Fundamentals of Financial Management

Companies are increasingly employing Inventory System. A computer start with an inventory counts in memory. Withdrawals are recorded by the computer as they are made, and the inventory balance is constantly revised. When the recorded point is reached, the computer automatically places an order, when this new order is received, the recorded balance is increased.

Retail stores have carried this system quite far, each item has a magnetic codes, and as on item is checked out, it passes over an electronic reader, which then adjusts the computers inventory balance, at the same time the price is fed to cash register tape. When the balance drops to the recorder point, an order is place. Chapter 3 Research Design The authors aim to develop a automated inventory system which is technically, operationally, and economically feasible for PhilHealth Company, Dagupan City. The method used by the researchers to develop a automated inventory system is Descriptive Method.

The researchers conduct several interviews in order to gather information about the present existing conditions of the inventory system, knowing its problems and enhancing it by developing an automated inventory system. Questionnaires were also distributed to all interviewees for additional information. Using the descriptive method, the researchers also observe the functionality of the present inventory system of the PhilHealth, which help them discover that Electronic Data Processing is Advantageous than other. REVIEW OF RELATED LITERATURE

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The review of the literature for this study focuses on creating computerize inventory system for Cavite State University Marketing Main Campus. In order to create we need to find some helpfull resources about the study. Related Literature Janes (2001) stated that computers are extremely reliable device and very powerful calculators with some great accessories applications like word processing problem for all of business activities, regardless of size, computers have three advantages over other type of office equipment that process information because computer are faster, more accurate more economical.

Reyes (2005) task would be time consuming to accomplish manually and more practical with the aid of computers field in cabinet. Dioso (2001) stated that computer assist careful intelligent planning, organizing, actuating and controlling . This maybe observed from the past that they monitor production activities, solve scientific problem and help arrive in tentative answer to a multitude of involve conditions. Ralph M. Stair (1999) emphasized that the development of technology through the years have enabled us to do more with less effort.

From the orientation of the light bulb to the industrial revolution and beyond, we have continuously tried to in a more efficient means of doing tasks. Lewis (2002) stated that the reason for using computers vary from person to person. Some of the computers in business are to perform accuracy, to be as productivity, to decrease bottle necks or hassles to alter cash flows or to simples elevate your status. Sybex Inc (1999) stated that visual basic provide a graphical environment in which the users usually designed the forms and control that become the building block of tour application .

Visual Basic support many useful tools that will help the user more productivity. Gold Chager et al (2003) said that computer as a device for processing information knew computer plays a significant role... [continues] Inventory Systems Summary According to the U. S. Small Business Administration, “Inventory refers to stocks of anything necessary to do business” (U. S. Small Business Administration, 2010, pp 1-2). The U. S.

Small Business Administration publication describes what constitutes successful inventory management (balancing cost versus benefits of inventory), including 1) Maintaining a wide assortment without spreading the rapidly moving items too thin, 2) Increasing inventory turnover without sacrificing service, 3) Keeping stock low without sacrificing performance , 4) Obtaining lower prices by making volume purchases, 5) Maintaining an adequate inventory without an excess of obsolete items. Anyone in business must understand the business of inventory.

Below is a look at six different inventory systems as well as a comparison of the advantages and disadvantages. Wal-Mart Inventory System Wal-Mart runs its stores on a perpetual inventory system. This system records the quantity of items sold as items are purchased. The computer system at Wal-Mart constantly keeps up with additions or deductions from inventory and tells management what items are on hand. The organization also conducts counts of employee manual counts of inventory periodically. When an item arrives at the Wal-Mart distribution center it is scanned into the inventory system.

When the items are purchased by the consumer, the point-of-sale system reduces the inventory from that purchase. According to Wal-Mart’s Gail Lavielle, a leaner inventory will help clear out store clutter and help Wal-Mart focus on specific brands and products that consumers want (The Associated Press, 2006). Advantages and Disadvantages of the Wal-Mart Inventory System The advantages of a perpetual inventory system are that inventory is quickly updated in real-time, which gives a constant picture of the inventory status. With this data, inventory counts will be more accurate and allow one to keep up with demand... continues] Anesthesia recordkeeping: Accuracy of recall with computerized and manual entry recordkeeping ProQuest Dissertations and Theses, 2011 Dissertation Author: Thomas Corey Davis Abstract: Introduction: Anesthesia information management systems are rapidly gaining widespread acceptance. Aggressively promoted as an improvement to manual-entry recordkeeping systems in the areas of accuracy, quality improvement, billing and vigilance, these systems record all patient vital signs and parameters, providing a legible hard copy and permanent electronic record. At risk is a potential loss of "connectedness" to the atient with the use of computerized recordkeeping, perhaps jeopardizing vigilance. Methods: This research analyzed differences in the accuracy of Certified Registered Nurse Anesthetists' (CRNAs) recall of specific patient variables during the course of an actual anesthetic case. CRNAs using computerized recordkeeping systems were compared to CRNAs using manual entry recordkeeping. Accuracy of recalled values of 10 patient variables was measured - highest and lowest heart rate, systolic blood pressure, inspiratory pressure, and end-tidal carbon dioxide levels, lowest oxygen saturation and total fluid volume.

In addition, a filmed educational vignette was presented to evaluate any effect on accuracy of recall following this presentation. Four tertiary care facilities participated in this research. A Solomon four-group research design was selected to control for the effect of pretesting on results of the filmed educational treatment. Results: 214 subjects participated in this study; 106 in the computerized recordkeeping group, and 108 in the manual entry recordkeeping group. Demographic covariates were analyzed to ensure homogeneity between groups and facilities.

No significant statistical differences were identified between the accuracy of recall among the groups. There was no statistically significant effect of the educational film vignette on accuracy of recall. Conclusions: There was no difference in the accuracy of practitioners' recall of patient variables when using computerized or manual entry recordkeeping systems, suggesting little impact on vigilance. The educational film presented did not have an effect on accuracy of recall following the discussion of benefits and limitations of methods of recordkeeping. ABSTRACT

ANESTHESIA RECORDKEEPING: ACCURACY OF RECALL WITH COMPUTERIZED AND MANUAL ENTRY RECORDKEEPING By Thomas Corey Davis, PhD A dissertation submitted in partial fulfillment of the requirements for the degree of PhD in Health Related Sciences at Virginia Commonwealth University. Virginia Commonwealth University, 2011 Major Director: Dr. Chuck Biddle Director of Research, Department of Nurse Anesthesia And Dr. Jeffery A. Green Assistant Chief of Anesthesiology, Department of Anesthesia Introduction: Anesthesia information management systems are rapidly gaining widespread acceptance.

Aggressively promoted as an improvement to manual-entry recordkeeping systems in the areas of accuracy, quality improvement, billing and vigilance, these systems record all patient vital signs and parameters, providing a legible hard copy and permanent electronic record. At risk is a potential loss of “connectedness” to the patient with the use of computerized recordkeeping, perhaps jeopardizing vigilance. Methods: This research analyzed differences in the accuracy of Certified Registered Nurse Anesthetists' (CRNAs) recall of specific patient variables during the course of an actual xiv nesthetic case. CRNAs using computerized recordkeeping systems were compared to CRNAs using manual entry recordkeeping. Accuracy of recalled values of 10 patient variables was measured - highest and lowest heart rate, systolic blood pressure, inspiratory pressure, and end- tidal carbon dioxide levels, lowest oxygen saturation and total fluid volume. In addition, a filmed educational vignette was presented to evaluate any effect on accuracy of recall following this presentation. Four tertiary care facilities participated in this research.

A Solomon four- group research design was selected to control for the effect of pretesting on results of the filmed educational treatment. Results: 214 subjects participated in this study; 106 in the computerized recordkeeping group, and 108 in the manual entry recordkeeping group. Demographic covariates were analyzed to ensure homogeneity between groups and facilities. No significant statistical differences were identified between the accuracy of recall among the groups. There was no statistically significant effect of the educational film vignette on accuracy of recall.

Conclusions: There was no difference in the accuracy of practitioners’ recall of patient variables when using computerized or manual entry recordkeeping systems, suggesting little impact on vigilance. The educational film presented did not have an effect on accuracy of recall following the discussion of benefits and limitations of methods of recordkeeping. 15 CHAPTER ONE: INTRODUCTION In the United States, over 50 million anesthetics are delivered each year (Ishizawa, 2011). For each of these anesthetics, a detailed record is generated that includes vital signs, medications, and events of the surgery or procedure.

Patients are monitored according to standards published by both the American Society of Anesthesiologists and the American Association of Nurse Anesthetists (AANA). These standards detail the vital signs and parameters that must be recorded by an anesthesia provider to document the monitoring of oxygenation, ventilation, circulation, and temperature (AANA - scope and standards for nurse anesthesia practice. 2007; ASA, 2005). The first known example of an anesthetic record can be found in the archives of the Massachusetts General Hospital, dated November 30, 1894 (Beecher, 1920). Developed by Dr. E. A.

Codman, the record allowed the continuous documentation of heart rate, temperature, and respirations throughout the course of the anesthetic (Beecher, 1920). Systolic blood pressure readings were added to anesthesia records appearing after 1903 (Beecher, 1920). Both Dr. Codman and his contemporary, Dr. H. A. Cushing, indicated the merits of documentation of ether anesthetics, “It was undoubtedly a step toward improvement in what had been a very casual administration of a dangerous drug (Beecher, 1920)”. 16 The first known example of an automated anesthesia recordkeeping device dates to 1929 (McKesson, 1934).

The device recorded three variables, oxygen percentage, respiratory volumes, and pulse pressure, on a continuous paper roll delineated in graphic form (McKesson, 1934). Fluctuations in these variables, primarily that of tidal respirations, indicated variations in the depth of anesthesia delivered, and any interruptions in the spontaneous breathing of the patient (McKesson, 1934). In his concluding remarks, Dr. McKesson indicated that such records would be “valuable for statistical study,” much as modern anesthesia records are used for quality improvement (McKesson, 1934). Dr.

McKesson also stated, “Automatic recording equipment is a more accurate means for the immediate determination of cause and effect during an administration. Such records stimulate closer observation and increase our knowledge of anesthesia, and should safeguard the patient (McKesson, 1934). ” Despite Dr. McKesson’s praise, such means of recording data during an anesthetic did not take precedence over the manual entry chart. Only with the advent of computerized systems introduced in the 1970s is there further mention in the literature of electronic recordkeeping (Drui, Behm, & Martin, 1973).

With improvements in computing technology, efforts to automate medical records have attempted to ease the task of recordkeeping (Drui et al. , 1973). Applications specific to the anesthesia record have begun to proliferate throughout the United States, due to established benefits of improved billing, legibility of the record, and access to data for quality assessment and improvement programs (Spring et al. , 2007). In a recent survey of academic medical centers, 14% currently utilize an anesthesia information management system (AIMS), 17 ith an additional 29% in the planning or implementation phase (Egger Halbeis, Epstein, Macario, Pearl, & Grunwald, 2008) Proposed benefits over traditional manual entry recordkeeping systems (MERS), such as a reduction in workload or increased vigilance, have not been well established (Saunders, 1990). The proposed reduction in workload intended to increase the practitioners’ time for monitoring of the surgical field or other activities of improved vigilance could also be spent in activities unrelated to direct patient care (Allard, Dzwonczyk, Yablok, Block, & McDonald, 1995).

With anesthesia reimbursement reductions and the steady advance of technology into all aspects of medical care, known benefits such as enhanced capture of billing services may result in the adoption of AIMS in many markets currently skeptical about their safety (Levitan, 2008). AIMS are cited as superior to MERS in the areas of time management (Heinrichs, Monk, & Eberle, 1997), data collection for quality improvement (Vigoda, Gencorelli, & Lubarsky, 2006), and the capture of billing elements (Levitan, 2008).

Concerns regarding the recording of artifact data as a potential source for malpractice claims (Feldman, 2004), excessive financial investment, increasing complexity of tasks, and decreasing attentiveness to the patient and monitors, thereby decreasing vigilance, (Abenstein, DeVos, Tarhan, & Tarhan, 1992) have all been cited as limitations of AIMS. Studies analyzing vigilance and workload have failed to show significant differences between the two methods (Thrush, 1992).

Examining the recall accuracy of specific vital signs, parameters, and events experienced by anesthesia practitioners utilizing AIMS and 18 MER should serve as a starting point for further evaluation of the benefits and risks of recordkeeping systems. Population and Recruitment Certified registered nurse anesthetists (CRNAs) administer more than 30 million of the 50 million anesthetics delivered each year (American Association of Nurse Anesthetists, 2008). This study will draw a sample of CRNAs from a population of more than 200 CRNAs practicing at four medical centers across Virginia.

CRNAs assigned to each facility on the day of evaluation will be asked to complete a simple questionnaire. A trained observer will provide each practitioner with brief relief from patient care, after constant attendance of the patient for a minimum of 30 minutes of anesthesia care during the maintenance phase of the case. The CRNA assigned to the case will be asked to turn away from the monitors and complete the questionnaire. The observer will document values directly from the trend data recorded in the patient monitor.

To evaluate the accuracy of anesthesia providers’ recall when recordkeeping with AIMS or MERS, a simple instrument has been developed (See Appendix I). Following establishment of face and content validity for this instrument, the research plan will be submitted for approval by the investigational review board (IRB) for Virginia Commonwealth University (VCU). With IRB approval, this instrument will be administered to practicing anesthesia providers participating in the actual delivery of anesthesia, and will require the provider to recall various aspects from the previous 30 minutes of their assigned case.

Actual patient data will be collected by the relief CRNA to compare to the practitioners' recollections. Practitioners utilizing both AIMS and MERS will be evaluated, to allow 19 comparison of any influence of the method of recordkeeping on the accuracy of practitioners’ recall. Four centers will be included in the project, selected by similarities of number of operating rooms, case load, and number of CRNA providers. These facilities are described in Table 1. All sites have agreed to participate in this research.

Table 1: Facilities Facility Number of Beds Number of Operating Rooms Number of CRNAS Method of Recordkeeping Virginia Commonwealth University Medical Center (VCUMC) 788 30 41 AIMS Inova Fairfax Hospital (IFH) 833 47 68 AIMS Bon Secours St. Mary’s Hospital 369 30 41 MERS Medicorp Mary Washington Hospital 412 26 51 MERS Research Design A Solomon four group design has been selected for this study. This design minimizes the threat of testing on the outcome through the inclusion of one site that receives neither a pre-test, nor a treatment, but only a post-test.

Each of the four facilities will be assigned to one of the four groups of this design as indicated in Table 2. Two sites will receive surveys as pre-tests, two sites will receive education with a trigger film (treatment), and all sites will be surveyed following the time of this presentation and again one month following the trigger film, as a post-test. 20 Table 2: Solomon Four-Group Design Statement of Purpose The purpose of this research is to analyze the practitioner’s accuracy in recalling patient data when using each method of recordkeeping.

A second purpose of this research is to assess the effectiveness of a trigger film that details the benefits and limitations of both recordkeeping methods on the subsequent recall accuracy of anesthesia providers. This project seeks to answer two research questions: • Do anesthesia providers using AIMS recordkeeping demonstrate equivalent recall accuracy of specific patient variables, as compared with anesthesia providers using a MERS? • Does the instruction of the benefits and limitations of recordkeeping practices by trigger film influence the recall accuracy of specific patient variables by anesthesia providers using AIMS or MERS?

To answer these research questions, the following hypotheses will be analyzed: H 1 For each anesthetic case, there will be no difference in the accuracy of recall of specific patient variables recorded by an anesthesia provider using AIMS or an anesthesia provider using a MERS. H 2 For each anesthetic case, there will be no difference in the accuracy of recall of specific patient variables recorded by an anesthesia provider who Group Survey Trigger Film Survey Survey– 1 month Post - treatment St. Mary’s (MERS) O 1 X O 2 O 3 Inova Fairfax (AIMS) O 4 O 5 O 6

VCUMC (AIMS) X O 7 O 8 Mary Washington (MERS) O 9 O 10 21 has attended a trigger film presentation on the benefits and limitations of recordkeeping methods than a provider that has not received such instruction. Significance In the United States today, approximately 67% of all anesthetics delivered each year are administered by nurse anesthetists (American Association of Nurse Anesthetists, 2007). Since the initiation of anesthesia documentation, the majority of anesthesia providers have recorded this data manually on pre-printed forms.

This form of MERS persists in more than 90 percent of anesthesia practices (Levitan, 2008), although the prevalence of AIMS is rapidly increasing (Egger Halbeis et al. , 2008). Improvements in the capture of billing elements, legibility of the record, and enhanced capabilities to review accurate data for quality improvement purposes have caused many experts in the field to brand the adoption of AIMS as inevitable (Levitan, 2008) (Hamilton, 1990) (Vigoda et al. , 2006). In 2001, the Anesthesia Patient Safety Foundation published an initiative to utilize AIMS to improve patient safety (Cooper, 2007).

This initiative was created in response to the Institute of Medicine’s landmark report in 1999, which called for efforts to utilize developing technology to reduce the number of medical errors (Kohn, Corrigan, & Donaldson, 1999). As recently as March 2008, an article in Anesthesiology News indicated that AIMS would “revolutionize anesthesia care” (Levitan, 2008). Despite these claims, the safety of AIMS recordkeeping has not been established. Early in the debate, voices called for caution in their use (T. N.

Noel, 1986)(Saunders, 22 1990). Studies of vigilance that compare AIMS and MERS have been hindered by confounding variables and small sample size (Thrush, 1992). At the present time, AIMS are utilized by only five to ten percent of anesthesia providers (Levitan, 2008). This small percentage is cited to be due to the high initial cost of AIMS. With the increasing appeal for the implementation of AIMS (Levitan, 2008), there is an excellent opportunity for research into the benefits and limitations of each method of recordkeeping.

Before widespread adoption of AIMS, researchers must examine differences in the “connectedness” of practitioners to the subtle trends of vital signs, parameters, and events that may influence patient safety. Researchers must also explore techniques to educate practitioners to enhance the benefits and minimize the limitations of either recordkeeping system. 23 CHAPTER TWO: REVIEW OF LITERATURE History From the time of development of the first documented use of diethyl ether by Dr. William T. G. Morton in 1842, the safety of anesthesia administration has steadily increased.

Initially the task of anesthetizing a patient was relegated to medical students under tutelage of a practicing surgeon, creating an anesthesia provider with a primary focus of studying the surgical procedure being preformed rather than vigilance toward the anesthetized patient. By the turn of the 20 th century, the morbidity and mortality of anesthesia delivery had become unacceptably high, and a provider dedicated to the specialty of anesthesia was sought (Gunn, 2005). At this time, physicians who specialized in anesthesia were few, due to the culture of medicine prevalent at the time.

Surgeons recognized the need for anesthetists with specialized training, particularly those who would “(1) be satisfied with the subordinate role that the work required, (2) make anesthesia their one absorbing interest, (3) not look on the situation of anesthetist as one that put them in a position to watch and learn from the surgeon’s technic {sic}, (4) accept the comparatively low pay, and (5) have the natural aptitude and intelligence to develop a high level of skill in providing the smooth anesthesia and relaxation that the surgeon demanded” (Thatcher, 1953) 24

Most often, this role fell to nurses rather than physicians (Thatcher, 1953). Many of the physicians who administered anesthesia during this time were called in to service from the ranks of medical students studying the practice of surgery, were unskilled in the delivery of anesthetic agents, and often met with tragic results. A personal report shared by Dr. Harvey Cushing from the time of his medical training of a patient’s death under anesthesia indicates not only the challenges of anesthesia delivery, but also the nonchalant attitude towards the mortality ascribed to such mortality by the surgeons at the time. Dr.

Cushing was advised by the surgeon, “that sort of thing happed frequently and I had better forget about it and go on with the Medical School. ” As a result of this and other such incidents, Dr. Cushing and his colleague, Dr. E. A. Codman of the Massachusetts General Hospital were encouraged to develop the first known examples of an anesthesia record. These documents recorded respirations, pulse rate, and temperature, along with narrative accounts of the events of the patients’ reactions to the anesthetic. As stated by Dr. Cushing, “It was undoubtedly a step toward improvement in what had been a very casual administration of a dangerous drug.

We do so much better with ether these days, but even so there remains much to learn" (Beecher, 1920). More widespread use of handwritten accounts of anesthesia and surgery were to follow, but not for more than 20 years after these initial accounts. Even at this early date, voices of caution were raised, indicating that the manual documentation of “too elaborate a record of this kind might take the administrator’s mind from his primary job”. In defense, Dr. Cushing stated, “I feel most emphatically that it keeps his mind on his job” (Beecher, 1920). 25 Perhaps as a result of similar concerns of distraction and reduced vigilance, in 1929, Dr.

E. I. McKesson (1934) developed a device to record respiratory volumes, oxygen percentage, and pulse pressure, from which both the systolic and diastolic blood pressures were derived. Dr. McKesson (1934) advised, “It is very difficult for one person to count the pulse and respiration, measure the blood pressure and the volume of breathing, to determine the volume of rebreathing or the quantity of carbon dioxid {sic} used (the anesthetic), to note the dosage and a few other factors in their proper sequence and with sufficient frequency to aid in the administration”.

Dr. McKesson (1934) also indicates that these same limitations were raised as cause not to keep such a record of anesthesia, to better maintain vigilance focused toward the patient. Through examples of anesthetic records generated by his device, Dr. McKesson (1934) also indicates the first recorded incidence of “artifact” or erroneous data. Listed in Chart 2 a “notch” is indicated in the graphic display of respirations. Such a “notch” indicates a reduction in tidal volume of respirations, as with “deep narcosis (McKesson, 1934).

In this example, this data is indicated to reflect a failure of the anesthetist to maintain an adequate mask seal to the patient’s face, and this is indicated by a handwritten notation on the record. Dr. McKesson (1934) indicated that such records could be applied toward the ongoing research of anesthetic delivery techniques. He also indicated that such automatic recordkeeping had a higher degree of accuracy than handwritten records, many of which may be generated after the completion of the anesthetic rather than at the time of the event. Finally, the value of automatic records could be shown through improved 26 nowledge of anesthesia by the practitioners, resulting in improved patient safety (McKesson, 1934). While prophetic, Dr. McKesson’s opinions and apparatus would not gain widespread use, and the handwritten record persisted with few changes into the distant future. Not until 1973 was there further mention of the benefits to accuracy in anesthesia recordkeeping that an electronic system could provide (Drui et al. , 1973). Early Development and Implementation With the introduction in 1972 of a compact computerized calculator, the HP-35, the faithful slide-rule became instantly obsolete (Computer history museum - timeline of computer history. 009). At this time of rapidly developing computing technology, Drui et al (1973) examined anesthesia practice with the intent of improving efficiency and, ultimately, patient care. The authors utilized “memomotion,” a video imaging system that recorded data slower than actual time, to document the tasks of anesthesiologists. In addition, a trained observer with a stopwatch documented a series of twenty-four tasks, including periods of inactivity. Tasks were then rated according to the percentage of time devoted to the task, and the required knowledge, skill, and importance of each activity.

The task of recordkeeping, while occupying a large proportion of the anesthesiologists’ time, was determined to have very low requirements of knowledge, skill, and importance. The authors determined that such an activity of low importance, requiring a minimum of skill and knowledge to perform should be automated (Drui et al. , 1973). Five years later, computing technology had advanced to the point that such automation had become possible, with Zollinger et al (1977) providing a comparison 27 between handwritten anesthesia records and those generated by “a computerized surveillance system”(Zollinger, Kreul, & Schneider, 1977).

Over this study of 100 patients, computer generated records were found to produce “acceptable blood pressure measurements 78 percent of the time,” at a rate of one reading every 2. 5 minutes. The resident anesthesiologists produced handwritten records that documented 94 percent of blood pressure measurements, at an interval of once every five minutes. Discrepancies between the two forms of recordkeeping occurred in 43% of the records, most of which occurred during times of high workload for the provider, such as during induction, or periods of time when the providers’ attention was focused on other tasks.

Some of the discrepancies were indicated, “…when the vital signs recorded by the anesthesiologist tended to make the record look smooth” (Zollinger et al. , 1977). Zollinger et al (1977) concluded that the records produced were similar in accuracy, and advocated that computerization of the record could collect data at times when the provider was “otherwise occupied,” and would eliminate data that was “underestimated by humans who tended to smooth out a record. Even at this early stage, voices of caution were raised, as the article included comments by a guest editor, calling into question the accuracy of the recording devices employed in the study, and cautioned against “a ‘hands off’ policy” (Zollinger et al. , 1977). A year later, Shaffer et al (1978) examined the prevalence of handwritten records and the potential use of these documents to improve the quality of anesthesia delivery. The authors cited a survey of 46 hospitals that revealed that as many as 8 percent did not maintain any form of anesthesia record, and that 17 percent did not record drug 28 dministration or dosages. This finding was supported by a similar study from Great Britain, finding that "25. 9 percent of the anesthesia records were comprised of a single written entry, 45 percent of the anesthesiologists never analyzed their records, and 51. 6 percent analyzed them only sporadically" (Shaffer, Kaiser, Klingenmaier, & Gordon, 1978). Further analysis of the methods of recordkeeping indicated that many limitations of production of these documents existed.

These limitations included the difficulties with production of copies, limited space available for documentation, incorrect or omission of entries, and illegibility of handwriting. These limitations indicated a need for greater automation of the anesthetic record, to improve the current deficiencies and reduce the anesthetist's time spent on the task of recordkeeping. Shaffer et al (1978) surveyed anesthesiologists at their facility to devise a list of attributes for an ideal automated recordkeeping system.

Shaffer et al (1978) summarized the survey into four main attributes deemed necessary by over 90 % of respondents: 1. Automatic capture of information with the ability to edit inaccurate or erroneous data. 2. Ability to enter data manually through a keyboard, light pen, or graphic display. 3. Reliability of function 4. Ease of electronic storage and retrieval of information Shaffer et al (1978) concluded that a "semiautomated" system would be the solution to the limitations of the system and account for the suggested improvements.

Such a system would maintain many aspects of the handwritten record, to allow for manual entry and 29 error correction, while providing automated capture of vital signs, allowing for a savings of 33 to 50% of the time spent producing a record by hand. At this time in history, standardization of anesthetic equipment was in its infancy. The Pin-Index system, a method to prevent errors of connecting incorrect gas cylinders to an anesthesia machine, had only recently been introduced (Thompson, 1978).

The automated non-invasive blood pressure device manufactured by Applied Medical Research, Tampa Florida, had just been introduced to the field, and was beginning to appear in clinical anesthetizing locations. This device, the Dinamap, provided an automated blood pressure reading with reliability, but provided only a visual display, and not an automated record of readings (Lindop, 1981). Against this background of developing technology, Apple et al (1982) offered a proposal for the development of a semiautomatic recordkeeping system similar to that called for by Shaffer et al in 1978.

Apple et al (1982) provides details of the Abbograph, from Abbot Labs in Houston, Texas. The Abbograph provided only vital signs on a graphic plotting device, and had no capability for manual entry, an attribute deemed essential by both research studies. The authors offered a system of their own design, capable of both automatic capture of vital signs, as well as manual entry through a keypad of seven categories of data, including "anesthetic gases, intravenous fluids, body fluid losses, blood pressure data, ventilator settings, general patient record information and general events. Entry of data into this system could be made at the time of the event, at a later time, or "time independent," for patient information that is not time sensitive. To evaluate the device, the authors compared 20 handwritten records and 20 keypad records. Of the entries made by hand, Full document contains 256 pages Abstract: Introduction: Anesthesia information management systems are rapidly gaining widespread acceptance.

Aggressively promoted as an improvement to manual-entry recordkeeping systems in the areas of accuracy, quality improvement, billing and vigilance, these systems record all patient vital signs and parameters, providing a legible hard copy and permanent electronic record. At risk is a potential loss of "connectedness" to the patient with the use of computerized recordkeeping, perhaps jeopardizing vigilance. Methods: This research analyzed differences in the accuracy of Certified Registered Nurse Anesthetists' (CRNAs) recall of specific patient variables during the course of an actual anesthetic case.

CRNAs using computerized recordkeeping systems were compared to CRNAs using manual entry recordkeeping. Accuracy of recalled values of 10 patient variables was measured - highest and lowest heart rate, systolic blood pressure, inspiratory pressure, and end-tidal carbon dioxide levels, lowest oxygen saturation and total fluid volume. In addition, a filmed educational vignette was presented to evaluate any effect on accuracy of recall following this presentation. Four tertiary care facilities participated in this research.

A Solomon four-group research design was selected to control for the effect of pretesting on results of the filmed educational treatment. Results: 214 subjects participated in this study; 106 in the computerized recordkeeping group, and 108 in the manual entry recordkeeping group. Demographic covariates were analyzed to ensure homogeneity between groups and facilities. No significant statistical differences were identified between the accuracy of recall among the groups. There was no statistically significant effect of the educational film vignette on accuracy of recall.

Conclusions: There was no difference in the accuracy of practitioners' recall of patient variables when using computerized or manual entry recordkeeping systems, suggesting little impact on vigilance. The educational film presented did not have an effect on accuracy of recall following the discussion of benefits and limitations of methods of recordkeeping. Paper-Based Versus Electronic Medical Record Keeping For many years, physicians’ offices documented all data in paper-based medical charts. Now, the physician or clinician records the medical data into a computer.

Information stored in this manner is known as an electronic-based medical record or EMR. By definition, an EMR is a computerized record of the important health information regarding a patient including the care of that individual and the progress of that patient’s condition (Bonewit-West, Hunt, & Applegate, 2009). The use of computers in physicians’ offices is not new. For decades, physicians have used computers and practice management software primarily to schedule appointments and for billing.

The government has offered physicians incentives designed to encourage the adoption of electronic medical records to promote medical information accessibility, better patient care, greater efficiency, and financial savings (Hamilton, 2010). In the face of advancing technology, small medical offices must compare the cost, ease of use, and maintenance of electronic medical record systems versus paper-based record keeping. The cost of keeping paper-based and electronic medical records is not just about the actual price tag of the record-keeping systems.

The cost of keeping an electronic medical record system (EMR) begins with the initial purchase and implementation of the hardware and EMR software. There are also ongoing maintenance expenses, loss of revenue associated with temporary loss of productivity due to converting paper charts to electronic ones, and the training of the staff (Menachemi & Collum, 2011). The way these record systems are stored is very different and can greatly affect the cost as well. EMR records are stored on a server, digitally, in a secure computer database within the office practice (Hamilton, 2010).

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