Information needs for the OR and PACU electronic medical record

Summary

Objective: The amount of clinical information that anesthesia providers encounter creates an environment for information overload and medical error. In an effort to create more efficient OR and PACU EMR viewer platforms, we aimed to better understand the intraoperative and post-anesthesia clinical information needs among anesthesia providers.

Materials and Methods: A web-based survey to evaluate 75 clinical data items was created and distributed to all anesthesia providers at our institution. Participants were asked to rate the importance of each data item in helping them make routine clinical decisions in the OR and PACU settings.

Results: There were 107 survey responses with distribution throughout all clinical roles. 84% of the data items fell within the top 2 proportional quarters in the OR setting compared to only 65% in the PACU. Thirty of the 75 items (40%) received an absolutely necessary rating by more than half of the respondents for the OR setting as opposed to only 19 of the 75 items (25%) in the PACU. Only 1 item was rated by more than 20% of respondents as not needed in the OR compared to 20 data items (27%) in the PACU.

Conclusion: Anesthesia providers demonstrate a larger need for EMR data to help guide clinical decision making in the OR as compared to the PACU. When creating EMR platforms for these settings it is important to understand and include data items providers deem the most clinically useful. Minimizing the less relevant data items helps prevent information overload and reduces the risk for medical error.

Citation: Herasevich V, Ellsworth MA, Hebl JR, Brown MJ, Pickering BW. Information needs for the OR and PACU electronic medical record. Appl Clin Inf 2014; 5: 630–641

http://dx.doi.org/10.4338/ACI-2014-02-RA-0015

Keywords

Anesthesia - electronic medical record - health information technology

 

Conflicts of interest

Mayo Clinic and authors (VH, BWP) hold the patent application on AWARE technology referenced in this paper. AWARE is licensed to Ambient Clinical Analytics Inc. The results of the survey will inform modifications to AWARE for the OR and PACU clinical settings.

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