Title : Feasibility study and prototype computerized program development of anesthesia electronic medical record
Abstract:
Normally, anesthesia personnel, particularly nurse anesthetists, make records on patients’ information during the surgical procedure. Pre and postoperatively, they visit patients to make sure that their customers are well informed regarding the whole process and satisfied with the service as well as any complications that might be existed. The investigators developed an anesthesia electronic medical record at the point of care. The objectives were to record peri-operative patients’ information in a real-time fashion, managed all administrative tasks as annual reports, and operated data as search engine for research and educational purpose. After IRB approval and ClinicalTrials.gov Identifier: NCT03037996, a prototype EMR including preoperative (AN01), intraoperative (AN02) and postoperative (AN03) events were developed and validated for its appropriateness. Target groups were thirty anesthesia personnel including 5 anesthesiologists, 5 for each 1st, 2nd and 3rd year residents; as well as nurse anesthetists and students. They all worked on 397 peri-operative patient data in virtual space. The fill-in anesthetic record was parallelly performed via the EMR and a paper-pencil matter (PPR). The AN01, AN02, and AN03 showed its reliability of 0.73, 0.73 and 0.78 respectively. There were no significant differences of recorded data between the EMR and PPR. An electronic medical record (EMR) is used not only to manage patient information but also to provide care service and perform job accountabilities. In addition, it yields comprehensive materials for clinical analysis.
Audience Take Away:
• It was user-friendly with flexibility and interactiveness, which yielded lively intercommunication.
• It could transfer data automatically from the monitor; then anesthetists had more time to care for their patients.
• It provided retrievable data, which delivered informative materials for administrative report, educational and clinical research.
• It was available with integrity and confidentiality, therefore consumer protection rights was highly secured.
