Emergency Room Overcrowding Reported at LMRC
This article, in the Lakeland Florida Ledger, is about 20 patients that were diverted from Lakeland Regional Medical Center in just over 6 hours this past Tuesday. Each of these 20 potential admissions represents $50,000 to $75,000 in missed revenue.
The cause for this emergency department overcrowding? A bottleneck in the ICU. This was their first complete diversion, attributed to increasing ED visits and hospital admissions. In addition to lost revenue, the diversion increased costs as the hospital geared up efforts to clear beds for new admissions.
Two common causes for ED diverts are bottlenecks in the ICU and Telemetry. Why? Many patients end up in these two units when they need monitoring, regardless of their acuity. Various studies have put the percentage of inappropriate ICU admissions between 17 and 23 percent. These are avoidable ICU over-stays, readmissions or off-service admissions made in an effort to “bring the patient to the monitor.” This care model provides more than appropriate care in the highest cost setting for this group of patients.
One solution to this problem goes by various names: universal bed, universal unit, variable acuity beds, flex beds and flexible monitoring. The goal is to provide appropriate care in the lowest cost setting, and results in shorter LOS and reduced intra-hospital transfers. The biggest change with this new care process is caring for a broader range of patient acuity in general care units (in some cases up to a level equivalent to high dependency units). Thus when a patient shows the first signs of crashing, or that hip replacement patient starts to throw PVCs after surgery, monitoring and clinical intervention can be done in their unit without the traditional transfer to ICU or Telemetry. This process provides appropriate care in the lowest cost setting and frees up ICU and Telemetry beds for the truly acute patients who need them most.
Improving patient flow is not a panacea, but it can create “virtual beds” until bed expansions come on line and reduce the number of new beds needed to be built out.
The story also mentioned that overcrowding is endemic throughout Florida, with frequent problems mentioned in Polk, Hillsborough, and Marion counties.
HIPAA Security Deadline Looms, Will Hospitals Be Ready?
April 21, 2005. Will you be ready when the new HIPAA Security compliance deadline hits? Two articles caught my attention this morning, one on how to comply with the new rules, and a survey on progress to date.
Medical Connectivity and the Connectologist
The other day someone asked me what a connectologist was. In short, a connectologist is someone with a proficiency in medical connectivity who uses that knowledge to integrate medical devices with clinical information systems to automate workflow. This begs the question, “what is medical connectivity?”
Medical devices have followed a general life cycle, whether a heart/lung machine or diagnostic ultrasound. Their life starts with an idea revolving around a clinical need and the technology to be applied to that need. In the beginning it’s all about the data, optimizing the device for its intended purpose. Others enter the market and compete on the quality of their data — data on efficacy in the case of perfusion and image quality in the case of a diagnostic modality. During this phase customers grapple with fitting this new technology into clinical practice and hospital operations. As the technology matures, products become undifferentiated; all remaining competitor's products produce good data, and have (more or less) equivalent features. Competition starts to revolve around price, which is bad news for vendors.
Customer needs shift as well. The new device isn't new any more, and is well integrated into clinical practice. Customers become less interested in the quality of data produced by the devices and much more interested in finding help in managing the data that's created. They want “connected” devices, connected to a network of PCs, servers and perhaps an archive. By this time, the device vendors have been in business for 10 or 20 years. Their cowboy days of innovation are but a dim memory. The successful vendors have established world class core competencies critical to their standalone device business: embedded software development, mechanical and electrical engineering, operator workflow relating to device use, and device service and support (basically board or unit swapping, parts depots, loaner pools, etc.).
Now someone steps up to meet these new market needs, typically some young upstart competitor (trouble makers or saviors, depending on your point of view). Customers understand their needs only partially because they've never bought or used the kind of connected solution they've envisioned. Customers know they want something new, but aren't sure exactly what. Vendors are presented with the option of steping out of the box that they've become so comfortable with over the last 10+ years, or not. They can tell that the world outside the box is different. Because they've never developed, manufactured, sold, serviced or supported a product of that type, they can't really conceive what is required of them.
My first medical connectivity experience was in the early 1980s, working for a software vendor. Trinity Computing Systems was writing software on Apple II and IBM PCs for the cath lab. A computer connected to the printer port on cath lab recorders, emulating a printer. The computer also had a graphics tablet for calculating ejection fractions, valve areas, and other values from cine films and the pressure recordings. All of this went into a database and was used to create custom diagnostic reports and a cross patient database. By far the largest recorder vendor at that time, E for M, decided they liked the box business and would not be offering a connected product. Trinity grew rapidly, evolving from a cath reporting product to a broad diagnostic cardiology information system called CardioNet. This was a great niche for a software company like Trinity, but the eventual winners were medical device companies liker Marquette who embraced connectivity and launched integrated solutions. Over the next several years, E for M faded away as demand for standalone recorders dwindled.
For vendors who commit to making the change from a standalone box company to a connected systems company, the way is long, arduous and expensive. Vendors must identify the “whole product” solution; you can't sell just do the parts you want and leave the rest up to the customer to figure out. Then new core competencies required for systems need to be identified and secured. Many vendors fail to recognize that connectivity is a basic requirement and consider it as a big new revenue opportunity, almost like a new business.
Buyers face mirror image challenges. What is the whole product solution, and can the vendor provide one? Does the vendor have the required core competencies to develop, sell, install, service, and support the system I want? Does my total solution require some portion that the vendor has not released? If I buy “futures,” will the vendor deliver in a timely fashion? What about coexistence and interoperability with other systems in my hospital? These are all essential questions.
The sad truth is that in most cases neither the vendor nor the buyer knows what they don’t know. They end up backing into solutions after trail and error. From a standalone box perspective, little about connectivity is either intuitively obvious or as easy as it looks. The good news is that with experience, effective planning and decision making processes can be used to take much of the risk and unnecessary cost out of connectivity. That is the job of the connectologist.
There are a number of key device markets presently going through some variation of this evolution. A whole group of devices have not been previously connected because they were too mobile and poorly suited to wired local area network connectivity. These devices are now getting wireless connectivity: infusion pumps, patient monitors, vital signs capture devices, and ventilators. Many of these devices have been connected in the ICU for some time, but the use model there is significantly different from the new target markets outside the ICU. But hey, that just entails putting a radio in the device, right? Hmmm, maybe…
Picis Pursues "Best of Breed" Strategy with Enterprise Vendors
There is an interesting post on HIStalk with some history on Picis, IDX and how Picis has worked with the IDX and other large health care IT vendors. IDX and Picis have been working together for quite some time (mid 90's?). Picis has done very tight integration with IDX Care Cast, Eclipsys CPOE, and McKession Pathways scheduling and materials management systems, in an effort to secure their “best of breed” position for ICU and perioperative applications. For it's part, IDX has gained a competitive advantage over Cerner, Epic, Eclipsys and other enterprise vendors by offering Picis applications to their customers. Their largest joint customer is the Mayo Clinic, with 180 operating rooms, 130 PACU beds and 350 ICU beds. I wonder how many of those ICU beds are filled with patients who need monitoring but don't need the high level of care provided by the one to one nurse/patient ratios in an ICU.
NaviCare Patient Flow Software at HIMSS 2005
Hill-Rom’s NaviCare patient management software included a number of new things at HIMSS this year. The highlight was the new software release version 6.0 with Care Traffic Control (cute name). Integration with Vocera for both messaging and data capture added demo sizzle, although the ambient noise in the convention center resulted in less than flawless performance.
Care Traffic Control is a new system configuration focused on the basics, targeting hospital bed management including modules for transport and housekeeping. Trimmed to the basics, Care Traffic Control represents a new building block for customers who found the complete solution too expensive or too big an implementation to take all at once. Starting with a bed tracking system, the new packaging allows for phased implementations resulting in the same feature rich and sophisticated solution, including special modules for the ED, surgery and general patient care. Their Platinum level product includes advanced process mapping, length-of-stay monitoring, discharge planning and staff-ratio monitoring.
In an effort to shorten sales cycles and make NaviCare easy to buy, Hill-Rom recently offered a turn-key monthly lease program that includes hardware and core patient-flow management features.
NaviCare was founded in 1994 with a system for streamlining operations in hospital surgical departments. Over time, they evolved into a scalable system that can optimize patient flow within a department, hospital wide, or across multiple facilities. NaviCare has an installed base of 50 systems.
Due to the scope, cost and complexity, patient management software sales cycles average 12 to 18 months. Successful deployment of patient flow software requires significant up front work with the client identifying patient flow bottlenecks and planning system implementation and configuration. Dropping a system into a hospital without proper preparation (let alone vendor qualification) will result in shifting bottlenecks around rather than removing them altogether – or worse. When system sales started to build, NaviCare made the decision to try to fund growth through cash flow. This growth strategy turned out to be inconsistent with the patient flow software business. Cash strapped NaviCare received a $2 million investment by Hill-Rom in February 2003. With this minority equity position (about 20%), Hill-Rom began jointly marketing NaviCare’s systems to hospitals. Almost a year later to the day, Hill-Rom acquired the remaining 84% of NaviCare Systems for $14 million.
Hill-Rom is in the process of interconnecting its portfolio of communication and patient flow solutions, so they can share information among themselves and with other hospital products and systems. This includes their patient and asset tracking system and communications module. The integration strategy with Vocera and others is across the patient workflow product line. If they are successful in connecting equipment, systems and solutions together in an intelligent, scalable open architecture Hill-Rom will have a powerful competitive product base.
