Douglas James R, Ritter Melody J
Department of Anesthesiology, Ochsner Clinic Foundation, New Orleans, LA.
Ochsner J. 2011 Summer;11(2):102-14.
During the administration of anesthesia, the anesthesia provider has historically created a paper record, charted manually, that included extensive patient care-related data (vital signs, other parameters, etc) and commentaries. DocuSys, a proprietary anesthesia information management system (AIMS), creates an electronic version of the anesthesia record and provides additional information. It electronically captures data from clinical monitors and other sources, including scheduling applications and laboratory computers. The AIMS facilitates chart entries such as drug doses and case narratives. Benefits of an AIMS include improved legibility of the anesthesia record and greater efficiency in documentation efforts. Use of the AIMS assists the practitioner with decision support logic, such as the timing of antibiotic administration and the inclusion of legally required documentation. Upon case completion, the AIMS data are immediately available to other information systems, such as billing and medical records. Data can be made available from a single case or, more important, from thousands of cases to analyze variables such as efficiency of services, adherence to best practices, patient outcomes, and clinical research. The AIMS was deployed at the main campus of the Ochsner Health System on March 26, 2009. In this article, we discuss the issues involved in the AIMS implementation process: the successes, surprises, and continued challenges.
在麻醉实施过程中,麻醉医护人员历来会创建纸质记录,手动记录包括大量与患者护理相关的数据(生命体征、其他参数等)及注释。DocuSys是一款专有的麻醉信息管理系统(AIMS),可创建麻醉记录的电子版本并提供额外信息。它能从临床监测仪及其他来源(包括排班应用程序和实验室计算机)电子采集数据。该AIMS便于录入诸如药物剂量和病例叙述等图表信息。AIMS的优点包括提高麻醉记录的清晰度以及提高文档记录工作的效率。使用AIMS有助于从业者运用决策支持逻辑,比如抗生素给药时机以及纳入法律要求的文档。病例完成后,AIMS数据可立即供其他信息系统使用,如计费和医疗记录系统。数据可从单个病例获取,或者更重要的是,可从数千个病例获取,以分析诸如服务效率、遵循最佳实践情况、患者预后及临床研究等变量。2009年3月26日,AIMS在奥克施纳健康系统的主校区投入使用。在本文中,我们将讨论AIMS实施过程中涉及的问题:取得的成功、意外情况以及持续面临的挑战。