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Fall 2009


The Anesthesia Record™ Powered by Shareable Ink®: A Dialogue with the Inventor

Vernon Huang, MD, Founder and Chief Medical Officer of Shareable Ink and inventor of Anesthesia Record™
San Francisco, CA

In this issue, Communiqué interviews Dr. Vernon Huang, Founder and Chief Medical Officer of Shareable Ink and inventor of their Anesthesia Record™ product. The Shareable Ink Anesthesia Record allows immediate capture of information written on paper anesthesia records. Dr. Huang is also a practicing anesthesiologist in the San Francisco Bay Area with an extensive background in medical informatics and technology. Dr. Huang can be reached at vhuang@shareableink.com. ABC will market the product under the name F1rstAnesthesia Record™.

Question: Dr. Huang, what is the Shareable Ink Anesthesia Record?

The Shareable Ink Anesthesia Record is a product that enables anesthesiologists and CRNAs to take advantage of the benefits of electronic medical records without disrupting their workflow. Using the system, anesthesia providers fill out a paper form — that is nearly identical to their current anesthesia record — using a “digital” ballpoint pen. Essentially, they chart on a paper anesthesia record just as they have always done.

But now, when they drop off the patient in the PACU, they simply dock their pen in a cradle, and all the information is immediately and securely transmitted to our servers. Then, the Shareable Ink system creates actual computerized data from the pen strokes — capturing times, signatures, diagnoses, procedures, and anything else written on the form. All the information in the pen is encrypted and transmitted to our secure servers where all the computing is done.

The Shareable Ink system can even automatically conduct rule checks and immediately notify providers if they forget to provide required information, such as a signature or anesthesia end time. Alerts can be sent via pagers, text messages or emails — before the anesthesiologist has even left the PACU. An immediate notification means that a provider can fix the record while it’s still in front of him or her, resubmit the record by docking the pen, and avoid callbacks and rework.

Question: The system’s simplicity is intriguing. How is the data utilized after it’s captured?*

After the data is captured from the paper record, it is immediately “electronic” and we can do all sorts of useful things with it. This is a key capability of the Shareable Ink Anesthesia Record.

We can “slice and dice” the data and push it out to various stakeholders of the anesthesia record. For example, information required for billing can be sent to the billing company without the delay and cost associated with scanning or mailing. Because our system conducts rule checking and can immediately notify the provider about errors, we can eliminate sending the chart back to the provider for rework that would normally add weeks to the A/R cycle.

We can also send information about narcotics used during the case to the pharmacy. Sometimes, we take the data from many forms and build “dashboards,” web pages that give a view into data aggregated from many cases. Institutions can use these dashboards to monitor SCIP measures such as antibiotic administration time and patient temperature on PACU arrival.

As another example, my group has always recorded anesthesia ready time in addition to surgery start time. This way, we can measure how efficiently the OR is running. If the hospital asks us to provide an extra anesthesiologist to staff a room, we may be able demonstrate that another room is not necessary by bringing attention to this OR “downtime.” If there is sufficient downtime, the resource issue can be addressed by scheduling existing rooms more efficiently.

Unfortunately, my group never had an easy mechanism for collecting and analyzing the data. The exercise would have been too tedious to retrospectively enter that data from all the paper charts. But now, using the Shareable Ink system, the data is available electronically and anyone with a spreadsheet can analyze it. The system can even attach time stamps to checkboxes, signatures, or any other data collected from the form. This allows groups using the Shareable Ink Anesthesia Record to do detailed data analysis with regard to CRNA supervision.

Question: How does the technology by Shareable Ink compare to scanning?

First, information is immediate and actionable with the Anesthesia Record. Scanning is not as timely because the process requires someone – usually not the anesthesiologist – to physically obtain the record, put it in a work queue, and then scan it. Scanned information is also less actionable. For example, if someone scans a record with no anesthesia end time or no signature, and then, submits it for payment, days or weeks would pass before the anesthesiologist is notified about the missing information.

Second, all you get is a “picture” of the record with scanning. You don’t really obtain any discrete data. You can’t easily answer questions like, “what percentage of my patients are ASA 4E?” or “how many central lines did I put in last year?” from an archive of scanned records.

Question: What made you come up with the Shareable Ink Anesthesia Record?

I’ve always been fascinated with technology. That’s probably why I chose anesthesia as a specialty. I took a break from clinical medicine before residency to manage the healthcare market for a division within Apple Computer. I remember giving a talk in 1993 in which I predicted that someday all doctors would be carrying PDAs. Since medical school, I’ve known that healthcare providers were mobile professionals with their own specific computing needs.

The digital pen is the ultimate extension of mobile computing. Finally, we have a technology that fits our workflow. Previously, in order to use an EHR, we had to modify our workflow to fit decades-old technology. With the Shareable Ink technology, we just do our jobs as we have for years. Only now, we seamlessly capture our information digitally in the background.

Question: How did you start Shareable Ink?

During residency, in the middle of the “dotcom” boom, I took a sabbatical to join a start-up company called PatientKeeper. PatientKeeper was one of the first companies to allow clinicians to use PDAs and smartphones in their workflow. The company has grown tremendously over the years, and now, they have signed contracts with about 12% of US hospitals.

I reached out to my friend Steve Hau, the founder of PatientKeeper, and was able to convince him to become the CEO and a co-founder of Shareable Ink. Steve has a proven track record of building new companies in healthcare IT and making customers successful. He quickly assembled a terrific team of industry veterans.

Question: Who is using the Shareable Ink Anesthesia Record?

Anesthesiologists from coast to coast are using our system, and we are also working with physicians in other specialties, in both the inpatient and outpatient settings. Our anesthesiologist clients aren’t limited to any particular location or sub-specialty. We can take any existing anesthesia record and make it work with our system.

Question: What are the benefits of using the Shareable Ink Anesthesia Record?

There are numerous benefits that accrue to both the individual anesthesiologists as well as to the institutions at which they practice. The main benefit to the providers is that they get almost all of the advantages of having an EHR – but without the hassles associated with changing workflow.

With our system, there is virtually no learning curve or training involved; everyone already knows how to fill out an anesthesia record with a pen. Because of immediate rule checks, anesthesiologists know that they are filling out their records completely and won’t be asked weeks later to recall, for a particular case, what time they transferred care in the PACU. Taken together, this positively impacts job satisfaction and the bottom line.

The benefit to the institution is that they get access to data that they have always wanted but never had before —and without having to scan or key enter the records. Also, there is essentially no burden on the IT staff. No Shareable Ink software is installed on site. All the information from the pen is encrypted and transmitted to our servers where all the computing is done. Administration and providers can optionally access the data using a standard web browser and the data is always owned by the client.

Question: What benefits does it bring to the anesthesia provider?

The benefits are multiple. From an administrative and workflow perspective, the Shareable Ink Anesthesia Record eliminates lost records, cuts down on the number of records that need to be reworked and decreases days in A/R. Providers no longer have to fill out billing tickets and carry around anesthesia records until they reach some critical mass that reminds them to do their billing and send in their paperwork.

From a clinical perspective, it encourages more complete and accurate charting since it can notify us if we’ve submitted a record with a required element missing, such as an unsigned CRNA compliance statement or missing signature.

From a practice management standpoint, the Shareable Ink Anesthesia Record allows you to capture all sorts of new data that was never easily available before. One of the first things my group implemented was recording our position on the call schedule on our records. With the Shareable Ink system, it’s easy to collect all this data so we can actually analyze how much a particular position on the call schedule works over time. This will allow us to staff more efficiently.

Finally, from a financial perspective, we now have all the data we need in order to qualify for pay by performance or to report a new PQRI measure. If a new performance measure is initiated, we don’t have to do a lot of computer and data entry work, we just have to introduce a new field on a form.

Question: How does Shareable Ink technology compare to current Anesthesia Information Management Systems (AIMS)?

Anesthesia Information Management Systems have been commercially available for over a decade yet they have been installed in less than five percent of the marketplace. I believe this lack of adoption is due to two primary factors: cost and difficulty of use.

The Shareable Ink Anesthesia Record costs only a fraction of the amount an AIMS costs, and we can capture all of the salient data that the institutions that pay for these AIMS want. The Shareable Ink Anesthesia Record is also incredibly easy to use. Training is minimal and the workflow of the user doesn’t change.

In addition, AIMS require providers to use a keyboard, mouse, or other data entry device, and thus modify the way they work in order to accommodate data entry. I think this is the main reason that there has not been more widespread adoption of these systems. The approach that we’ve taken with Shareable Ink allows providers to practice the way they do now, input data in a way that is natural and familiar, and still get the benefits of an electronic system.

Question: How does the cost compare to AIMS?

Current AIMS systems require new computer hardware to be installed in every operating room, sometimes even requiring the replacement of anesthesia machines! The Shareable Ink Anesthesia Record not only costs a fraction of the cost of an AIMS in implementation, it also saves the institution ongoing costs related to training and support. Our physicians report that they require about half an hour of training. CRNA users, who don’t need to take advantage of the alerting or reporting functions, report that their training took just five minutes! On the support side, we’re not asking the providers to do anything new other than place the pen in a cradle. There’s not much that can go wrong so ongoing support costs are miniscule.

Question: What about automated vitals signs capture?

We don’t automatically capture vitals signs, and I believe that that is one of our strengths. Using the Shareable Ink Anesthesia Record, providers are still engaged with the case and record the vital signs every five minutes. This means that every five minutes the vitals have to go from our eyes, through our brains, and then be written on the anesthesia record.

It’s been suggested that while using an AIMS, providers have a tendency to let the record go on “autopilot,” and they can actually be less vigilant to the vital signs. I know some controversy surrounds this.

What we know for a fact is that cases have been litigated where the automated anesthesia record failed to record the vital signs for extended periods. Also, many providers are concerned about AIMS systems capturing spurious data, such as recording an abnormally high pulse because the cautery is in use. They fear that these data might increase their liability and lead to increased documentation burdens to edit the readings. The Shareable Ink approach still allows for the human filtering of inaccurate vital signs so that the record reflects what actually happened during the case.

Question: What are the challenges of implementing the technology?

The main challenge is in educating the institution. Hospitals are often reluctant to start new IT projects because of their history of being over budget and behind schedule. Normally, once we show the parties involved how little training is involved and how minimally disruptive it is to their workflow, things go very fast.

The only requirement to deploy the system is that the location have an Internet connection. As I mentioned, we don’t install any software on site. All we leave behind is a docking cradle for the pen and a driver to allow that cradle to communicate with our servers. Computing is done securely and remotely by Shareable Ink’s servers.

Another challenge is interfacing to the wide range of hospital IT and OR information systems that exist. Fortunately, the interface work isn’t required to get started. And the team at Shareable Ink has a deep knowledge and significant experience at this task.

Question: How does the Shareable Ink Anesthesia Record work with OR information systems?

We can interface into the OR information system. Often, the anesthesiologist keeps the most accurate and up to date record. This is especially true if the circulating nurse is expected to enter data into an OR system while performing clinical duties. By extracting data from the anesthesia record, powered by Shareable Ink and uploading it into the existing OR information system, Shareable Ink relieves physicians and nurses from the mundane, distracting and expensive task of data entry. The Shareable Ink Anesthesia Record is very complementary to traditional information systems because it draws on their strengths of storing, retrieving, and displaying data. Data entry is a limiting factor on all existing systems, and now, we’ve made that process a part of the existing workflow nearly effortless.

Question: Why did you choose ABC to be your partner?

I’ve been an ABC customer from within two busy anesthesia practices. Every few years, we re-evaluate the marketplace and consider changing billing vendors and every time, we return to ABC for our business.

We chose ABC to be Shareable Ink’s reseller in the anesthesia marketplace because of their market share, focus on the anesthesia market, their expertise in anesthesia billing and practice management, and their willingness to embrace new technologies.


Reference: Vigoda, M.M., Lubarsky, D.A. Failure to Recognize Loss of Incoming Data in an Anesthesia Record-Keeping System May Have Increased Medical Liability. Anesth Analg 2006;102:1798-1802