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Received April 2, 2019, accepted September 15, 2019, date of publication November 3, 2019

Integration of the trans-operative information 
with the patient's electronic record
By E. K. Souza1, A. M. Marciano2

1Moinhos de Vento Hospital/ Clinical Engineering, Porto Alegre, Brazil
2Moinhos de Vento Hospital/ Clinical and Hospital Engineering, Porto Alegre, Brazil

ABSTRACT
This article presents an integration project between the anesthetic station used in the step of trans-operative (life signals 
multiparameter monitor, anesthesia device and controlled-target infusion pump) and the system of hospital information. 
The main goal of this project is to automatically capture the vital signals from the medical equipment and the records 
trans-operatives and provide an anesthesia record to be stored in the patient’s electronic medical record. The integration 
mode is through a gateway that executes the conversion of the machine- specific language into data/information of the 
HL7 standard. This interaction will allow integrating data and information from multiparametric monitors, anesthesia 
devices, Controlled-target infusion pumps, and the intra-operative anesthesiologist inputs. 

Keywords – Medical Equipment, Anesthesia Station, Step of the trans-operative, Patient Data Integration, Electronic Records. 

Copyright © 2021. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY): Creative Commons - Attribu-
tion 4.0 International - CC BY 4.0. The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) 
are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is 
permitted which does not comply with these terms.

INTRODUCTION
The patient’s record is a mandatory document in Health 

Assistance Establishment and is considered an extremely 
important tool that requires a mechanism of follow up of 
the data inserted in it. The electronic medical record can 
be quoted as one of the mechanisms that present many 
advantages to the institution such as paper use reduc-
tion, digital certification, more reliability and safety for 
the data inserted in the records and, to the information 
derived from it.1

It has been claimed that a combination of Information 
Technology (IT) devices such as computers, communication 
networks, medical information, and online electronic data 
can improve the quality and decisions concerning health 
care. Therefore, the automation of the patient’s records 

(even incomplete) contributes significantly to the quality 
improvement of the treatment beyond the effective control 
of costs involved.2 A medical record system is represented 
by a series of components that form mechanisms so the 
records can be created, used, stored, and accessed as part 
of a hospital information system (HIS).3

In the surgical environment, there are examples of 
software development that consists of the data integration 
of monitoring parameters during anesthesia and a group 
of rules configured by the anesthesiologist. Alerts gener-
ated by the software provide important information about 
the patient’s condition and eventual risk situations which 
wouldn't be highlighted if only the individual alarms of the 
parameters coming from the monitors were considered.4

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Souza, Marciano: Integration of the Trans-Operative Information with the Patient's Electronic Record

J Global Clinical Engineering Vol.2 Issue 1: 23-27; 2019  24

This project presents an integration proposition 
between the anesthesia station equipment used in the 
trans-operative stage (multiparametric monitors, anes-
thesia devices, controlled-target infusion pumps) and the 
patient’s medical electronic records (PEMR). The goal is 
to automatically capture the vital signals from the medical 
equipment and the records of the trans-operative data to 
create anesthesia file that integrate the PEMR with the 
HIS. The specific goals of this project are: (a) increase the 
safety and reliability of data and information from the 
trans-operative stage; (b) qualify this data and informa-
tion via automatic inputs with no further manipulation; 
(c) improve the medical document and protocol pattern; 
(d) diminish the probability of failures and increase clar-
ity; (e) facilitate the data research and information for 
studies, benefiting doctors, hospitals, and patients.

METHODS
Described below are the development phases of the 

project, the integration alternatives, the integration method 
option used, and the information that will be integrated 
into the implementation stage.

A. Project Development
The stages of development flow-gram of the project 

are described below in Figure 1.

As demonstrated in Figure 1, risk evaluations were 
executed as well as the vulnerability/fragility of the an-
esthetic procedure related to the absence of automated 

records and data integration and information from the 
medical technology used in this stage of the surgical pro-
cess. Next, we surveyed the hospital’s equipment that can 
already transmit data for then plan and the sub-stages 
of the implementation. The next stage consisted of the 
processes/operations/activities detailing the peculiari-
ties that determine which data and information would 
be registered and integrated, the technologies available 
in the market for this type of record integration as well 
as the costs.

B. Architecture/Topology of the Integration 
System

The definition of interoperability, according to the 
Institute of Electric and Electronic Engineers (IEEE) deals 
with the capacity of two or more systems to exchange 
information and being able to use the information ex-
changed.5 The communication Health Level 7 (HL7) is a 
communication structure with determined standards to 
the exchange execution, integration and sharing of com-
munication information between devices or clinical data 
system devices.6

The architectures or topologies of communication can 
be divided into two suggested formats, “without Gate-
way” and “with Gateway.” In the topology format without 
gateway, the data are transmitted from equipment in HL7 
and are processed before storage in HIS. The format with 
Gateway requires an intermediary device that physically 
separates the HIS and the biomedical equipment. This 
device performs the machine-specific language conver-
sion of HL7 standard to be consequently processed and 
stored. Concerning the integration method of monitoring 
data and trans-operative stage information, the topologies 
and/or architectures are demonstrated in Figures 2 and 3.

FIGURE 1. Project development flow-gram.

FIGURE 2. “Direct” topology without Gateway.



25 J Global Clinical Engineering Vol.2 Issue 1: 23-27; 2019

Souza, Marciano: Integration of the Trans-Operative Information with the Patient's Electronic Record

In the architecture model of Figure 2, the equipment 
provides the information directly in the HL7 language 
allowing the storage of clinical data in the HIS database. 
In Figure 3 below, it is demonstrated the topology using 
the intermediary device, named Gateway.

In this type of topology, the information from the equip-
ment needs a data converter named Gateway responsible 
for trans-coding the information from the equipment to 
clinical storage data in PEMR.

In this last model evaluated it is observed the need 
of more devices to integrate and intercommunicate data 
treatment and information storage appliance so the 
information generates an electronic anesthesia file with 
further storage in PEMR.

Considering the evaluated options of integration meth-
ods and equipment profiles installed in hospitals it was 
necessary to use the topology demonstrated in Figure 4.

RESULTS 
The suggested method was applied in a private, non-

profit hospital that has around 400 hospital beds and is 
located in the capital of Rio Grande do Sul (a Brazilian 
State). The hospital has around 4500 pieces of biomedi-
cal equipment.

Among the various areas that execute assistance health 
care treatment, using technologies, was defined the au-
tomatic capture of information from the trans-operative 
process from the equipment that was able to transmit 
data referring to the patients’ monitoring and therapy, in 

5 specific surgical rooms to store in PEMR and HIS. The 
topology to be used in this project is illustrated in Figure 4.

The data to be captured and information inserted in 
this integration are related in Table 1. 

In the architecture of Figure 4, the data of the anesthe-
sia station provided by the equipment (multiparametric 
monitors, anesthesia devices, Controlled target Infusion 
pumps) and the information and events manual input in 
the trans-operative (executed by the anesthesiologist) 
are integrated and converted in HL7 by an All in One 
Computer (AOC) attached to the anesthesia activities 
medical-assistance device, providing the institution the 
information to improve its procedures.

As described in Table 1, this integration allows to au-
tomatically register data from the patient’s vital signals 
in surgery, ventilator mechanics, anesthetic gases, drugs 

TABLE 1. Integration Parameters

Origin Information

Multi - parameter 
Monitor

Vital Signals (ECG, SpO2, PNI, PI, CO2)

Anesthesia Equipment
Ventilator Data and  Anaesthetic Gases 
(Vmin, Aereal vias pressure, frequency, 

PEEP, ventilator mode)

Controlled Target 
Infusion Pumps Drugs

Volume and administered concentrations

Anaesthesiologist Input Events and information trans-
operative elapsed

FIGURE 3. “Indirect” topology with Gateway.

FIGURE 4. Topology used in the project (without Gateway).



Souza, Marciano: Integration of the Trans-Operative Information with the Patient's Electronic Record

J Global Clinical Engineering Vol.2 Issue 1: 23-27; 2019  26

infused, as well as the events and information trans-op-
eratively executed and informed by the anesthesiologist.

It was also possible to identify which types and quanti-
ties of equipment are integrated with further stages so 
the solution can be implemented in all surgical rooms in 
the hospital, and thus allow the estimation of the financial 
resources needed to invest in future implementation to 
include budget planning in the institution’s posterior year.

DISCUSSION
This project is a consequence of the maturing associ-

ated with the continuous improvement of the storage 
processes of the patient information from the service 
promoted by a large hospital in the south region of Brazil.

It’s worth pointing out that the success of this project 
is directly tied to the active participation of the Medical, 
Technology Information, Clinical Engineering teams beyond 
investing in needed hospital equipment that can export 
data, besides in technology information infrastructure 
including processing and storage servers, cabling, enabled 
network points, etc.

Attention is needed concerning issues including con-
cept alignment with the board of directors and scenario 
evaluation referring to opening the service suggested 
(because this project will change the modus operandi). 
Another important factor is in the previous capacity of 
all the teams involved.

The data safety has worried various sectors in many 
areas in the world, therefore, it is recommended that the 
product selection and technologies have the recognition 
of the National Health Surveillance Agency (ANVISA) or 
similar group in the application country and are in com-
pliance with the Information Safety Rules.

The continuity of application of this integration, the 
way the data and information are transferred, stored 
and further accessed, and the safety protocols, are sus-
ceptible to further analysis, developments, adjustments, 
and validations.

CONCLUSION
The health organizations using electronic systems tend 

to have more effective control over data and patients’ 

clinical information. This more efficient way of informa-
tion collection can provide safety, transparency, and better 
service to the patient, allowing the audit of activities such 
as medical-assistance, providing the institution data to 
improve its procedures.

In more advanced centers and some Brazilian hospi-
tals this form of more efficient collection, storage, and 
information integration begins to develop, mainly in the 
application of intense therapy unities.7

The clinical engineering teams with their multidisci-
plinary knowledge can contribute to the medical teams, 
assistance, and information technology and become in-
creasingly applied to the integrated possible technologies.

The expectation is that the project will automatically 
capture the vital signals from the medical equipment and 
the records from the trans-operative and to provide an 
anesthesia file to be stored in the PEMR and in HIS, which 
can effectively contribute to the safety and reliability of 
data and information from the trans-operative stage. The 
project will also qualify the data and information via the 
automatic inputs and with no further manipulation.

This will contribute to improving the standardization 
of documents and medical protocols, decrease failures, 
and provide more clarity in adverse events via the ease 
of data search and information for studies which benefits 
doctors, assistants, hospitals, and patients.

CONFLICT OF INTEREST
The authors declare that they have no conflict of interest.

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