title: Organizational performance and regulatory compliance as measured by clinical pertinence indicators before and after implementation of Anesthesia Information Management System (AIMS).
abstract: Previous studies have suggested that electronic medical records (EMR) can lead to a greater reduction of medical errors and better adherence to regulatory compliance than paper medical records (PMR). In order to assess the organizational performance and regulatory compliance, we tracked different clinical pertinence indicators (CPI) in our anesthesia information management system (AIMS) for 5 years. These indicators comprised of the protocols from the Surgical Care Improvement Project (SCIP), elements of performance (EP) from The Joint Commission (TJC), and guidelines from the Centers for Medicare and Medicaid Services (CMS). A comprehensive AIMS was initiated and the CPI were collected from October 5, 2009 to December 31, 2010 (EMR period) and from January 1, 2006 to October 4, 2009 (PMR period). Fourteen CPI were found to be common between the EMR and PMR periods. Based on the statistical analysis of the 14 common CPI, there was a significant increase (p < 0.001) in overall compliance after the introduction of EMR compared to the PMR period. The increase in overall compliance was significantly progressive (p = 0.013) from year to year over 2006 and 2010. Of the 14 CPI, Documentation of a) medication doses, and b) monitoring of postoperative physiological status, mental status, and pain scores showed significant improvement (p < 0.001) during the EMR period compared to the PMR period.
authors.affiliation: Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
authors.forename: Clark K
authors.initials: CK
authors.lastname: Choi
authors.forename: Darlene
authors.initials: D
authors.lastname: Saberito
authors.forename: Changa
authors.initials: C
authors.lastname: Tyagaraj
authors.forename: Kalpana
authors.initials: K
authors.lastname: Tyagaraj
mesh_terms: D000758:Anesthesia / Q000592:standards*; D057286:Electronic Health Records / Q000458:organization & administration; D019983:Guideline Adherence / Q000706:statistics & numerical data; D063025:Health Information Management / Q000458:organization & administration*; D006784:Hospitals, Teaching / Q000458:organization & administration; D006801:Humans; D017410:Practice Guidelines as Topic; D058996:Quality Improvement / Q000458:organization & administration*; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data*; D014481:United States