title: The influence of the type and design of the anesthesia record on ASA physical status scores in surgical patients: paper records vs. electronic anesthesia records.
abstract: BACKGROUND
  The American Society of Anesthesiologists Physical Status classification (ASA PS) of surgical patients is a standard element of the preoperative assessment. In early 2013, the Department of Anesthesia was notified that the distribution of ASA PS scores for sampled patients at the University of Iowa had recently begun to deviate from national comparison data. This change appeared to coincide with the transition from paper records to a new electronic Anesthesia Information Management System (AIMS). We hypothesized that the design of the AIMS was unintentionally influencing how providers assigned ASA PS values.
  
  
  METHODS
  Primary analyses were based on 12-month blocks of data from paper records and AIMS. For the purpose of analysis, ASA PS was dichotomized to ASA PS 1 and 2 vs. ASA PS >2. To ensure that changes in ASA PS were not due to "real" changes in our patient mix, we examined other relevant covariates (e.g. age, weight, case distribution across surgical services, emergency vs. elective surgeries etc.).
  
  
  RESULTS
  There was a 6.1 % (95 % CI: 5.1-7.1 %) absolute increase in the fraction of ASA PS 1&2 classifications after the transition from paper (54.9 %) to AIMS (61.0 %); p < 0.001. The AIMS was then modified to make ASA PS entry clearer (e.g. clearly highlighting ASA PS on the main anesthesia record). Following the modifications, the AS PS 1&2 fraction decreased by 7.7 % (95 % CI: 6.78-8.76 %) compared to the initial AIMS records (from 61.0 to 53.3 %); p < 0.001. There were no significant or meaningful differences in basic patient characteristics and case distribution during this time.
  
  
  CONCLUSIONS
  The transition from paper to electronic AIMS resulted in an unintended but significant shift in recorded ASA PS scores. Subsequent design changes within the AIMS resulted in resetting of the ASA PS distributions to previous values. These observations highlight the importance of how user interface and cognitive demands introduced by a computational system can impact the recording of important clinical data in the medical record.
authors.affiliation: Department of Anesthesia, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA, 52242, USA. anil-marian@uiowa.edu.
authors.forename: Anil A
authors.initials: AA
authors.lastname: Marian
authors.affiliation: Department of Anesthesia, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA, 52242, USA. emine-bayman@uiowa.edu.|Department of Biostatistics, University of Iowa College of Public Heath, Iowa City, USA. emine-bayman@uiowa.edu.
authors.forename: Emine O
authors.initials: EO
authors.lastname: Bayman
authors.affiliation: Healthcare Information Systems, University of Iowa Hospitals and Clinics, Iowa City, USA. anita-gillett@uiowa.edu.
authors.forename: Anita
authors.initials: A
authors.lastname: Gillett
authors.affiliation: Department of Anesthesia, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA, 52242, USA. Brent-hadder@uiowa.edu.
authors.forename: Brent
authors.initials: B
authors.lastname: Hadder
authors.affiliation: Department of Anesthesia, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA, 52242, USA. Michael-todd@uiowa.edu.
authors.forename: Michael M
authors.initials: MM
authors.lastname: Todd
mesh_terms: D000328:Adult; D000368:Aged; D000758:Anesthesia / Q000706:statistics & numerical data*; D057286:Electronic Health Records / Q000706:statistics & numerical data*; D005260:Female; D055991:Health Records, Personal; D006751:Hospital Information Systems / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D013514:Surgical Procedures, Operative / Q000706:statistics & numerical data*