PRINTER-FRIENDLY VERSION AT ANESTHESIOLOGYNEWS.

COM

Anesthesia
Information
Management
Systems
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A Guide to Their Successful

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Installation and Use

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JESSE M. EHRENFELD, MD
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Harvard Medical School

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Department of Anesthesia and Critical Care

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Massachusetts General Hospital

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Boston, Massachusetts
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Dr. Ehrenfeld has no relevant financial conflicts to disclose.

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Introduction
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AIMS are a specialized form of electronic

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nesthesia information management
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health record (EHR) systems that allow the

automatic and reliable collection, storage, and
systems (AIMS) are rapidly
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presentation of patient data during the periop-

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increasing in both their adoption erative period. In addition to providing basic

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record-keeping functions, most AIMS also allow

and overall functionality. These systems end users to access information for manage-
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ment, quality assurance, and research purposes.

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have become much more than automated

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AIMS typically consist of a combination of hard-

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ware and software that interface with intraop-

record keepers. They have been shown to
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erative monitors, and in many cases hospital

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improve patient care and, in some cases, clinical data repositories or EHRs. Although the
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primary role of an AIMS is to capture data dur-

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the financial health of a department. ing the intraoperative phase, most systems also
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can incorporate pre- and postoperative patient

Although the underlying technology has information (Figure 1). Typically, all of this infor-
mation is stored in a robust relational database
improved greatly over the past 5 years,
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that can be accessed simultaneously by multiple

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the process of selecting and implementing users either via a vendor’s commercial applica-
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tion or standard database tools, such as struc-

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an AIMS remains complex, and must be tured query language.

Widespread adoption of AIMS, which have
approached carefully in order to obtain all been in existence since the 1970s, has been hin-
of the benefits these systems can provide. dered primarily by the financial barriers associ-
ated with implementation of these systems.1 As
a result of these hurdles, only an estimated 5%

I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G A N E ST H E S I O LO GY N E WS • S E P T E M B E R 2 0 0 9
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Figure 1. AIMS intraoperative display.

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Image courtesy of Dräger.

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of US operating rooms in 2006 had an AIMS.2 Adop- of the information, electronic systems can facilitate the
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tion has accelerated recently (44% of academic centers capture and interpretation of data.
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have implemented or are now planning to implement an In addition to assisting providers with the specific
AIMS), driven primarily by a need to address increased task of record keeping, AIMS have been shown to
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regulatory reporting requirements and a desire to improve patient safety in a variety of settings by facili-
improve routine clinical documentation.3 The areas tating appropriate clinical care13,21 and providing accu-
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where AIMS have proved beneficial to both patients and rate documentation for retrospective review. Most
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anesthesia departments are summarized in Table 1. systems can generate point-of-care alerts for patient
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The specific benefits of a particular AIMS installa- allergies or drug–drug interactions. In fact, the Anesthe-
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tion (Table 2) depend on a number of factors includ- sia Patient Safety Foundation has both endorsed and
ing the system purchased, the overall implementation advocated the use of AIMS because of the ability of the
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scheme, and the departmental work flow. One mis- technology to provide high-quality data.22
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take institutions often make when installing an AIMS is Although the potential safety and clinical benefits of
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to simply replace paper with the electronic system— an AIMS installation are compelling to some facilities,
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without changing processes in order to obtain the full others choose an AIMS because of its potential to pos-
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benefit of these systems. For example, after installing itively impact a department’s economic performance
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an AIMS, one institution continued to send copies of despite large upfront capital costs ($4,000-$9,000 per
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incomplete anesthesia records to physicians via inter- operating room plus an additional $15,000-$40,000
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office mail with a handwritten note asking for correction for AIMS servers). The actual return on investment will
of the documentation error. The rate of unbillable charts depend on the specific institution’s existing manage-
was unchanged until the institution began using elec- ment, financial, and billing practices.22 A recent review
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tronic tools that interfaced with the new AIMS installa- of the literature revealed 4 ways that installing an AIMS
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tion to facilitate error correction.5 can contribute to a positive return on investment. These
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include reduced anesthesia drug costs, improved staff

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Why Purchase an AIMS?
Many departments choose to install AIMS because
fundamentally, anesthesia relies on the provision and
timely documentation of accurate information. These
data are the basis for how anesthesiologists make deci-
sions; given the ever-growing amount and complexity
scheduling and reduced staff costs, improved billing/
charge capture, and improved hospital reimbursement
resulting from better hospital coding.5,23,24 For exam-
ple, one institution customized its AIMS so that the
system would generate reminders about more accurately
billing for placement of arterial lines, central lines, and

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 epidural catheters, which had previously gone unbilled5;
other hospitals have used their AIMS to reduce the time
Table 1. Areas Impacted by
patient bills spend in accounts receivable, thus speed- Anesthesia Information Management
ing up revenue cycles.7 Systems4
Finally, many departments are using AIMS to facil-
itate reporting of the increasing number of quality Impact on patients
measures (such as on-time administration of prophy-
More accurate recording of patient responses to
lactic antibiotics and maintenance of normothermia) as
anesthesia
a condition of participation in various pay-for-perfor-
mance contracts. In the absence of an AIMS, reporting Improved availability of historical records
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on these types of quality metrics typically requires a Allow anesthesiologist to focus on patient, rather
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laborious—and often expensive—manual chart review. than charting

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Electronic systems also offer the additional advantage

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Impact on the practice of anesthesia

of providing a means for changing provider behavior,
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through clinical decision support, to meet quality met- Improved quality assurance functionality due to
more accurate and complete records
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rics, as opposed to merely reporting on them.

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Ability to quickly search for specific occurrences

Functionality
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or rare events across multiple cases

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The core strength of most AIMS is still recording

Provide a means to track individual provider
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intraoperative data. However, many systems now offer

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preoperative evaluation modules, clinical decision sup-

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port, and advanced management tools for process Assessment of patient outcomes through
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integration with other hospital databases

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improvement.
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Preoperative modules vary widely in terms of their Availability of accurate, high-resolution charts for
educational purposes
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breadth and features. Some simply provide a way to

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input patient demographics (name, age, American

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Legal protection through provision of more accu-

Society of Anesthesiologists physical status) and type rate, unbiased information
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free-text notes. Others provide robust electronic his-

Impact on departmental management
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tory-taking questionnaires and suggest preoperative

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Facilitate accurate and timely billing

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laboratory tests based on customizable algorithms

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that take into account the specific procedure and any Allow analysis of supply costs by patient/
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comorbidities for a particular patient.25 Systems that provider/type of surgery

capture preoperative data as structured data elements
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Can assist with concurrency and other regulatory

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via check boxes or pull-down menus (rather than free- compliance issues
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text comments) also can provide on-the-fly patient risk

stratification by using algorithms such as the modified Satisfy Joint Commission requirements for com-
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prehensive, legible records

Lee-Goldman index.26 Most systems provide an easy
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way to access a completed evaluation, either by provid- Provide ready verification of ACGME case
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ing an information summary or sending data to a hospi- requirements for residents in training programs
tal EHR system. All preoperative modules should allow
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ACGME, Accreditation Council for Graduate Medical Education

providers to reduce redundant entry of information by
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carrying data (such as a patient’s weight) forward into

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the intraoperative record. When selecting a system, it is

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necessary to decide which features are important to the

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particular department, as well as how the system will

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impact existing work flow. For example, use of a preop-

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erative module may require installing an AIMS in preop-

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erative anesthesia clinics or holding rooms in order to

obtain the maximum benefit of the technology.
Intraoperative charting remains the core piece of
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any AIMS installation and involves 2 primary activities:

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the automatic transcription of data from physiologic

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monitors (eg, vital signs and ventilator settings) and the

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manual entry of case events (eg, intubation events, case

times, and drug administrations) into the EHR. Because
the vast majority of data is used in real time during a
case, the user interface must allow easy and continu-
ous access to the accumulating anesthesia record.22 The
user interface also should facilitate the work flow of end

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 users so that manually recorded events may be entered
Table 2. Specific Benefits of AIMS easily and rapidly. The AIMS should allow performance
In Peer-Reviewed Literature of basic tasks—initiating a case, recording an event—
with little training. Ideally, the user interface should be
Cost and billing improvements
flexible enough that users can enter data at their own
Controlling and reducing anesthesia drug costs6 pace and in ways that complement their existing work
Improving capture of anesthesia-related charges5,7 flow, rather than requiring them to change their pro-
cesses to meet the needs of a particular system. Finally,
Impact on hospital reimbursement8,9
the intraoperative charting module should facilitate sit-
Decision support and provider education uational awareness by organizing and highlighting crit-
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Clinical decision support10,11 ical data elements as they become available. This might
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involve placing a key piece of information in a larger

Training and provider education12
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font or in a different color so that it is quickly identified

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Patient safety and quality assurance by the user.27 For example, some systems will flash on-
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Increased patient care and safety13 screen notifications when heparin is due to be readmin-
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Enhancement of clinical quality improvement istered while a patient is on cardiopulmonary bypass.

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programs14 Decision support, or the provision of tools that allow

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end users to more effectively accomplish a particular

Support of clinical risk management15
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task, is a fast-growing area within AIMS product develop-

Monitoring for diversion of controlled substances16
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ment. Although this advanced feature is not universally

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Data quality and clinical research available, decision support can facilitate both improve-
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Enhancement of clinical studies17,18 ments in the quality and reductions in the cost of provid-
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ing care. The most basic decision support tools—such as

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Improved intraoperative record quality19,20

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systems that provide drug-dosing guidance based on a

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patient’s weight—offer passive guidance. More complex

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tools are designed to actively manage provider behav-

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ior; they may use on-screen pop-up displays or link to

Table 3. AIMS-Based Decision
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a hospital’s paging or e-mail system to alert clinicians

Support Features
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about changes in a patient’s clinical condition. Because

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not every product supports all of these functionalities,

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Medication administration it is important to decide which features are indispens-

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Drug-dose calculations able for any particular department prior to generating a

request for proposal (RFP).
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Drug–drug interaction checking

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Quality improvement is supported by AIMS in sev-

Drug allergy checking
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eral ways. First, these systems enable the rapid and

Drug-redosing reminders objective collection of complete data sets that can
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Quality of care delivery provide insight into existing deficiencies in care pro-
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cesses. By gaining insight into practices through uni-

Guidance around maintenance of normothermia
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form collection of data, AIMS can facilitate the careful

Reminders to document presurgical antibiotic planning of process improvement exercises. In addi-
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management tion, the availability of a large electronic data set, which

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Compliance and billing issues can be quickly scanned, can help to rapidly identify
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Ensuring electronic charts contain elements practice trends—a process that often is time-consum-
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required for billing ing and cost-prohibitive when performed with paper
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charts. Second, once areas for improvement have been

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Attending physician compliance statements

identified, many AIMS can be customized to provide
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Case type (general/MAC/regional) clinicians with electronic tools to reach better levels of
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Patient details (ASA physical status, case times) performance. (Table 3 lists AIMS-based decision sup-
Concurrency checking port features.) These may include improvements in
patient flow or reductions in missed billing opportu-
Algorithm support for critical events
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nities. Finally, many systems allow direct capture of or

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Critical event detection (chaotic ECG + no pulse- provide links to quality-assurance tracking systems.28
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ox wave form ➔ consider ventricular fibrillation)

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Algorithm display and guidance (ACLS, malignant Purchasing an AIMS

hyperthermia) The decision to purchase an AIMS is a complex one
that touches on every aspect of an anesthesia depart-
ACLS, advanced cardiac life support; ASA, American Society
of Anesthesiologists; ECG, electrocardiogram;
ment (clinical operations, billing, contracting, physician
MAC, monitored anesthesia care credentialing, quality assurance), as well as many places
outside of a department (medical records, clinical

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 engineering, admitting, compliance office, information
technology, security).
Table 4. Questions To Consider
The first step when considering an AIMS purchase When Purchasing an AIMS
is to determine the overall scope of the project and
to identify the specific needs of the department. This What will be the scope of the system?
process usually involves discussions among key mem- Which activities will the system handle
bers of the departmental leadership team in conjunc- (preoperative evaluations, intraoperative
tion with representatives from the hospital information recordings, postoperative checks)?
systems department. The selection of a system is best
How will the AIMS integrate with existing
done after addressing some of the key questions listed departmental work flow?
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in Table 4.29
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Which sites will the system support (main operat-

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SELECTING A VENDOR ing room only, off-site locations, labor and deliv-
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ery, free-standing ambulatory sites)?

Once the overall scope and system functionality have
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been decided, an RFP is generated. The RFP should Will the system stand alone? Will it interface with
existing hospital systems?
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describe the functional requirements of the planned

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installation, the level of clinical activity to be supported, What additional infrastructure will be required to
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and the type of locations involved.22 The RFP should support an AIMS?
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be sent to a wide range of vendors (Table 5) to ensure

Who will provide AIMS support personnel
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complete and competitive bids are received.

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(department or hospital)?
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Responses from vendors to the RFP should include

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itemized implementation costs for hardware and soft- What physical infrastructure will be required
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(network connections, secure location for the

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ware licenses, training and support options, warranty

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AIMS server, hardware/displays for use within

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details, and service pricing. Vendors should outline their operating room suites)?
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built-in redundancy systems and ability to manage cat-

How will the system be deployed and maintained?
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astrophic events such as power outages, and hardware

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or network failures. The vendor should detail all inter- When and how will installation and testing occur?
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faces and network requirements required for the sys-

Who will provide initial and ongoing training?
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tem to function fully. Live demonstrations or site visits

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What kind of backup systems will be available?

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to existing clients can be extremely helpful when try-

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ing to make a sound product assessment. When eval- Who will provide ongoing system maintenance
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uating a system during a demonstration, key points to and upgrades?

assess should include overall ease of use, coherent dis-
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play of and access to intraoperative data, system sta-

bility, and security.22
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During the contracting process, vendors should item-

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ize all costs associated with system implementation, as

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well as the dates and the terms of delivery. Ongoing

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maintenance fees and support costs—typically 20% of

the initial purchase price—should be outlined clearly. The
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total cost of a new system will depend on the number of

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clinical and administrative workstations to be installed.

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Workstations may cost between $4,000 and $9,000

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per anesthesia location, and from $2,000 to $3,000 per

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administrative site. The hardware required for the AIMS

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server itself may cost 3 to 5 times that of a clinical work-

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station. All of these costs will be highly vendor-specific,

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with wide ranges in price reflecting the different fea-

tures made available by competing manufacturers.22

SYSTEM IMPLEMENTATION Figure 2. Physical setup of a clinical

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workstation.
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Once a system has been selected, an implementa-

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tion plan should be developed that outlines the over-

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Image courtesy of GE Healthcare.

all approach (incremental or one time) and timing for
system implementation. This plan must account for
changes in the clinical and administrative work flow
of the department. The need for additional technol-
ogy support staff and training also must be considered
carefully. A committed clinical champion, who is familiar

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Table 5. Commercially Available AIMS

AIMS Vendor System Name Web Site

Acuitec GasChart www.acuitec.com
Cerner SurgiNet www.cerner.com
DocuSys DocuSys AIMS www.docusys.net
Dräger Innovian Anesthesia www.draeger.com
GE Healthcare Centricity Anesthesia www.gehealthcare.com
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iMDsoft MetaVision www.imd-soft.com

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Merge Healthcare Frontiers www.merge.com

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Philips Healthcare CompuRecord www.healthcare.philips.com/us/

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Picis Anesthesia Manager www.picis.com

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Surgical Information Systems SIS Anesthesia www.SISfirst.com

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with the departmental work flow and who can set up

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and maintain the AIMS interface, should be identified.

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This individual often is an anesthesiologist who is famil-

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iar with information systems and other medical device

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interfaces.30
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During the implementation phase, a careful plan for

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testing and deployment should be outlined and made

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widely available within the department to ensure that

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all individuals who will be affected are aware in advance

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of the upcoming installation. This list may include sev-

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eral people outside the anesthesia department, such as

staff members in perioperative services, nursing, com-
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pliance, medical records, and billing. Finally, a contin-

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gency plan should be developed in case unexpected

problems or a system failure occur during the installa-
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tion phase.
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ERGONOMICS
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The physical setup and characteristics of a clini-

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cal workstation have a tremendous impact on overall

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usability of a particular system.31 Many vendors rec-

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ommend mounting touch screens on adjustable arms

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either on the anesthesia machine or nearby (Figures 2

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and 3). These displays typically accommodate both a

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full keyboard for data entry as well as flexible position-

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ing during a case. The physical setup matters tremen-

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dously, as it will facilitate the end user’s work flow and

is likely to impact the quality of data captured.

Figure 3. AIMS workstation mounted END-USER TRAINING

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on an anesthesia machine.
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In order to receive the maximum benefit from a new

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AIMS, all users will need to be trained on the technol-

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ogy. Although all modern AIMS have graphical user

interfaces that will be familiar to most anesthesiolo-
gists, the specific details about how to accomplish any
particular task will vary from system to system. Initial
training should occur as close as possible to the instal-
lation date, so that end users will be able to apply

I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
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 and practice what they learned.22 Clinical, administra-
tive, and technical support staff should receive sepa-
rate training that emphasizes the functions unique to
each specific group. Initial training may take the form of
one-on-one tutorials, classroom sessions, or Web-based
tutorials; it is helpful to have dedicated support staff
available on demand during the first few weeks of sys-
tem implementation.
DATA DEFINITIONS AND TIMELY DOCUMENTATION
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Table 6. Advantages and Limitations
Of Currently Available AIMS
Advantages
Automated and accurate intraoperative data col-
lection may enhance quality of anesthesia records10
Provide real-time decision support33
Increase time providers can focus on providing
patient care34

The data stored within an AIMS are only as robust as

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what end users enter into the system. Consistent docu- Support efforts to improve quality and processes
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mentation depends on clear definitions of data. These

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May increase billing revenue through enhanced

definitions will vary by institution—for example, what is charge capture35
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the induction of anesthesia?—and the data will be used

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Enhance accessibility and quality of data for

for reporting, billing, and in many cases, to support clin-
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research
ical decisions. Consistent documentation, therefore, is
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essential to obtain the full benefit of an AIMS. Further- Support automated process monitoring and
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more, many decision support systems rely on the avail- control10

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ability of timely information, which may be adversely Limitations

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impacted by delayed data entry.32

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Inadequate vertical integration (information does

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not transfer easily from one phase of care to the

ADVANTAGES AND LIMITATIONS
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next)36
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The major advantages and potential limitations of

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Limited mobility (AIMS typically accessed on

AIMS are summarized in Table 6. Overall, adoption of
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desktop computers; pre- and postoperative

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these systems has been slow because their potential to assessments usually performed at bedside)36
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improve patient care has not been as obvious as with

No AIMS standards across vendors
other technologies, particularly the new physiologic
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monitors and late-generation anesthesia machines.29 Unrecognized system failures can lead to gaps in
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data collection37
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However, as AIMS continue to demonstrate an ability to

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markedly improve processes of care, billing efficiency, Initial expense may not be recovered quickly in
and quality assurance, they will no longer remain a small practices
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prized luxury owned by a small number of early adopt-

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Requires significant time and effort for initial

ers.30 Instead, these systems will become an essential training and implementation
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modality for providing the lowest-cost, highest-quality

Potential introduction of monitoring and record-
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care across institutions.

ing artifacts into electronic record
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Summary Limited interoperability and compatibility with

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other electronic or hospital systems

The adoption of AIMS appears to be accelerating
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for several reasons, most notably their increased func-

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tionality, decreased cost, and increasing pressure to

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report data for external review, such as with pay-for-

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performance contracting. AIMS have been reported

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in the literature to be able to increase quality of care

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and improve operating room efficiency, but only with

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careful planning, installation, and customization.

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Successful implementation of an AIMS requires signif-

icant resources, above and beyond those that will be
directly specified in a vendor’s contract because of
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the time required for training, installation, and soft-

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ware customization.30 Although growing federal pres-

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sure to increase overall use of EHR systems likely will

d.

impact the practice of anesthesiology, the direct effect

on AIMS remains unclear. Despite significant advances
in technology that have led to the development of mod-
ern AIMS, widespread adoption of these technologies
will not occur without better interoperability, standard-
ization, and integration between vendors.

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5. Spring SF, Sandberg WS, Anupama S, Walsh JL, Driscoll WD, 23. Lubarsky DA, Glass PS, Ginsberg B, et al. The successful imple-
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Raines DE. Automated documentation error detection and notifi- mentation of pharmaceutical practice guidelines. Analysis of
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