The Perioperative Environment

The perioperative environment is one of the most technologically advanced areas of the modern health care enterprise. From the anesthesia machine to the physiologic monitors to advanced imaging devices, the use of computer technology in the operating room now collects and displays thousands of data points per hour. It would be reasonably sound to make the claim that the computing power that resides in the typical operating room today could form the basis of a small, dedicated supercomputing cluster found in most academic computer science departments. Very rarely, however, is there the intent or capability of integrating this computing power or the information systems that medical devices host in order to make the perioperative process more efficient and patient care more effective.

The barriers to integration have been well documented and discussed by many frustrated clinicians [38]. This common concern has spawned little commitment in the health care industry, surgery in particular, in the direction of integration and interoperability. Medical device manufacturers continue to produce valuable breakthrough technologies that can successfully fit into clinical practice models as stand-alone components. When integration is offered, it is usually in the form of proprietary add-ins or suites of instrumentation. Other than being network capable and accessible with unique intranet protocol addressing, very little work has been forthcoming in the area of common data structures, machine-to-machine languages, and machine-to-hospital information data exchange schema that would foster true interoperability of information. However, common industry data protocols such as HL7 [18], which were created for the exchange of medical information between providers, payers, and regulators, has highlighted the glaring lack of interoperability of technologies in most clinical settings, including surgery.

The practice models currently utilized in surgery today were designed and implemented decades before the information technologies we rely on today were envisioned. The fact that these models survive in spite of the explosion of technology embedded in surgery is atypical of evolution of information technology in almost every other industry. The key feature of coordination in most processes associated with surgery continues to be human-to-human communication. That is why telephone, fax, and e-mail continue to have such prominence in the surgical suite. It is particularly troubling that the ever-increasing complexity of technology and clinical protocols in surgery will continue to be managed by perioperative staff performing job descriptions that have not changed except for the lengthening list of technology implementations, patient care responsibilities, and regulatory requirements.

The culture of surgery has also been slow in transforming along with the technology in its midst. In a national surgical conference held in Baltimore, Maryland, in 2002 it was noted by the keynote speaker, Dr. Bruce Jarrell, that surgery today could be characterized in the following manner:

• Teamwork is fragmented.

• Communications are by voice and grease board.

• A significant amount of energy goes into making it function rather than patient care.

• Surgeon personalities are a strong factor in its operation.

• The workload is highly variable but has high peaks.

• The complexity is high.

• Time is wasted. Someone in the operating room is always looking for some critical thing while the patient and surgeon wait.

• Information systems are used to a limited degree.

The issues, as identified by Dr. Jarrell, are classic production problems experienced in most other industries, including manufacturing, finance, and transportation among many others, and were early targets of technology-based solutions. A hospital-based surgical unit's exposure to technology-based solutions developed by other industries often occurs in the form of contracted relationships with business partners, a predominant example being automating supply chain processes. In this case, operating room staffs are frequently not the sponsors of the new technology solutions but are invited users of the solutions.

What is found in most modern surgical suites are surgical and anesthesiology information systems. Both perform scheduling, coordination of preoperative processes, and case management and medical coding functions. Anesthesia systems typically go beyond these basic functions and utilize data extracted from connected monitoring and other medical devices to populate a medical encounter record, usually based on proprietary solutions. These systems are often justified based on revenue capture although they have significant patient safety and outcome implications.

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