The electronic health record: marching anesthesiology toward value-added processes and digital patient experiences

The Institute for Healthcare Improvement’s (IHI) Triple Aim framework—reduce the per capital cost of health care, improve patient experience, and improve population health—continues to set major goalposts for health care delivery. Although the first aim was an indirect embrace of Michael Porter’s adage for valuebased health care, the United States continues to increase its annual budget allocation for the health care system. According to the Centers for Medicare and Medicaid Services (CMS), the US health care expenditures were close to $11,582 per person in 2018, or 17.7%of the US gross domestic product (GDP). Health care expenditures are projected to grow to 19.7% of GDP by 2028. Although much of health care services are still being charged and compensated in a fee-for-service system, appropriate for traditional solution shop delivery of services, surgical and anesthesia services have the potential to price transparently related to outcomes, thus creating value-added processes (VAPs). However, creating and continuously improving VAPs require granular analytics to augment patient triage and monitor processes of care. The electronic health record (EHR) system has evolved in the last decade and can provide some of the necessary analytic data to help anesthesiologists participate in and achieve IHI Triple Aim elements. Although there was an early expectation that EHRs would help stem rising health care spending, early data from the growing $18.4 billion EHR industry showed that EHRs merely helped to house recorded patient data, replace traditional paper charting, and more accurately capture billing activities to generate higher volume fee-for-service revenue. However, the evolution of analytics built upon the data housed in the EHR has reached a tipping point that helps anesthesia practices focus on the processes of care and transition practices to develop VAPs for their surgical patients. VAPs inherently require reduced variance. To deliver a reliable and predictable outcome, manufacturing systems, for example, have little variance in their processes to ensure a small error rate in producing high-volume, reliable goods from rawmaterials that have predictable quality. Patients do not fit these parameters as easily: they have inherent variance in their comorbidities, physiology, social determinants of health, familial support structure, and even personal wants that must be accounted for to deliver patient-centered care. However, more recently developed tools have allowed new capabilities to utilize information with the EHR to help for more sophisticated triage of patients coming for surgery andmechanisms tomonitor our surgical care processes to target constant improvement. As patient experience is an equal pillar in the Triple Aim, the integration of telehealth and patient monitoring opens a modern digital clinic, from which anesthesiologists can advance their purview of care and stewardship of patient experience after surgery. These digital portals will facilitate further involvement of anesthesiologists into the perioperative environment. They may also serve as touchpoints for patient interaction, promote joint decision-making, and create new access back to the clinician and hospital. These objectives will be accomplished using digital tools to augment the modern patient experience and extend anesthesiologists’ brand beyond the walls of the hospital (see Fig. 1 for a conceptual framework).