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Fall 2009


13 Steps to a Disastrous Anesthesia Information System Implementation

Phil Mesisca, MBA, CMPE
University of Pennsylvania Health System, Philadelphia, PA

Implementing an Anesthesia Information System (AIS) is a major undertaking for an anesthesia practice. The question is less about “should we” and more about “when or how should we” as it is inevitable that most practices will eventually make the move. This article will review the steps to be avoided for a successful AIS implementation.

1. Purchase Vaporware

Ignore any discussion with a vendor that includes ”...not now, but we will be able to handle that in our next version…”.

2. Assume The Ais Will Fix All Your Operational Problems

In the words of Bill Gates “The first rule of any technology used in a business is that automation applied to an efficient operation will magnify the efficiency. The second is that automation applied to an inefficient operation will magnify the inefficiency.” If you have someone constantly tracking down missing anesthesia records now, you’ll probably have someone tracking down incomplete or open electronic anesthesia records later.

3. Under-Estimate The Time And Resources Needed For Implementation

Most large capital investment projects come in late and over-budget. There will be significantly more issues than you will anticipate and make sure you prepare for the time devoted to the one out of every 5 clinicians who will offer significant resistance.i

4. Only Consider The Costs And Resources Needed To Implement

You can’t prepare for every future problem so prepare for your response to a problem. Think about on-going issues and future needs such as technical support, upgrades, training, record security, interfaces, on-going fees, data mining, expansion licenses, backup processes, etc. There is an enormous amount of work in preparing for the implementation, but many practices don’t properly plan for the continued resources and time needed for the months/years after the go-live date.

5. Let The Administrative Team Take Complete Responsibility For Implementation

Key physicians and CRNAs must be involved for a successful implementation. These individuals must also be given the needed time to properly plan and implement—and remember “implement” is beyond the day the system goes live.

6. If The Hospital Is Funding The AIS, Make Sure You Allow It To Dictate What System You Will Implement Even If You Know That It Will Not Meet Your Needs

You certainly need to be reasonable, but implementing a system that isn’t going to do the job properly will be a lose/lose for both your group and the hospital.

7. Modify The Ais To Accommodate How You Do Things Today In Your Practice

The more willing a practice is to be flexible and modify work processes to take advantage of the technology, the higher the probability that the potential benefits will be realized.

8. Ignore The Research That Documents The Enormous Difficulty For People To Change And Just Assume That Everyone Will Embrace This New Technology

Consider a recent study that showed that despite the real possibility of death if patients did not change their lifestyle, fewer than 15% of heart attack survivors were following their doctor’s advice to adhere to a healthy diet just one year after their heart attack.ii Even if things go perfectly, few people embrace change.

9. Don’t Fill The Open Clerical Position In Your Practice Since You Are About To Implement Your New Ais And You’ll Surely Have Much Less Need For These Positions Once You Go Live

Before, during and for months after implementation you will have more need than ever for administrative support. This is also a critical time to have stability in key positions. President Abraham Lincoln believed that his nomination as the Republican candidate for his second term had not come because he was the best man, but rather because the party had concluded that it would be best to “not swap horses while crossing the river” since they were in the middle of the war. Good advice to remember.

10. Set Unrealistic Expectations

No system will meet all your needs and wants. Forget about your wants. Prioritize your needs.

11. Be An Eternal Optimist And Avoid Conflict

It is imperative to confront the issues, debate them, fix them, and move on. Consider the Stockdale Paradox as noted by famed author Jim Collins in his landmark book Good to Great. It’s named after Admiral James Stockdale, who survived 7 years as a POW during the Vietnam War. You can listen to a brief audio on this on Collins’s web site, but the key quote from the book is “You must never confuse faith that you will prevail in the end – which you can never afford to lose – with the discipline to confront the most brutal facts of your current reality, whatever they might be.”iii

12. Worry That This Will Be Bad For Billing Compliance, Malpractice Claims, Or Patient Care.

Billing compliance documentation will be much better as long as your actions are compliant. Non-compliant actions will be duly noted in the electronic system (e.g. If you note at 11:00 that you were present for induction but induction actually occurs at 11:42 you will have a problem). So if you do the right thing the documentation proving that will be better than ever.

A survey published in Anesthesia & Analgesia showed that departments using an AIS for anesthesia record keeping believed that these systems were useful for managing malpractice risk and did not increase malpractice exposure.iv

A study at the University of Michigan showed that the use of electronic reminders improved procedure documentation compliance and professional fee reimbursement.v Another study at Massachusetts General Hospital showed that real-time checking of electronic records for documentation errors and automatically text messaging clinicians greatly improved the quality of documentation.vi

13. Underestimate The Value Of An AIS

An MGMA survey across all medical practices reflected that after the first 6 to 24 months, the benefits of electronic health record adoption generally increasingly exceed the cost, and most practices eventually wonder how they ever conducted business without an electronic record. vii Although anesthesia is certainly very different from other specialties, similar results can be expected.

So the good news is that eventually you will have better documentation for billing compliance. Eventually charge capture will be more accurate. Eventually the billing cycle will be faster. Eventually malpractice risk will be reduced. Eventually patient care will be better. Eventually you’ll be telling stories to the residents and SRNAs about life before the AIS implementation and how paper was used. They will stare at you in disbelief.


i.MGMA Information Exchange – Electronic Health Records, November 2006.

ii.University of Massachusetts Medical School (2008, February 1). Patients Diagnosed with Coronary Heart Disease Continue Poor Diets, Study Shows. ScienceDaily. Retrieved August 28, 2009, from http://www.sciencedaily.com.

iii.Collins, Jim. Good to Great: Why Some Companies Make the Leap…and Others Don’t. Harper Business; Edition 1, October 16, 2001.

iv.Feldman JM. Do Anesthesia Information Systems Increase Malpractice Exposure? Results of Survey. Anesthesia & Analgesia. 2004; 99: 840-843.

v.Kheterpal S, Gupta R, Blum JM, Tremper KK, O’Reilly M, Kazanjian PE. Electronic reminders improve procedure documentation compliance and professional fee reimbursement. Anesthesia & Analgesia. 2007 March; 104(3):592-7.

vi.Sandberg WS, Sandberg EH, Seim AR, Anupama S, Ehrenfeld JM, Spring SF, Walsh JL. Real-time checking of electronic anesthesia records for documentation errors and automatically text messaging clinicians improves quality of documentation. Anesthesia & Analgesia. 2008 January; 106(1): 192-201.

vii MGMA Electronic Health Records: Perspective from the Adopters, October 2007.


Phil Mesisca, MBA, CMPE is the Chief Operating Officer for the Department of Anesthesiology & Critical Care and the Department of Otorhinolaryngology – Head and Neck Surgery at the University of Pennsylvania Health System in Philadelphia. He can be reached at mesiscap@uphs.upenn.edu.