一个麻醉医生在2000年对麻醉信息系统的展望

Matthew.wang

看看到现在那些实现了

麻醉师必须在新技术的发展和应用中起到主导地位（Leading role）。如果我们允许工程师和商人去开发我们每天使用的工具，我们会发现他们不会提供我们所需要的功能，包括提供一些不需要的功能并且非常不好用。如果我们让其他人决定在新手术室技术方面采用什么功能，当我们发现最终产品不够满意或者很难用、提供一些无用的功能，而且不能提供对我们有用的功能，我们只能自责。
http://www.oyston.com/anaes/utopia.htm

Anesthesia Information Systems: The future of the "Anesthesia Machine"?
Developments in fast, inexpensive, small, powerful computers, wireless technology, and the Internet are revolutionizing anesthesia in many ways including better patient monitoring, easier, more accurate record keeping, and improved patient care through the use of expert systems.
However, anesthesiologists must take a leading role in the development and implementation of new technology. If we allow engineers and business executives to develop the tools we use every day, we may well find that they fail to incorporate the features we need, include undesirable features, and are inconvenient to use. If we allow others to decide what features should be incorporated in new operating room technology, we have only ourselves to blame if we find the end product unsatisfying or difficult to use, that it incorporates features that are useless and fails to provide features that would be of advantage to us.

At present, I am unclear as to how anesthesiologists as a group can develop a vision for the future of technology in anesthesia, or how we can influence or control the means of production. As a way of commencing a dialogue about these issues, I would like to invite you to visit Utopia General Hospital, where I will show you the operating room of 2010.

Welcome to the Operating Room at Utopia General Hospital. You have come to check out our anesthesia machines? Here, take a look: The anesthesia workstation consists of two components, the ventilator and the Anesthesia Information System, or AIS. Allow me to show you some of the features of the workstation: THE AIS IS KNOWLEDGEABLE The AIS knows who I am At the start of the day, I show my thumbprint to the AIS, so it recognizes me. This automatically sets the display and the alarms to my personal preferences, arranges that messages for me are forwarded to the AIS, and sets the security level of the machine to the staff anesthesiologist setting The AIS knows the patients The AIS accesses the OR Schedule for the day from the hospital network. As each patient enters the OR, a nurse scans the barcode on the patient's ID band to confirm that we have the correct patient, and to notify the network that the patient had entered the OR. The PACU will scan the patient when he or she arrives in that unit, so that the family can be paged to let them know that the surgery has been completed.The AIS now displays the patient's relevant information: Age, weight, medications, drugs, allergies, lab results, and notes from previous anesthetics. Abnormal findings from the preoperative questionnaire are highlighted. New information, since I reviewed the chart at home last night, is also highlighted. If necessary, the whole previous chart can be called up. The AIS knows the operation and the surgeon It shows the average duration of surgery, and data on the usual blood loss. It can show the surgeon's anesthetic preference ("Always needs nasogastric tube" "Give cefazolin if not allergic") and previous anesthetists' comments ("Can do this case with laryngeal mask"). The AIS knows how I am likely to give the anesthetic For most cases, almost the entire chart can be filled in by the AIS. It knows the usual drugs I use for this type of case, and the typical doses I would use, given the patients age, weight and medical history. For children, I allow it to calculate the doses based on the patient's weight. If I decide to give a different dose, based on the patient's response to titration, then I have to edit the anesthesia chart appropriately, but often I just confirm that I have given the dose as calculated. If I enter a drug on the chart before I give it, the AIS will check this information against a database of doses, interactions with drugs the patient has taken recently, and the known patient allergies. This provides a useful safeguard. I enter information about the airway management, using menus based on my known style of practice, and the monitors write to the anesthesia record automatically. THE AIS IS CONNECTED The AIS is the anesthesiologist's communication center It allows and controls access to telephone, voicemail, local e-mail and the Internet. Instant messaging can be used to contact anesthesiologists working in other rooms in the OR suite, or anywhere else in the world. Videoconferencing between ORs is also possible. Of course, any other monitor on the network can be called up on any other AIS. The AIS is connected to my P3 P3? Sorry - that's a combined Phone, Pager and Personal Digital Assistant. While I am in the OR all my phone calls and e-mail are routed to the AIS, which intelligently filters them. Only calls from certain numbers, or with certain security codes, get forwarded to me in the OR. The level of filtration depends on how busy I am. Only emergency calls get through during intubation, emergence, or if the patient is unstable. During long boring cases with stable vital signs almost all calls are allowed to go through. If I have to leave the OR, or if I am supervising more than one operating room, alarms on any of the AISs I am responsible for generate a page on my P3. The alarm system uses intelligent filtering. For example, if a resident is in the OR and the 02 Sat drops below 90, I have set the system up so the resident has one minute to correct the problem. If the trend is not upwards after a minute, I am alerted. If the patient is a child, or if the resident is in his first year, I am warned earlier. Display options I am experimenting with a heads-up display built into my spectacles, which allows me to view the monitor screen of any AIS from anywhere in the OR suite, projected onto the lens of my spectacles in such a way that the screen appears to be floating in the air about six feet in front of me. The Operating Room table includes the BP machine and is connected to the AIS The patient position can be controlled from the AIS, and is automatically entered in the chart. The non-invasive blood pressure machine is built into the OR table. The patient's BP cuff, the ECG, pulse oximeter and other monitors are plugged into the OR table which communicates wirelessly with the AIS, so there are no cords between the patient and the AIS. The suction is connected to the AIS A small monitor wraps around the suction tubing, measuring flow rates and hemoglobin concentration in the suction fluid, dynamically calculating the blood loss and the patient's hemoglobin concentration. These figures are displayed on the AIS and will generate appropriate alarms. The AIS has a built-in printer Sometimes a paper document is still the easiest way of recording or transmitting information. One of the main uses of the AIS printer is to give the patient a copy of the anesthesia record. The AIS has a floppy drive Floppies are still not quite extinct. Data can nearly always be transmitted over the network. One function of the floppy drive is to produce a tamper-proof authenticated medical record in the case of an undesired outcome. The record is put in an electronic "envelope" so that it cannot be tampered with. In this way the AIS functions rather like the "black box" flight data recorders on aircraft, documenting everything that happened prior to an incident. The Weather Camera This, I must admit, is a bit of a gimmick. The Quality of Working Life, Recruitment and Retention Committee approved it, as our new ORs, with real windows, will not be ready for another couple of years. In a corner of the monitor, I can display a view of the current weather, from one of three cameras on the hospital roof, along with temperature, humidity and wind information. It's nice to know, especially on winter days when I arrive before dawn and leave after sunset. The little humanoid figure is advises what to wear when leaving the hospital. In summer it notes if sun block is needed, and in winter it gives a wind-chill warning. The AIS is connected to expert systems If the AIS notes abnormal vital signs, it interprets them and suggests possible causes and treatments. For example, if the patient develops a fever, a protocol for investigating and treating malignant hyperthermia appears in a window on the screen. THE AIS IS INTELLIGENT (IN A LIMITED FASHION) Automatic Ventilation Instead of setting a tidal volume and rate, mostly I just allow the AIS to tell the ventilator to ventilate to my preferred end-tidal CO2 reading. It gives a couple of test breaths, based on the patient's weight, then measures the compliance and decides on an optimum respiratory pattern. It tells me what it has decided, and I press "confirm" to signal my agreement. If anything changes by more than 10%, the AIS is programmed to alert me. Automatic Scheduling The AIS shows me when it anticipates that we will have finished the scheduled list. This is based on the surgery, the surgeon, the number of nurses, cleaners and porters available, as well as my work habits. The finish time is not always accurate, but it is close enough to predict patient flow through PACU and the Day Surgery Unit, so that the lists can be re-arranged or nursing staff rescheduled to avoid bottlenecks. The Overall Physiological Score (OPS) The OPS is a way of integrating all the available data related to the patient's status into a single number. The AIS considers the O2 Saturation, the Blood Pressure, Heart Rate and data from any other monitors in use to give a single number, ranging from 100% - ideal health - to 0%, which is death. If the OPS is over 95, it is hardly necessary to check the rest of the data - everything must be close to normal. The average OPS during the course of an anesthetic can be used as a measure of the quality of anesthesia. Productivity and approval rating This was very controversial when it first came out. The rating is based on turnover times, adverse events such as abnormal blood pressure readings or nausea in the PACU, and feedback from patients, surgeons and nurses. Once the data was available as part of the electronic record, it was inevitable that administration would begin to use it to evaluate staff and physician performance. So it was decided that everyone should be able to access their own rating, and be able to see the scores of other members of their group, but with no names attached. It was also decided to use the ratings only to reward top performers, not to punish those who fared poorly. For example, the hospital is funding an all-expenses-paid trip to the ASA Annual meeting for the top performing anesthesiologist. The AIS is a powerful research tool For example, if I decide I need to compare two anti-emetic agents for routine use, the AIS can select suitable patients, find matching controls, and gather the necessary outcome data. In fact, it becomes very easy to make almost every case part of a research protocol The AIS does my billing for me It knows the name and insurance details for each patient, and bills from five minutes before the patient enters the OR till ten minutes after. I can alter these times if necessary. If the monitor detects an arterial waveform, it bills for insertion of an arterial line. This feature is called "plug and pay". The AIS generates postoperative orders It also generates the postoperative PCA orders for me to confirm, and sends a message, with all the relevant patient details, to the Acute Pain Service anesthesiologist once the patient is in PACU. At present there are no vacancies for anesthesiologists at the Utopia General Hospital, but if you are interested I could put your name down on the waiting list. This utopian description of the operating room environment of the future is not wishful thinking, but is based entirely on technology that is already available today, that only needs adapting to our needs. As anesthesiologists we need to become aware of what technology could theoretically do for us, decide which of these possibilities are of most importance and relevance to us, and then work with manufacturers to implement these features in the anesthesia workstations of the future. If we fail to do this, the fancies of engineers, and the pressure of the market departments, will determine the technology we will be working with in the future. We will get the anesthesia machines we deserve. Where should we go from here? Firstly we need a dialogue within the international anesthesia community about our long-term goals. What technology would we like to have available in five or ten years? This dialogue could take place in the letters column of a journal, as an exchange of messages on the GASnet Anesthesiology Discussion Group, and during discussion at a major anesthesia meeting such as the ASA's Annual Meeting. Secondly, we need to involve an anesthesia equipment manufacturer or other company with the resources necessary to assist us in converting our thoughts into reality. It may be easier for a company with skills in information management and user interface design to acquire the rights to use good existing ventilators and monitors, rather than for an equipment manufacturer to develop the necessary skills in information management. The third step would be for the establishment of a demonstration project, taking people away from their usual work in producing next year's model that are only a small incremental step from this years model, and developing a new system from scratch. This process would have to involve practicing anesthesiologists at every stage. It would have to begin by asking very basic questions, and observing how anesthesiologists interact with existing systems, noting what information they need and how they use it. This step would lead to the development of a "concept machine", like a concept car the auto manufacturers sometimes develop for car shows. However, in order to demonstrate the functionality of the new AIS, it would also have to be installed in a suitable hospital, connected to the hospital network, and used by regular anesthesiologists on real patients, as this would be the only real test of its usability. October 5th, 2000 John Oyston Department of Anesthesia The Scarborough Hospital 3050 Lawrence Ave East Toronto, ON Canada M4W 2C6 Oyston Associates has produced several other anesthesia Web sites. © Dr John OYSTON, 2000