How electronic health records (EHRs) and digitalisation improve outcomes
Welcome to the podcast of the European Society of Anesthesiology and Intensive Care. I'm your horse, professor Wolfgang Burer. I'm a professor of perioperative medicine from the University Medical Center in Utrecht, The Netherlands, and I'm also the current president of our society. And today, we will talk about how electronic health records and, digitization can improve outcomes. For me, it's a it's a great pleasure and also a honor to welcome doctor Warren Sandberg.
Speaker 1:Hello, Warren.
Speaker 2:Hello. Good to see you.
Speaker 1:Warren is a professor of, anesthesiology, at the department of anesthesiology at Vanderbilt University Medical Center in Nashville. He's also the chief of, staff of the Vanderbilt hospital. And we know each other for a very, very long time. And we share our common interest in adding value for patient care. And we both explored at certain parts in our career that electronic data recording and the working with is is, is quite an important step in this endeavor.
Speaker 1:So, Warren, my first question is you're working quite long in that field, and you was one of the first who was proponents of electronic data recording for a couple of reason, not only for documentation. And as in Europe, we have a very heterogeneous situation. Some of us are working still on paper, some using different kinds of electronic patient data recording. Can you elaborate a bit about your journey in that field? Sure.
Speaker 2:So, actually, you you give me credit for being a early proponent, but, really, the person who, shaped my career was my former boss, the chair of the Department of Anesthesiology at Mass General, Warren Zapol, who, as part of his negotiations, become chair there in the nineties, included a requirement that MGH invest in electronic record keeping for anesthesiology. And the reason that he did that was to provide a searchable and readily available record both for clinical use, I'll give you an example in a minute, but also, to make sure that the department was able to fully capture the value of what it was doing. And in The United States, we're on a very much a pay per click model of reimbursement for health care. And so every activity that adds value to patients course also generates revenue for the department. And every activity that you do that you don't record is an expense that you're not reimbursed for.
Speaker 2:And so Warren recognized very early, Zaple, that getting paid for what you're doing was easier if you had an electronic record to capture all of that and structure the data in a way that you could find it. And, actually, one of my first publications in that space demonstrated that the department recognized real pickups in lost revenue that would've that was lost because people didn't complete their documentation in a timely way, sufficient to actually pay for an additional anesthesiologist or at least keep that system in place forever. The real value, though, for a clinician is, something I experienced last week. I was presented with a patient whose electronic record was marked very clearly right at the top when you open the page that they had a difficult airway. And we all know about the difficult airway who presents in a normal looking patient, and the patient in front of me looked very normal.
Speaker 2:And so I opened their record, and I looked for records of prior intubations and was able to discover that they had been intubated previously at Stanford University, about eleven months before, with a simple, Macintosh laryngoscopy and a grade one view of the vocal cords. So the splash screen, which is really concerning, was actually in error. I was able to correct that and was able without any effort whatsoever to, get a look at somebody else's record of that patient's care and avoid what could have been a real pain that patient.
Speaker 1:Yeah. I think that that's a great example. And I think both parts of it to have the information of the individual patient right away available Yep. Is a is a very major step forward.
Speaker 2:Well, in an integrated system now across you know, so, you know, there are some systems that are that integrate across multiple hospitals independent of your network, right, or your or in your case, so you're of your country. So that is a real increase in leverage.
Speaker 1:Yeah. After being in, Nashville for a while, you implemented something I find very interesting. This is the anesthesiology perioperative informatics department or subdepartment Mhmm. Which is associated with with a very active research group.
Speaker 2:Mhmm.
Speaker 1:Can you show or tell our people why you did that, why you made that decision together with the team?
Speaker 2:So, yeah, it it's actually called the the Vanderbilt Anesthesia Perioperative Informatics Research Group, VAPOR, for short. And so Vapor actually started off as the department's, sort of local clinical informatics group to help us answer, clinical informatics questions. Some of the operational ones were related to finance, like the ones I just talked about for revenue. But, over time, VAPOR has actually evolved into an institutional resource, and they are able to do data management to support one of Vanderbilt's calling cards, which is the hospital wide implement fully implemented pragmatic trial. And so now VAPOR serves a function of a data management for all kinds of patients who are having pragmatic trials that touch the perioperative space.
Speaker 2:And so, they did the data management, for example, for several famous pragmatic trials, like such as the SALT study, which, basically compared normal saline to balanced crystalloid solutions for patients both admitted to the ED and also for patients in the ICUs and demonstrated a clear difference between those two outcomes or those two interventions. And and it's it's not widely appreciated that the data management and randomization for those trials were conducted by
Speaker 1:VAPOR. Yeah. It's a great story. I think when
Speaker 2:Can I have one more second?
Speaker 1:Yes.
Speaker 2:So, we have, there there's there's an inter there's a lot of interconnection here. I think you might talk a little bit later about our enhanced recovery programs. And, we have turned, our attention in vapor to doing pragmatic trials of various, interventions in an enhanced recovery program and testing whether or not those individual interventions are necessary to achieve the ERAS outcome. And, the results are not for most recent trial were actually quite surprising. Can't really discuss them in detail, but they will show up in publication eventually.
Speaker 2:So we're we're now using the electronic record, to both scaffold our pragmatic trials and then the vapor group to do the data management randomization in those trials. And we're coming back now with dispositive answers about things that people have argued about for a long time and felt to be an equipoise. So but we're beginning to realize the real value both of the electronic record and the informatics group.
Speaker 1:This is a very interesting part because, yesterday, we had a webinar about the use of routine data and big data in perioperative medicine, and I was, allowed to give one of these talks. And, I said that in our environment, the availability of electronic patient data from different sources allows us much better than earlier to answer the real world questions in anesthesia, which are impossible to get funded by a randomized controlled trial and even impossible to be executed because you need enormous amount of of patient records. And if I understood you're right, the Weyper group made that evolution quite naturally in in the last years starting from documentation, going over to business, and ending or now reaching also a very high research level.
Speaker 2:Yes. Yes. Without actually any loss of function in those other areas. Yeah.
Speaker 1:Yeah. Great. One very interesting part of it is are that we are much more interested in in following our patients for a longer time. Mhmm. In my opinion, we need to do so because we never will learn about quantification of pain or value of interventions when we don't stay connected with our patients for Yep.
Speaker 1:Six months, a year. How how long does it take? You was, a very early adapter of that of that part. And, to my knowledge, since more than ten years, you are following your patients quite on a regular basis. Can you elaborate a bit on that?
Speaker 2:Yeah. Gladly. Again, we were pushed in this direction partly by the exigencies of some of some of our regulatory framework in The United States. So, just to give you come back to enhanced recovery programs for a second, we actually, track an outcome called days alive at home 30 dash 30, which I think is a metric that most of you are familiar with. And the reason we we do this for a lot of reasons, but, one of them relates to, maintaining compliance with prohibitions on inducement, inducing patients to have medical care.
Speaker 2:So in The United States, we're limited in what we can give to a patient. Now, in our enhanced recovery bundles, we would like our patients to have good nutrition coming up to surgery and, have you know, be able to use chloroxidine wipes if that's indicated, for example. And that bundle of stuff costs a fair bit of money. And from an equity perspective, we felt it was necessary that every patient that we care for have access to that. It is not reimbursed in American insurance programs, and so some patients have to pay out of pocket for it and not all patients can afford it.
Speaker 2:So we wanted to give it to them. So to demonstrate to to provide protection for ourselves against an inducement, scheme, we had to demonstrate that giving these supplies to patients actually improve their outcomes. Yeah. And so because we have a great electronic system that captures all these data automatically, including the readmission, if there is one, measuring dash 30 was easy. It we were measuring it constantly for everybody all the time.
Speaker 2:And, we were also able to demonstrate very clearly that provision of this bundle, improves dash 30 for patients. They spend more time alive at home, than if we don't actually provide that bundle. And so we were able to make the case that it was good business, if you will, to give these things to patients, not as an inducement, but as a an an outcome improver. And it improved our financial outcomes too because we don't get reimbursed for readmission within 30. So by avoiding a readmission, we actually save money.
Speaker 2:This is all attributable to the fact that we've got really good data capture about our patients.
Speaker 1:And it seems to me it it it's a classical, example for adding value to the section by staying connected with them and being interested in the patient's behavior.
Speaker 2:Yes. Yes. There are other examples of this ongoing connection. I think my favorite one is the patient portal, to their own electronic record that we provide to them on their mobile devices. And I myself am a user.
Speaker 2:I'm a patient at Vanderbilt. And it is just the easiest way to transact business, with your health system. And, of course, your health system can reach out and transact business with you as well. And it not just business business. It's the business of caring for the patient.
Speaker 2:And so we try we stay connected to our patients through that portal with everything from, you know, wellness messages through to, hey. Remember, you've got an appointment coming up in three months. Are you gonna be there or not? So it's it's it's it's a really good connection and and very valuable. And, again, the the foundation is the electronic health record.
Speaker 2:Without that, you you have nothing.
Speaker 1:Yes. When when listening to you, it seems that anesthesiology or anesthesiologists like us, relatively attractive to to organizing workflows, processes with the the quality of patient care in the center, but also with some view on the economical, technical, safety environment. Do you have any idea why we as anesthesiologists are are so good in that?
Speaker 2:I could talk for a while. I think it comes down to, the nature of our primary environment where we started, which is in Operating Room Suites. Right? So that is a shared space. It's a workspace for surgeons, but we are, traditionally permanent denizens there.
Speaker 2:And our well-being as a specialty depends on the efficient management of that space, in a way that is fair, and even handed. And so in the best circumstances, we wind up being seen as the honest brokers of access to the space, manager to the space for the benefit of all the surgeons about the same and all the patients as as clearly as we can manage. And when that's recognized in a health system, then whenever there is a space where an honest broker who doesn't, to use an American colloquialism, have a dog in the fight, over territory, access to hospital beds or resources, but rather, benefits from being a good steward of those resources, that's where you'll find anesthesiologists in leadership in enlightened organizations.
Speaker 1:I think also our interest in data and and and staying connecting, is is quite important because, a couple of the not only the research group, but also the standardized hospitality, standardized hospital mortality rate groups are very interested in in taking the patient in the center, but moving from there to to bringing people together, feed them with the appropriate information in a in a digitized manner, and and having the good discussions instead of having, let's say, a lot of emotional territory files. I think this is something we we both can agree on.
Speaker 2:Yes. Yes. Indeed. So, we are we thinking specifically about, undesired events, you know, individual events that lead to patient harm or or patient injury or, in some cases, death. We actually look for system level failures first and look for system level fixes for those.
Speaker 2:And, again, the electronic medical record as a tool to trap and eliminate those opportunities for error is foundational. And so you could think of something like what I would call if then conditional or clinical decision support. If the patient arrives in your hospital with an insulin pump, then, you should mandate a consultation to the endocrine service in the absence of an endocrine specialist on the admitting team, because the end the admitting team is unlikely to know the details of how to manage that pump. That's one use. Right?
Speaker 2:So we can use we can write a rule to actually make that happen in the electronic record, but then you can generalize that to all sorts of if then conditions. If the patient has a positive blood culture, then you will mandate an infectious disease, consultation. And this, again, it can be made automatic in the sense that the record keeping system will do that work and then present an option to the clinician. They don't have to accept the recommendation to have an endocrine consult. But if they choose to decline it, they're gonna have to actually log that, and they in turn will be logged in when that happens.
Speaker 2:Yeah. So they're really great tools for managing performance.
Speaker 1:Yeah. And I think we we both agree these systems in particular when they compromise comprise, decision support, they are partners. They help us to use the at adequate knowledge in our field appropriately. They are not concurrence, but they are just partners in in looking for the best possible patient care.
Speaker 2:Yes. Yes. To to continue on the if then decision support, suppose, let's talk about a baclofen pump instead, and you are a general internist admitting a patient with an unrelated problem, you might not recognize the patient has a baclofen pump. Yes. You might not you and if you don't take a good history, the patient might not tell you that.
Speaker 2:But in an interconnected electronic health system, the fact of that baclofen pump will be part of the patient's record. And so when you pass that admission milestone, that would activate the decision support even if you as the clinician had missed the fact that this patient had this condition. But it can be a really helpful device.
Speaker 1:As obvious, we we normally start our video cast with an open question. I did that, and we closed them with an open question. And at least in Europe, we have a lot of discussion about allowing systems to talk to each other, communicate the pitfalls of, digital systems. That's one thing. So I'm very much interested, and I'm I'm sure our audience also, what's your vision?
Speaker 1:How can we design the next steps? A lot of buzzword through the orbit, the the use of artificial intelligence, the use of big data, and everything else. And I'm very much interested. What what's your opinion on that?
Speaker 2:That's a big open question. I think that, you know, I've I've always admired, European, governments for and and organizations for their privacy concerns, especially. And, so in the in The United States, we we are also very serious about privacy, but I think probably a little more promiscuous in the allowing data to flow back and forth. And I think that that has has led to real, advantages in terms of our ability to know things about patients, and we assume that there's a beneficent intent. I think the assumption, may not always be a correct one, but here up until now, apart from data breaches that have led to hacks and information being sequestered, we haven't yet seen somebody get injured by the accidental, sharing of data too much, but we have seen clear benefits of allowing that sharing.
Speaker 2:But I'm not exactly sure where we're going to go from here. I think we're we're we're capturing enough benefit now that in if it were if if I were the person as the patient, I would want a more permissive sharing environment than what most people might accept. I think that the value to me of having my clinicians know everything about me outweighs any potential privacy risk. Of course, I've not been on the wrong side of one of those privacy problems, so I was speaking to you with a bit of a bias. Think going to the future.
Speaker 2:We are just beginning to see the opportunities to do these one off decision support topics. Right? I think, though, eventually, the electronic health systems will have these features built in to their base systems, and we will come to take that for granted. And that will allow physicians and other health care providers to go from needing to remember and pay attention to fine detail and to monitor things that humans are not good at and focus more on the human relations aspect of patient care and on noticing subtle abnormalities and changes in condition, things that humans are really well primed to do naturally, but they're right now are being obscured by the need to take a very detailed history. Remember to make a checklist to do all these things, especially if you're in a paper record system.
Speaker 2:I can't I I would I would be really reluctant to move back to a system like that knowing the advantages that we already experienced and the potential that we could have.
Speaker 1:Yeah. I think this is a this is a very nice and and and, evidence based, I would like to say, look into the future. Because, I'm absolutely sure that all of us which are used to adequately, use this electronic system, work with digitized data, able to make connections to patients, to other caregivers, which increase our role in the multidisciplinary treatment of patients significantly. This is has really led to online execution of of perioperative medicine. Yes.
Speaker 1:Of just being part of the operating theater team because, at least in our country, anesthesiology is, let's say, one of the last holistic specialties in in the hospital. Mhmm. Overseeing a lot of patients, a lot of patients' flows, and, having access to, yeah, the majority of specialties in the meantime.
Speaker 2:Yes. You know, I would say that our our department has had the journey of being an OR based specialty to a broader hospital based specialty because the electronic health record has allowed us to prosecute these enhanced recovery protocols from the decision for surgery all the way through hospital discharge and beyond. And these are protocols that are the development of them is actually hosted, convened by anesthesiologists with our surgeon stakeholders. But in fact, we are the glue that hold these programs together. And at my hospital, at least, these have become so important to the hospital's, success that it is now a hospital based initiative with us not really so much in the lead as, leading from behind to take a phrase for Barack Obama.
Speaker 2:And, you know, so orchestrating, but without without being flamboyant about it. It's exactly the role that anesthesiologists play in our in our first environment, which is the operating room. Yeah. And it's been a real tool for us.
Speaker 1:Yeah. And I think it it also creates a lot of recognition. It increases self confidence a lot, which is always good for a specialty like ours. Yep. So, Baron, thank you very much for for being with us, for us tonight, for you in the afternoon.
Speaker 1:And, thank you everyone for listening to this episode of the European Society of Anesthesiology and Intensive Care Medicine podcast. Look on our website. We have a couple of, very attractive other podcasts in our academic list. You can get them also via various other streaming portals. Warren, I hope to see you soon.
Speaker 1:I wish you a very good day, and goodbye. Thank you. Goodbye.
