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Anesth Analg 2004;99:840-843 © 2004 International Anesthesia Research Society doi: 10.1213/01.ANE.0000130259.52838.3B
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Abstract |
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Anesthesia information systems (AIS) record data from patient monitors and create a detailed electronic anesthesia record. Because the anesthesia record is a primary piece of evidence used in court during a malpractice proceeding, the ability to create an anesthesia record has fostered considerable debate concerning the impact of this method of record keeping on malpractice exposure. Fifty-five departments using AIS were surveyed to document their medicolegal experience with electronic anesthesia records. Twenty-four departments responded to the survey, 18 of which had more than 5 yr experience with the technology. Respondents reported 41 malpractice cases filed since adopting AIS technology. Of the cases filed, 30 were dropped, and 11 went on to settlement or litigation. There were no reported cases in which the automated record hindered the defense process. Eighteen respondents viewed this technology as valuable for risk management, and three more viewed it as essential. The experience reported by these departments indicates that AIS are useful for managing malpractice risk.
IMPLICATIONS: A survey of departments using an anesthesia information system for anesthesia record keeping suggests that these systems are useful for managing malpractice risk and do not increase malpractice exposure.
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Introduction |
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For more than 100 years, the handwritten anesthesia record has been the commonly accepted method for documenting anesthesia care. In recent years, anesthesia information systems (AIS) have become available that use computer technology to assist the clinician in creating the anesthesia record. AIS automatically record data from patient monitors and allow providers to enter drug dosages and event annotations to create an electronic anesthesia record that contains more data than the handwritten record. The electronic data are stored in a database, and a summary of the electronic data is typically printed at the completion of the procedure to be included in the paper medical record. AIS became available almost 20 years ago, yet acceptance into clinical practice has been slow. One major obstacle to acceptance of this technology is concern over the impact of the electronic anesthesia record on malpractice exposure.
Those who argue that AIS will increase malpractice exposure describe two scenarios where automatically recorded data could be exploited by a plaintiff’s attorney to support a case for malpractice. In the first scenario, a patient experiences a brief physiologic change such as hypotension or desaturation, which is documented in the electronic record. Physiologic changes like this are common during anesthesia care but may not be documented on the handwritten anesthesia record either because they are too evanescent to be important or because of concern that the data will be misinterpreted in the event of a bad outcome (1). The other scenario involves artifactual data from patient monitors that are automatically recorded and incorporated into the anesthesia record. It is not uncommon for data from patient monitors to falsely indicate a significantly abnormal value when such an abnormality did not actually occur. When keeping a handwritten anesthesia record, artifactual data can be identified by the anesthesia provider and not included on the handwritten record, whereas AIS faithfully record the artifactual data along with the true data.
Those in support of AIS argue that the electronic anesthesia record is a more contemporaneous, complete, and legible rendition of actual events than the handwritten record. As such, the electronic record can eliminate questions of negligence if there was none or facilitate settlement if that is the appropriate outcome. Furthermore, plaintiff’s attorneys exploit illegible or ambiguous notations on the handwritten record to raise questions about the care that was provided, leaving juries to rely upon competing oral testimony to decipher the truth. That strategy is not possible when using an electronic anesthesia record. Compelling arguments can be made to support both sides of the debate, but speculation will not resolve the issue (2,3). The answer lies in real-world experience.
Although a small fraction of anesthesia departments actually use AIS, a large number of anesthetics have been recorded by the systems that are in use. Departments that could be identified as users of AIS were surveyed in an attempt to document the impact of this technology on their malpractice exposure.
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Methods |
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A survey was sent to those departments in North America that could be identified as users of AIS. The list of departments using the technology was created using information from the Society of Academic Anesthesia Chairs and from vendors of this technology who were willing to share the contact information of their installed base. A cover letter accompanying the survey indicated only that the data were being collected to prepare for a presentation at the 2003 annual meeting of the American Society of Anesthesiologists (ASA), that the identity of the department would remain confidential, and provided instructions for returning the response.
The survey was designed to elicit information about several aspects of the medicolegal experience with AIS technology (Table 1). Given the regional differences in the medical liability climate, the geographic location of the department was requested. A question on the length of time the system had been in use was included as a marker for the experience of each department with the technology. Several questions were designed to elicit the total malpractice experience using these systems and whether the automated systems had helped or hindered the defense process. Finally, an overall opinion on the value of these systems for risk management was sought. No attempt was made in the survey to identify the vendor of the system being used by a particular department.
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Results |
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Surveys were sent to 55 departments. Of these, 24 returned the surveys, and 22 surveys were sufficiently complete to be useful. Two surveys were not included in the tabulated responses because only one or two questions were answered. The geographic distribution of departments surveyed was determined by the mailing lists that could be obtained with most departments located in the eastern one half of the United States. Not surprisingly, respondents were predominantly from the eastern half of the United States, with 20 of 22 no further west than Texas. Fourteen of the respondents had more than 5 yr experience with AIS, six had 1–5 yr, and two had less than 1 yr.
Respondents reported 41 malpractice cases filed since adopting AIS technology with a range of 0–10 cases per department. There was no obvious relationship between the geographic location of the department and the number of malpractice cases reported. Of the cases filed, 30 were dropped, and 11 went on to settlement or litigation. In five cases that were dropped, the automated record helped to document the absence of negligence. Of the cases that were settled, in five instances the automated record facilitated the decision to settle. With regard to cases that went on to litigation, the respondents reported two instances where the automated record was helpful in the litigation. There were no reported cases where the automated record hindered the defense process. Eighteen respondents viewed this technology as valuable for risk management, and three viewed it as essential. None of the respondents felt automated anesthesia records were detrimental to the risk-management process or should not be used. Finally, 19 of the 22 respondents indicated they would absolutely recommend acquiring AIS technology as part of the risk-management strategy if asked to manage another anesthesia department (Table 1).
Many respondents provided written comments about their malpractice experience since acquiring an AIS. The comments supported the use of AIS, not only to defend against a suit, but also to prevent lawsuits by helping to identify unsafe practices before the lawsuit occurs (Table 2).
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Discussion |
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The survey results indicate that AIS are helpful to the risk-management process. No data were collected in the survey on the number of cases recorded by the respondents since adopting an AIS. However, assuming that the 14 departments with more than five years experience performed on average 10,000 cases per year, that estimate would yield about 700,000 cases. If the experience of the other respondents could be added, the collective experience of the departments using AIS technology may well approach one million anesthetics or more recorded using this technology. If there were a significant potential for the automated anesthesia record to falsely support an allegation of malpractice, then the collective experience of these departments would likely include at least one example. All respondents reported a positive or neutral impact of the automated record on the risk-management process with no indication that the technology increased malpractice exposure.
One must be careful about interpreting the data from this survey too rigorously. The results reported here are the opinions of a small number of practitioners who have adopted AIS and, as supporters of the technology, are more likely to view it in a positive light. Furthermore, hospitals with the funds to purchase AIS likely also have well-funded risk-management offices. In addition, the return rate for the surveys was <50%, indicating that there is a significant amount of experience with this technology that was not reported. The impact of the nonresponder experience on the results will never be known, and one wonders whether these departments have extensive medicolegal experiences they were reluctant to share.
The results of the survey lend credibility to the argument that AIS help to reduce malpractice exposure. Real-world experience from malpractice cases documented in the legal literature would be even more compelling. Anesthesia records produced by AIS have been used in the courtroom, and the highly legible document enlarged to poster size seems very authoritative to the jury.1 The initial plan for this project was to review the case evidence from the legal literature on the role of the electronic anesthesia record in past litigation. Unfortunately, it was not possible to identify case law precedent using the LexisNexis legal literature database (www.lexis.com).
Another potential source of information regarding the medicolegal impact of AIS is the ASA closed claims database. Closed claims reviewers are currently asked to indicate whether an AIS was used in each case reviewed and whether or not it played a role in the litigation. A recent search of that database revealed 27 cases in the database where an AIS was used. In four of those cases, data from the AIS were deemed to play a role in the litigation, although the exact role was not entirely clear. With time, the closed claims database will almost certainly accumulate additional cases where an AIS was used and become a more valuable resource for addressing the question of malpractice exposure with automated records.
Arguments against the use of automated records on the basis of concern for malpractice liability are highly emotional. This is not surprising given the aggressive medicolegal climate in the United States. Neither the handwritten nor the electronic anesthesia record can eliminate malpractice exposure completely. The value of the anesthesia record to either the plaintiff or defense attorney derives from its use to the expert witness as a means to determine the sequence of actual events, relate those events to the patient’s injury, and convince the jury of their opinion. The completeness, accuracy, and legibility of the automated record are all assets for documenting and defending a well-conducted anesthetic. When involved with patient care, especially during an untoward event, it is difficult to create a handwritten anesthesia record that is as complete and legible as the printed automated record. Indeed, the handwritten record will always be suspect because it is created by the person who will ultimately use it for his or her own defense.
Although there are legitimate concerns about the impact of the electronic anesthesia record on malpractice exposure, the experience reported by the survey respondents suggests that it is a useful risk-management tool. As AIS proliferate, we will learn more about how to best use these systems as risk-management tools. These systems actually create two anesthesia records, a printed summary for the medical record, and a much more detailed electronic version that is stored in the departmental database. The electronic version contains information recorded at more frequent intervals than the typical five minute intervals shown on the printed record. This version also maintains an audit trail clearly identifying any changes made to the anesthesia record. The more complete electronic data will no doubt prove useful in the courtroom, but there is no experience reported to date on the discoverability of the electronic data or the manner in which it should be presented to the jury.
The potential of AIS to revolutionize anesthesia care goes far beyond the automated anesthesia record. These systems create an extensive database of information surrounding the perioperative care of the patient that can support many aspects of anesthesia practice including efficient billing, personnel and resource management, and quality of care documentation. Concern over the impact of AIS on medicolegal exposure continues to be an obstacle to realizing the benefits of this technology. The results of this survey suggest that AIS are a risk-management asset and do not increase malpractice exposure.
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Acknowledgments |
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Thanks to Kevin Tremper, MD, PhD, Professor and Chair, Department of Anesthesiology, University of Michigan School of Medicine, Greg Beidler and Scott Bamford, Draeger Medical Inc, and Charles Stahley, Philips Medical/Compurecord for their assistance in developing the contact list for the survey. Thanks also to Karen L. Posner, PhD, ASA Closed Claims Project and ASA Committee on Professional Liability, University of Washington, Seattle, WA.
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Footnotes |
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Dr. Feldman spends a portion of his time serving as Consulting Medical Director for Draeger Medical Inc., Telford, PA.
1 Personal conversation. Susan Nicholson, MD, Department of Anesthesiology, Children’s Hospital of Philadelphia, Philadelphia, PA. 
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References |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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- Cook RI, McDonald J, Nunziata E. Differences between handwritten and automatic blood pressure records. Anesthesiology 1989; 71: 385.[Web of Science][Medline]
- Eichhorn JH. Disadvantages of automated anesthesia records. In: Gravenstein JS, Holzer JF, eds. Safety and cost containment in anesthesia. Boston: Butterworths, 1988: 223–32.
- Whitcher C. Advantages of automated anesthesia records. In: Gravenstein JS, Holzer JF, eds. Safety and cost containment in anesthesia. Boston: Butterworths, 1988: 207–21.
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