Allan F. Simpao

A Review of Analytics and Clinical Informatics in Health Care

Federal investment in health information technology has incentivized the adoption of electronic health record systems by physicians and health care organizations; the result has been a massive rise in the collection of patient data in electronic form (i.e. “Big Data”). Health care systems have leveraged Big Data for quality and performance improvements using analytics—the systematic use of data combined with quantitative as well as qualitative analysis to make decisions. Analytics have been utilized in various aspects of health care including predictive risk assessment, clinical decision support, home health monitoring, finance, and resource allocation. Visual analytics is one example of an analytics technique with an array of health care and research applications that are well described in the literature. The proliferation of Big Data and analytics in health care has spawned a growing demand for clinical informatics professionals who can bridge the gap between the medical and information sciences.

Big data and visual analytics in anaesthesia and health care

Advances in computer technology, patient monitoring systems, and electronic health record systems have enabled rapid accumulation of patient data in electronic form (i.e. big data). Organizations such as the Anesthesia Quality Institute and Multicenter Perioperative Outcomes Group have spearheaded large-scale efforts to collect anaesthesia big data for outcomes research and quality improvement. Analytics--the systematic use of data combined with quantitative and qualitative analysis to make decisions--can be applied to big data for quality and performance improvements, such as predictive risk assessment, clinical decision support, and resource management. Visual analytics is the science of analytical reasoning facilitated by interactive visual interfaces, and it can facilitate performance of cognitive activities involving big data. Ongoing integration of big data and analytics within anaesthesia and health care will increase demand for anaesthesia professionals who are well versed in both the medical and the information sciences.

The Design and Implementation of an Automated System for Logging Clinical Experiences Using an Anesthesia Information Management System

BACKGROUND:Residents in anesthesia training programs throughout the world are required to document their clinical cases to help ensure that they receive adequate training. Current systems involve self-reporting, are subject to delayed updates and misreported data, and do not provide a practicable method of validation. Anesthesia information management systems (AIMS) are being used increasingly in training programs and are a logical source for verifiable documentation. We hypothesized that case logs generated automatically from an AIMS would be sufficiently accurate to replace the current manual process. We based our analysis on the data reporting requirements of the American College of Graduate Medical Education (ACGME). METHODS:We conducted a systematic review of ACGME requirements and our AIMS record, and made modifications after identifying data element and attribution issues. We studied 2 methods (parsing of free text procedure descriptions and CPT4 procedure code mapping) to automatically determine ACGME case categories and generated AIMS-based case logs and compared these to assignments made by manual inspection of the anesthesia records. We also assessed under- and overreporting of cases entered manually by our residents into the ACGME website. RESULTS:The parsing and mapping methods assigned cases to a majority of the ACGME categories with accuracies of 95% and 97%, respectively, as compared with determinations made by 2 residents and 1 attending who manually reviewed all procedure descriptions. Comparison of AIMS-based case logs with reports from the ACGME Resident Case Log System website showed that >50% of residents either underreported or overreported their total case counts by at least 5%. CONCLUSION:The AIMS database is a source of contemporaneous documentation of resident experience that can be queried to generate valid, verifiable case logs. The extent of AIMS adoption by academic anesthesia departments should encourage accreditation organizations to support uploading of AIMS-based case log files to improve accuracy and to decrease the clerical burden on anesthesia residents.

Contribution of the active metabolite, norcocaine, to cocaine's effects after intravenous and oral administration in rats: pharmacodynamics

Abstract. Rationale: Oral cocaine is more effective than IV cocaine by pharmacokinetic and pharmacodynamic analysis. One explanation is involvement of the active metabolite, norcocaine, in cocaines effects. Objectives: To evaluate norcocaines contribution to oral cocaines effects, norcocaines effects as a parent compound were determined and compared to those of cocaine using a differential reinforcement of low rate (DRL 45-s) schedule and spontaneous activity (large and small movements) after IV and PO routes of administration. Methods: The effects of cocaine and norcocaine on DRL performance (shorter-response and reinforcement rates) and spontaneous activity were investigated in 3-h sessions. The changes in effects across time (effect-time profiles) and dose-response curves (DRCs) were constructed to evaluate the duration of action and potency (ED50) of both drugs. Results: Under the DRL 45-s schedule, effect-time profiles showed both drugs via the two routes of administration significantly increasing and decreasing shorter-response rates and reinforcement rates, respectively. However, cocaine produced greater effects on shorter-response rates than norcocaine, while both drugs produced comparable effects on reinforcement rates. For spontaneous activity, although IV cocaine, PO cocaine, and PO norcocaine dose- and time-dependently increased spontaneous activity, cocaines effects were more profound than those of norcocaine. Effect-time profiles revealed that the duration of drug action was a function of dose, route, and behavioral paradigm used. According to ED50 values, IV cocaine was more effective than PO cocaine; however, PO cocaine was more effective than IV cocaine as judged by ED50 values corrected for absolute oral bioavailability. Conclusions: Norcocaines contribution to oral cocaines effects on DRL performance is evident. Other mechanism(s), such as a greater acute tolerance to IV cocaines effects than to PO cocaines effects, can be excluded.

Early detection of critical pulmonary shunts in infants

This paper aims to improve the design of modern Medical Cyber Physical Systems through the addition of supplemental noninvasive monitors. Specifically, we focus on monitoring the arterial blood oxygen content (CaO2), one of the most closely observed vital signs in operating rooms, currently measured by a proxy -- peripheral hemoglobin oxygen saturation (SpO2). While SpO2 is a good estimate of O2 content in the finger where it is measured, it is a delayed measure of its content in the arteries. In addition, it does not incorporate system dynamics and is a poor predictor of future CaO2 values. Therefore, as a first step towards supplementing the usage of SpO2, this work introduces a predictive monitor designed to provide early detection of critical drops in CaO2 caused by a pulmonary shunt in infants. To this end, we develop a formal model of the circulation of oxygen and carbon dioxide in the body, characterized by unknown patient-unique parameters. Employing the model, we design a matched subspace detector to provide a near constant false alarm rate invariant to these parameters and modeling uncertainties. Finally, we validate our approach on real-patient data from lung lobectomy surgeries performed at the Childrens Hospital of Philadelphia. Given 198 infants, the detector predicted 81% of the critical drops in CaO2 at an average of about 65 seconds earlier than the SpO2-based monitor, while achieving a 0.9% false alarm rate (representing about 2 false alarms per hour).

A Narrative Review of Meaningful Use and Anesthesia Information Management Systems.

The US federal government has enacted legislation for a federal incentive program for health care providers and hospitals to implement electronic health records. The primary goal of the Meaningful Use (MU) program is to drive adoption of electronic health records nationwide and set the stage to monitor and guide efforts to improve population health and outcomes. The MU program provides incentives for the adoption and use of electronic health record technology and, in some cases, penalties for hospitals or providers not using the technology. The MU program is administrated by the Department of Health and Human Services and is divided into 3 stages that include specific reporting and compliance metrics. The rationale is that increased use of electronic health records will improve the process of delivering care at the individual level by improving the communication and allow for tracking population health and quality improvement metrics at a national level in the long run. The goal of this narrative review is to describe the MU program as it applies to anesthesiologists in the United States. This narrative review will discuss how anesthesiologists can meet the eligible provider reporting criteria of MU by applying anesthesia information management systems (AIMS) in various contexts in the United States. Subsequently, AIMS will be described in the context of MU criteria. This narrative literature review also will evaluate the evidence supporting the electronic health record technology in the operating room, including AIMS, independent of certification requirements for the electronic health record technology under MU in the United States.

The first 100 infant thoracoscopic lobectomies: Observations through the learning curve and comparison to open lobectomy

OBJECTIVE The objective of the study is to describe our initial 100 attempted infant thoracoscopic lobectomies for asymptomatic, prenatally diagnosed lung lesions, and compare the results to contemporaneous age-matched patients undergoing open lobectomy. BACKGROUND Infant thoracoscopic lobectomy is a technically challenging procedure, which has only gained acceptance worldwide in recent years. METHODS This is a retrospective review of all patients undergoing thoracoscopic or open lung lobectomy between March 2005 and January 2014. Included were all asymptomatic infants younger than 4months. Excluded were patients undergoing emergent lobectomy and patients with isolated extralobar bronchopulmonary sequestrations. RESULTS A total of 100 attempted thoracoscopic lobectomies were compared with 188 open lobectomies. In the thoracoscopic group, mean age and weight at surgery were 7.3weeks and 4.8kg, mean operative time was 185minutes, and mean hospital stay was 3days. Twelve cases were converted to open (12%). Ten conversions occurred within the first third of the series and none in the last third. There were no mortalities. There were no differences between the thoracoscopic and open groups in perioperative complications or hospital stay. There was a significant difference in the operative time: 111minutes vs. 185minutes (open vs. thoracoscopic; p<0.001). There was a higher mean end-tidal carbon dioxide (ETCO2) and lower mean peripheral capillary oxygen saturation (SpO2) in the thoracoscopic group versus the open group (51.7 versus 38.6mmHg and 97.5 versus 99.1%, respectively). CONCLUSION In high volume centers, the learning curve of thoracoscopic lobectomy can be overcome and the procedure can be performed with equivalent outcomes and, in our opinion, superior cosmetic results to open lobectomy.

Visual analytical tool for evaluation of 10-year perioperative transfusion practice at a children's hospital

Children are a vulnerable population in the operating room, and are particularly at risk of complications from unanticipated hemorrhage. The decision to prepare blood products prior to surgery varies depending on the personal experience of the clinician caring for the patient. We present the first application of a data visualization technique to study large datasets in the context of blood product transfusions at a tertiary pediatric hospital. The visual analytical interface allows real-time interaction with datasets from 230 000 procedure records. Clinicians can use the visual analytical interface to analyze blood product usage based on procedure- and patient-specific factors, and then use that information to guide policies for ordering blood products.

From simulation to separation surgery: a tale of two twins.

110 January 2014 T days prior to the planned separation of 8-month-old, thoraco-omphalopagus female twins, a 2-h full-environment simulation of the separation surgery was performed. The simulation consisted of a lifelike manikin of the twins with color-coded tubing, equipment, and monitors (fig., “Simulation”), and all of the personnel who were to participate in the separation: nursing, anesthesiology, general surgery, and plastic surgery. The teams had consistently taken care of the twins during their multiple prior procedures (e.g., imaging studies and tissue expander placement). The promulgated simulation ground rules included treating the simulated patients and environment as real, maintaining professionalism, and—of considerable benefit— minimizing unnecessary conversations. Anesthetic preparation and the 8-h surgical procedure proceeded without complications, delays, or the need for additional personnel (fig., “Actual”). The entire simulation team was present and the solutions that were rehearsed during simulation were implemented. For example, the team had spent considerable time solving the challenge of maintaining sterility while transferring one twin immediately postseparation to a second table in the operating room; this task was performed smoothly on the day of surgery. Simulation had also revealed unanticipated issues, such as determining the optimal position of the twins to maintain a sufficient interface between the twins’ body surfaces and the gel grounding pad system. While conjoined twin separation surgery is both extremely complex and exceedingly rare,1 simulation offers a variety of logistics in how to prepare surgically and to accomplish the myriad steps that nursing, surgical, and anesthesia personnel must perform. Teamwork principles (e.g., leadership and communication) can be practiced and enhanced by the use of simulation to ensure the optimization of team synergy and to ensure safe, effective patient care.2,3

Interactive pediatric emergency checklists to the palm of your hand - How the Pedi Crisis App traveled around the world

Cognitive aids help clinicians manage critical events and have been shown to improve outcomes by providing critical information at the point of care. Critical event guidelines, such as the Society of Pediatric Anesthesias Critical Events Checklists described in this article, can be distributed globally via interactive smartphone apps. From October 1, 2013 to January 1, 2014, we performed an observational study to determine the global distribution and utilization patterns of the Pedi Crisis cognitive aid app that the Society for Pediatric Anesthesia developed. We analyzed distribution and utilization metrics of individuals using Pedi Crisis on iOS (Apple Inc., Cupertino, CA) devices worldwide. We used Google Analytics software (Google Inc., Mountain View, CA) to monitor users’ app activity (eg, screen views, user sessions).