Development and Deployment of an Intraoperative Clinical Summary Document: A Veterans Health Care Affairs Perspective

Abstract

Background Clinical summary documents that abstract details of episodes of care are essential to Advancing Care Information requirements for electronic health records. Few examples exist for intraoperative clinical summary documents (ICSD).

Methods We describe the development and deployment of an ICSD at a tertiary hospital within the United States. Development included identification of needs of key stakeholders, evaluation of current clinical and data workflows, iterative development of prototypes with primary stakeholders, i.e., anesthesiologists and evaluation of prototypes with test patients. We deployed the ICSD over 6-months with tracking of (1) usage (number and types of end users and surgery types) and (2) written and oral feedback.

Results Current workflows involved accessing a 10 to 40 page document presenting all surgery details with review described as burdensome. The ICSD prototype was a separate one-page summary optimized for viewing on a monitor or paper. The document had four sections: (1) administrative data, allergies, and precautions; (2) medications, infusions, and fluid intake and output; (3) airway assessments and a graphical presentation of hemodynamic trends (blood pressure), and (4) standardized text for events (hypotension) occurring intraoperatively. During the 6-month deployment, postanesthesia care unit and intensive care unit nurses were most prominent users followed by anesthesiologists. While overall well received, our pilot users reported challenges for readability, font size, and the lack of customization.

Conclusion While the ICSD was designed for anesthesiologists, postanesthesia care unit and intensive care unit nurses were the most frequent users. Future development will involve customization for different stakeholders.

Keywords

intraoperative clinical summary documents - clinical summary - provider - health records - anesthesiology - quality improvement - anesthesia information management system

Protection of Human and Animal Subjects

This was a quality improvement effort and as per our university guidelines exempt from review by our Institutional Review Board.

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