Kadry Bassam, Feaster William W, Macario Alex, Ehrenfeld Jesse M
Stanford University School of Medicine, Stanford, CA, USA.
Mt Sinai J Med. 2012 Jan-Feb;79(1):154-65. doi: 10.1002/msj.21281.
Documenting a patient's anesthetic in the medical record is quite different from summarizing an office visit, writing a surgical procedure note, or recording other clinical encounters. Some of the biggest differences are the frequent sampling of physiologic data, volume of data, and diversity of data collected. The goal of the anesthesia record is to accurately and comprehensively capture a patient's anesthetic experience in a succinct format. Having ready access to physiologic trends is essential to allowing anesthesiologists to make proper diagnoses and treatment decisions. Although the value provided by anesthesia information management systems and their functions may be different than other electronic health records, the real benefits of an anesthesia information management system depend on having it fully integrated with the other health information technologies. An anesthesia information management system is built around the electronic anesthesia record and incorporates anesthesia-relevant data pulled from disparate systems such as laboratory, billing, imaging, communication, pharmacy, and scheduling. The ability of an anesthesia information management system to collect data automatically enables anesthesiologists to reliably create an accurate record at all times, regardless of other concurrent demands. These systems also have the potential to convert large volumes of data into actionable information for outcomes research and quality-improvement initiatives. Developing a system to validate the data is crucial in conducting outcomes research using large datasets. Technology innovations outside of healthcare, such as multitouch interfaces, near-instant software response times, powerful but simple search capabilities, and intuitive designs, have raised the bar for users' expectations of health information technology.
在病历中记录患者的麻醉情况与总结门诊就诊、撰写手术记录或记录其他临床遭遇有很大不同。一些最大的差异在于生理数据的频繁采样、数据量以及所收集数据的多样性。麻醉记录的目标是以简洁的格式准确、全面地记录患者的麻醉经历。能够随时获取生理趋势对于麻醉医生做出正确的诊断和治疗决策至关重要。尽管麻醉信息管理系统及其功能所提供的价值可能与其他电子健康记录不同，但麻醉信息管理系统的真正优势取决于它与其他健康信息技术的充分整合。麻醉信息管理系统围绕电子麻醉记录构建，并整合从实验室、计费、影像、通信、药房和调度等不同系统中提取的与麻醉相关的数据。麻醉信息管理系统自动收集数据的能力使麻醉医生能够在任何时候都可靠地创建准确的记录，而不受其他并发需求的影响。这些系统还有潜力将大量数据转化为可用于结果研究和质量改进计划的可操作信息。开发一个验证数据的系统对于使用大型数据集进行结果研究至关重要。医疗保健领域之外的技术创新，如多点触控界面、近乎即时的软件响应时间、强大而简单的搜索功能以及直观的设计，提高了用户对健康信息技术的期望标准。
