(Credit: Health IT Security)

The recent institutional support for EHR and the proliferation of data accessing devices in the healthcare industry present both significant opportunities and threats. This “data-ization” of health has numerous consequences, not the least of which involves the ushering of Big Data to healthcare. With EHRs, telehealth, and IoT medical devices constantly generating patient data, the hope is that eventually the data can be leveraged to optimize machine learning algorithms that will significantly enhance care decisions.

We are a long way from truly integrating Big Data utilization in healthcare, but given the large role that data does and will continue to play in health care, it’s only fair to wonder what steps health care organizations can take to safeguard their data.[i] While big data can yield significant potential boons, it can only realize its benefits if stakeholders are willing to fully engage in the technological transfer. That will not happen in the absence of data security.

The Age of Cyberattacks

According to a 2016 report by the Ponemon Institute, healthcare facilities have been victims of one cyber-attack per month, and that half of all healthcare facilities “have experienced the loss or exposure of patient information.” A further quarter of healthcare facilities reported being unsure whether they have lost patient data or not.[iii] Organizations that find themselves the victims of cyberattacks may lose considerable sums of money to ransom, delays in operations, and loss of reputation.[iv]

Cybersecurity threats that are the most common include malware that may expose or steal sensitive patient information, including financial details, as well as ransomware, a type of malware that blocks user access to data or threatens exposure of data unless a ransom is paid. These attacks primarily favour systems that have not been properly maintained. The structure of today’s multi-stakeholder healthcare system is also expected to dilute security, as the number of entry points for cyberattacks increases with each participating actor.

What can health organizations do to prepare for these attacks?

Among the viable security options are to increase user access security through multi-factor verification and device security, or BYOD (“bring your own device”) security, as the frequency of use of personal mobile devices and PCs in care increase to meet the demands of telehealth.[v] Additionally, security of the actual patient data may be economically relegated to a third-party IT security firm. The security needs of EHR increasingly encourages centrality, in which the administrative and management expertise of healthcare organizations can allocate funds to address cybersecurity concerns across a variety of independent, certified providers.

As malicious use of private information and the extensiveness of data’s role in healthcare increases, so will the financial incentive of targeting healthcare organizations with malware. Experts foresee attacks, girded by machine learning algorithms, to increase in frequency and sophistication. It is essential for healthcare providers to protect both themselves and their patients.

[i] https://www.healthcatalyst.com/big-data-in-healthcare-made-simple

[ii]http://healthaffairs.org/blog/2017/01/17/building-the-value-based-health-care-system-of-the-future-depends-on-meeting-clinicians-data-needs/

[iii]https://www2.idexpertscorp.com/sixth-annual-ponemon-benchmark-study-on-privacy-security-of-healthcare-data-incidents

[iv] http://healthitsecurity.com/news/preparing-for-the-2017-healthcare-cybersecurity-threats

[v] http://healthitsecurity.com/news/prioritizing-byod-security-mdm-in-evolving-healthcare-sector

As outcomes research in anesthesiology progresses to novel heights, an increased emphasis on quality data reporting will be essential to optimize the impact of research, from practitioner to patient. Intrinsic to quality data reporting are the ability and consistency of EMR, or electronic medical records, in combination with actor leadership in the realm of research.

Electronic medical records (EMR) are emerging as an invaluable tool for harnessing the power of data.

While these three intents are consistent across the board, individual EMR platforms may vary by storage capability, metrics gathered, and/or access to data input. The database capabilities of an EMR platform are often a highly negotiated factor. As the transition from paper to EMR takes place among anesthesia facilities, practices, and hospitals, it is necessary for the storage capabilities of the platform to keep pace with the rate of data acquisition. This is particularly important in anesthesia services, which are often paired with other practices, e.g. surgery or rehabilitative care. Data must be easily stored and transferred among practices within a facility or hospital, with appropriate capacity to render large files and collect multiple quantities of data.

Moreover, what data should be collected? The metrics for anesthesia services are oft debated by practitioners, anesthesia management companies, and academics alike. High-quality metrics must include patient outcomes, patient experiences, and, more recently, the cost incurred to the patient, in order to form a comprehensive summary of the clinical case. The Anesthesia Quality Institute provides several frameworks for collecting outcome data from both the physician and patient perspectives. These metrics include such descriptors for adverse patient experiences (anaphylaxis, adverse drug reactions, cardiac arrest); operating room or facility events (OR fire, equipment malfunction); and administrative errors (wrong patient, wrong site surgery). The AQI is a preeminent source for practice-based quality management, and thus has a fundamental role in developing guidelines for metric-driven outcome research.

In collecting data, attention must be placed on confidentiality and right to access. The relationship between availability of data and patient confidentiality is a delicate balance that is increasingly addressed by EMR platforms, most recently by use of mandatory identity verification functionalities. The ability to access data varies depending on the selected platform. For example, large-scale EMR platforms may only be accessible by an anesthesiologist or CRNA, while more modern start-up EMR ventures may include patient inputs in the platform design.

The importance of harnessing data, as explored through the versatility of EMR platforms, is an essential component to maximizing outcomes research in anesthesia practices. However, EMR and robust data must work in concert with effective actor leadership in order to ensure that outcomes research plays a role in modifying anesthesia policies and practices. Historically, leadership for anesthesia outcomes research came primarily from physicians or academics. Yet, a modern approach to research-based practice includes a variety of actors. The American Association of Nurse Anesthetists notes in a scientific paper that, “80% of CRNAs conducting research participated in quantitative research”, concluding that “[it] is likely that the CRNAs conducting research are doing quality research” (Cowan et al., 2002). As active practitioners of anesthesia care, CRNAs demonstrate valuable potential to lead the field of outcomes research in anesthesiology. In addition, patients are evidently central to outcomes research, as partners in the journey to the highest-quality anesthesia care. Patient advocate organizational leadership may represent a resource to further develop outcomes research. Finally, anesthesia management services play an important role in mobilizing outcomes research to research-driven quality improvement in care. A high-quality anesthesia management service organization such as Xenon Health can integrate physician perspective with quality benchmarks and cost-effective practices in order to deliver excellent care to patients. Anesthesia management services take a practical approach, ensuring a commitment to high-quality care and research-driven practices.

Anesthetic management of the geriatric patient is becoming increasingly commonplace. It is predicted that by 2030, 20% of the U.S. population will be over the age of 65, and many senior citizens will have complex medical issues often requiring surgical intervention. Recognizing the physiologic changes that occur with aging and tailoring anesthetic care to this unique patient population is an asset to the practicing anesthesiologist.

CNS changes occurring with age include decreased white and gray matter, as well as reductions in neurotransmitter levels (e.g. dopamine, acetylcholine, norepinephrine, and serotonin). Elderly patients are therefore more sensitive to anesthetics (MAC decreases 4-6% per decade after age 40) and are at increased risk for perioperative delirium and postoperative cognitive dysfunction. Neuraxial local anesthetic dosages should also be decreased, given the smaller epidural space, increased dura permeability, and decreased CSF volume.

Cardiovascular changes include left ventricular thickening and diastolic dysfunction, decreased contractility due to myocyte loss, decreased β-adrenergic sensitivity due to decreased conduction fiber density and a decreased number of sinus node cells, and increased resting sympathetic tone. Vascular stiffness due to breakdown of elastin leads to higher mean arterial pressure and increased pulse pressure. These changes explain why geriatric patients benefit from adequate preload, low heart rates to ensure time for coronary perfusion, and sinus rhythm. Loss of the elevated native sympathetic tone by anesthetic induction or neuraxial anesthesia are not tolerated as well in the elderly, given decreased responsiveness to sympathomimetic drugs.

Respiratory changes include increased lung compliance due to loss of elastic elements and altered surfactant production, decreased chest wall compliance, increased closing capacity (CC) due to early collapse of the small airways on exhalation, and loss of overall alveolar surface area. These result in increased anatomic dead space, decreased diffusion capacity, increased work of breathing, impaired gas exchange, and increased air trapping. Total lung capacity is unchanged, vital capacity decreases, residual volume increases, functional residual capacity (FRC) is unchanged or slightly increased. At 44 years of age, FRC and CC are equal in the supine position, and at 66 years of age in the upright position (CC is not affected by position, unlike FRC). As FRC falls below CC, increased shunting occurs leading to desaturation. The importance of fastidious preoxygenation of the elderly patient is therefore especially important, as is the maintenance of PEEP during positive pressure ventilation.

Renal changes include decreased GFR, necessitating cautious dosing of renally cleared medications. Serum creatinine remains unchanged given a coincidental decrease in muscle mass, and is therefore a poor predictor of GFR in the elderly. Liver volume decreases 20-40% with aging, and hepatic blood flow decreases 10% per decade.

The physiology of aging is important to understand for the proper anesthetic management of the geriatric patient. General trends are toward conservative dosing of medications, accounting for decreased cardiopulmonary reserve, and keeping in mind the susceptibility to a prolonged postoperative recovery.

Micro-hospitals have emerged as a growing trend nationwide that presents an alternative to traditional health care facilities. According to a recent US News & World Report, these smaller-scale inpatient facilities are already in 19 states and “serve as a middle ground between freestanding emergency departments that may not offer all the required services and major hospitals that offer more than the community needs” (1). Micro-hospitals cater to the needs of their communities and provide medical services in areas lacking necessary facilities and resources. Since micro-hospitals are tailored to suit the local demographics, the provision of these services is dependent on distinct needs, and no two micro-hospitals are the same.

Micro-hospitals operate 24/7 and tend to be low-trauma facilities with varying degrees of advanced surgical capabilities. The typical facility has eight to ten observation and short-stay beds, according to a report by the Advisory Board, and a micro-hospital is usually between 15,000 to 50,000 square feet. The emergency department, pharmacy, imaging, and laboratory are core services of a micro-hospital, while primary care, low-acuity outpatient services, dietary services, and women’s services constitute some of the various ancillary services provided (2). Essential anesthesia service providers and board-certified, emergency room-trained physicians are needed due to the provision of some of the acute and emergency services often performed in larger hospitals, however, there is are no defined standards for staffing a micro-hospital. Examples of possible procedures performed in micro-hospitals include endoscopic procedures, plastic surgery, cardiac catheterization, and spinal surgery, to name a few (1).

Areas with specific medical needs that are incapable of supporting a full-service facility are ideal locations for the establishment of micro-hospitals, and many health systems use micro-hospitals as entry points into these markets where demand cannot support facilities of a greater size (2). Either existing major hospitals with preexisting internal facility development capabilities or groups of doctors partnered with external organizations and micro-hospital developers develop micro-hospitals, the cost of which can range from seven to thirty million dollars according to the Advisory Board. In addition to a relatively lower cost of construction compared to micro-hospitals’ larger counterparts, the location and size of these facilities can provide care that is more patient-centered, accessible, and convenient in relation to major hospitals. Patients may need to be sent to larger facilities, however, since not all medical situations can be addressed due to the small scale of micro-hospitals. Ensuring a smooth transfer process when needed is crucial to patient health, and the Advisory Board recommends that micro-hospitals are built within 18 to 20 miles of a full-service hospital. Although critics have expressed concerns about the safety and provision of care in micro-hospitals, specifically regarding the amount of experience one gets practicing in such a small facility, micro-hospitals present a possible health care delivery model to reduce costs and improve delivery of care in today’s health care climate (1).

References:

(1) https://www.usnews.com/news/healthcare-of-tomorrow/articles/2017-04-24/micro-hospitals-offer-an-alternative-health-care-model-for-local-communities

(2) https://www.advisory.com/research/financial-leadership-council/at-the-margins/2016/05/micro-hospitals

(3) http://www.emerus.com/think-small-making-case-micro-hospitals/

The management of the difficult airway is a topic both ubiquitous and enigmatic in the realm of clinical anesthesia care. Like the famous Justice Stewart quote, you know it when you see it, but no one has a hard and fast definition of what it is. Commonly it’s characterized as a clinical situation in which a conventionally trained anesthesiologist has difficulty with mask ventilation, intubation, or both. How each practitioner chooses to approach such situations, both expected and unexpected, varies based on whom you ask. Even among the world’s airway experts there are patterns of agreement, but no clear rules on how to handle airway management.

The first step of difficult airway management is recognition and preparation. Red flags in the patient’s history (previous difficult mask/intubation, obstructive sleep apnea, head and neck radiation, mediastinal mass, ankylosing spondylitis to name a few) and physical exam (table below) should be reviewed whenever possible and adequate preparation made for cannot ventilate/cannot intubate scenarios.

Informing the patient of possible difficulties involving airway management, having an extra pair of hands if possible, ensuring adequate preoxygenation, and actively pursuing avenues to continue delivering supplemental oxygen for the duration of airway management (via nasal cannula, LMA, insufflation, etc) are part of the basic preparation recommended by the ASA. Choosing appropriate avenues to secure the airway is based upon provider familiarity and specific patient circumstance, and includes but is not limited to video laryngoscopy, fiberoptic intubation, and light wand. Perhaps more important than how to intubate the patient is to decide whether to perform intubation after induction or awake. Choosing the former without convincing evidence of the ability to mask ventilate would be difficult to defend should adverse consequences occur.

In spite of adequate preoperative assessment, unanticipated difficult airways are still encountered and can have devastating consequences. Reference to the difficult airway algorithm below is helpful in systematically attempting to establish adequate ventilation and/or intubation.

References:

Apfelbaum, JL et al.  Practice Guidelines for Management of the Difficult Airway: An Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 02 2013, Vol.118, 251-270.