Reducing the Barriers to Electronic Documentation in Anesthesia Practice Settings

Issues, Impacts and Insights Column

by Kathleen A. Piotrowski DNP, CRNA

- Guest Editor


Piotrowski, K. (2012). Guest Editor. Reducing the Barriers to Electronic Documentation in Anesthesia Practice Settings.  Online Journal of Nursing Informatics (OJNI), 16 (3), Available at  http://ojni.org/issues/?p=2003



As a DNP student, I was challenged to identify a clinical problem and then develop a scholarly, evidence-based solution. As a veteran Certified Registered Nurse Anesthetist (CRNA) with a new-found interest in informatics, I was drawn to investigate the lack of electronic medical records in the anesthesia work environment.

Anesthesia work environments and practice arrangements are often very different across locations and facilities. CRNAs must rapidly complete cases, maintain high vigilance, work in small spaces, and travel to remote locations within the hospital. Some CRNAs are solely hospital-based. These CRNAs work in the operating rooms within one facility, but also may be required to provide anesthesia coverage in different locations within the hospital such as Obstetrics, Endoscopy, Radiology, Intensive Care, Cardiology, Emergency Departments and pain centers. Other CRNA practice arrangements, especially common in Arizona, are independent contractor CRNAs who work at several locations. These CRNAs may provide work on an as needed basis in hospitals, eye centers, endoscopy centers, dental offices, and office-based surgical specialties.

Until recently, traditional pen and paper documentation was all that was used by anesthesia practitioners for documentation purposes. My own literature search revealed that only 5-10% of anesthesia departments had adopted computerized charting (Epstein, Vigoda & Feinstein, 2007; Egger Halbeis, Epstein, Macario, Pearl & Grunwald, 2008). Yet, with new government incentives and threats of payment penalties, this percentage was expected to change (Towery, 2009).

At each medical facility where I currently work, I have encountered a different brand of electronic health record (EHR) used by the operating room staff. Of note, a fully functional electronic anesthesia record or anesthesia information management system (AIMS) has not been implemented at any of the facilities where I currently practice. However, I am required to be proficient with each hospital’s EHR in order to gather all the preoperative data regarding a patient’s health history and to be able to maneuver postoperative order writing; although I am not required to perform my own anesthesia charting electronically. My hand-written record is eventually scanned into the patient’s EHR. During recent clinical site visits to hospitals on the East Coast, I saw that AIMS had been adopted in all three of the academic-type hospitals that I visited along with a fully integrated hospital-wide EHR, suggesting that there may be a wide disparity in adoption rates across the country.

Why is there such slow adoption of AIMS? Barriers described in the literature include cost, complexity to implement and use, quality issues, a steep learning curve, problematic interface, fear of increased liability, and fear of not achieving a return on investment (Egger Halbeis, et al., 2008; Anesthesia Business Consultants, 2009). This led me to wonder whether a simpler device such as a digital pen and paper system might reduce some of these barriers. To test this notion, I conducted a feasibility study, which I describe briefly below:

A Feasibility Study


For my feasibility study, I focused on the digital pen and paper system developed by Shareable Ink®. Digital pen and paper technology has been studied previously on nursing units and in an obstetric anesthesia department with mixed results (Despont-Gros, Cohen, Rutschmann & Geissbuhler, 2009; Despont-Gros, Landau, Rutschmann, Simon & Lovis, 2005; Dykes, Benoit, Chang, Gallagher, Spurr & McGrath, 2006; Yen & Gorman, 2005). However, the technology had not been studied with anesthesia practitioners in a general operating room or a rapid turnover environment like an endoscopy suite. Therefore, I examined the ability of experienced nurse anesthetists to perform a typical anesthesia documentation task using the device as they would in their own work environments. In addition, I obtained input from other stakeholders who would be affected if the device were implemented in their setting.


After obtaining approval for the study from the University of Arizona Human Subjects Committee, I recruited seven Arizona CRNAs for a cognitive walkthrough. A cognitive walkthrough is a usability engineering technique in which participants are observed as they use an actual technological device as if they were in their own workplace (Kushniruk & Patel, 2004). Prior to the cognitive walkthrough, each participant completed a computer and work experience questionnaire adapted from Balen & Jewesson (2004) and McLane (2005). During the cognitive walkthrough, each participant was asked to talk aloud as they used the digital pen to perform the typical documentation tasks I assigned. At the end of the walkthrough, the participants completed a user satisfaction survey adapted from QUIS (Chin, Diehl & Norman, 1988). Their verbal responses during the walkthrough were audio recorded, and their comments were then categorized thematically.

I then demonstrated the digital pen and paper system to potential stakeholders at a community hospital in the Midwestern United States with basic EHR capability. After the demonstration, I conducted semi-structured interviews with the Chief of Anesthesia, Chief of Information Technology, Assistant Director of Medical Records, an anesthesia biller and a Post Anesthesia Care Unit (PACU) RN and recorded their comments and questions.


The CRNA sample varied in background and work experience. Each participant reported having basic computer skills and using computers routinely at home.  Overall, 80% rated the digital pen technology as highly satisfactory. Common themes identified in the verbal data obtained during the cognitive walkthroughs included that the device was easy to use, quick to learn, permitted user control of data entry and had the same qualities of the traditionally used ink pen and paper documentation method, but provided a way to meet the electronic data needs of today’s world. Problems observed with the pen during the cognitive walkthrough were either due to unfamiliarity with the generic anesthesia record used for the walkthrough, biases resulting from prior experiences with other (successful or not successful) information technology, and concerns about loss, breakage, or bulkiness of the pen. The interviewed stakeholders voiced similar responses, e.g., the pen appeared easy to learn and seemed to perform the task, but raised concerns about its durability and the potential problem of losing the pen (Piotrowski, 2011).


As a practicing CRNA, my uneasiness going into a hospital is not due to the patient’s condition, the surgeon, or even the surgery being performed. I am quite comfortable taking care of patients. My concerns are: 1) not knowing how to find things that I need for the day and, 2) remembering how to access the EHR. An EHR training session completed three months ago is not sufficient. I refuse to sacrifice vigilance because I have to hunt to input data on a computer keyboard for documentation purposes. Safety and efficiency could be compromised.

Unfortunately, in today’s competitive market, no single EHR product will be purchased and used by every anesthesia department. However, for those facilities that utilize a pool of temporary CRNAs, have a small budget and a rapid patient turnover expectation, and lack the ability to track quality indicators, digital pen and paper technology may be a viable solution. Moreover, the digital pen is a solution that staff members can learn to use quickly.

Electronic documentation should not deter or detract practitioners from being able to do their job. Multiple different complex documentation systems that require 3-6 hours of training may create barriers to practice which, in turn, may lead to poor staffing, surgical delays and surgical cancellations. The digital pen may be a workable solution for some anesthesia departments, although it is unlikely to be the solution for all environments. Ultimately, EHR technology needs to fit the workers and workplace.

The concerns raised here are not limited to CRNAs or even to the anesthesia setting, but pertain equally to any healthcare professional who works in multiple environments using a variety of documentation systems. Developers and purchasers of EHRs and other documentation technologies need to be made more cognizant of the risks to practitioners, patients, and organizations imposed by disparate systems due to the dangerous combination of human memory limitations, high stress work environments, and inefficient designs.


Anesthesia Business Consultants. (2009). Electronic medical records in anesthesia: Are we getting closer?  Retrieved from http//www.anesthesiallc.com/ealerts-electronic-medical-recordsIn-anesthesia-2009

Balen, R., & Jewesson, P. J. (2004). Pharmacists’ computer skills and needs assessment survey. Journal of Medical Internet Research, 6(1).

Chin, J. P., Diehl, V. A. & Norman, K. L. (1988). Development of an instrument measuring user satisfaction of the human-computer interface. Proceedings of SIGCHI’88, (pp.213-218), New York ACM/SIGCHI.

Despont-Gros, C., Cohen, G., Rutschmann, O., Geissbuhler, A., & Lovis, C. (2009). Revealing triage behavior patterns in an ER using a new technology for handwritten data acquisition. International Journal of Medical Informatics, 78, 579-587.

Despont-Gros, C., Laundau, R., Rutschmann, O., Simon, J., & Lovis, C. (2005).  The digital pen and paper: Evaluation and acceptance of a new data acquisition device in clinical settings. Methods of  Information in Medicine, 44, 359-368.

Dykes, P., Benoit, A., Chang, F., Gallagher, J., Spurr, C., McGrath, E.J.,…Prater, M. (2006). The feasibility of digital pen and paper technology for vital sign data capture in acute care settings. AMIA 2006 Symposium Proceedings, 229-233.

Egger Halbeis, C., Epstein, R. H., Macario, A., Pearl, R.G., & Grunwald, Z. (2008). Adoption of anesthesia information management systems by academic departments in the United States. Anesthesia & Analgesia, 107(4), 1323-1329.

Epstein, R., Vigoda, M. M., & Feinstein, D. M. (2007). Anesthesia information management systems: A survey of current implementation policies and practices. Anesthesia & Analgesia, 105(2), 405-411.

Kushniruk, A. W., & Patel, V. (2004). Cognitive and usability engineering methods for the evaluation of clinical information systems. Journal of Biomedical Informatics, 38, 75-87.

McLane, S. (2005). Designing an EHR planning process based on staff attitudes toward and opinions about computers in healthcare. CIN: Computers, Informatics, Nursing, 23(2), 85-92.

Piotrowski, K. (2011). A feasibility evaluation of a digital pen and paper system for accomplishing electronic anesthesia record-keeping. Dissertation Abstracts International, 73(3). (UMI  No. 3487228).

Towery, C. (2009). Is now the time to adopt electronic health records? Retrieved from http://www.chiroeco.com/chiropractic/news/7987/1100

Yen, P.-Y., & Gorman, P. N. (2005). Usability testing of a digital pen and paper system in nursing documentation. AMIA 2005 Symposium Proceedings, 844-848.


Proofed by Paula Lane.

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