to charting in other clinical specialties.
We were able to confirm that they are equally applica-
ble to the area of obstetric anesthesia. The program, as
configured, is vers;itiJe, inexpensive, reliable and easy
to use. It provides a mechanism for introducing guide-
lines mto the evaluation process and insures that the
DEC 30 ' '37 07: '::ARM SMRRT FOLlr'lDRT IOtl
6
infonnation that is collected will be standardized. This
will aid in our future Quality Assurance and Quality
Improvement activities.
On the basis of these results. we are conducting a
similar exercise in the gene.ral preoperative clinic. It
Is our long-range objective to compile a record of our
patient care activities that spans temporal and organi
zational boundaries that are now common in our insti-
tution. We would like the records generated in the pre
operative and pain clinics and the initial evaluations
performed in the trauma center, the pen-operative data
and physician obser;ations and followup examinations
aud treatment to all be stored in a similar format and
accessible both for patient care and research. It seems
inevitable that each of these settings will employ dif-
ferent types of critical care and rnonitori.ng equipment.
We would prefer to treat the monitoring signals. images
and other mechanically acquired data to be adjuncl.;;
or addenda to the longitudinal comprehensive med-
ical record rather that the cum:nt situation where each
pie.ce of specialty equipment duplicates own small
piece of the medical record leaving it to the physician to
locate, retrieve and integrate the infonnahon necessary
to care for the patient.
Acknowledgements
TI1is study was partly supporled by a gram from the
S.M.A.R.T. Foundation.
P. E./6
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