Triage Wireless Secures $3 Million in Series A Round
Startup Triage Wireless closed their first major round
of outside equity. This is a very interesting company targeting the
ambulatory blood pressure monitoring market. Lead investors in this
round were London based VC 3i and (almost) local firm Sanderling. Both firms specialize in biomedical startups, and both VC firms get seats on Triage Wireless' board.
The product, called the Advance BPM system, provides a platform for
remote patient monitoring using wireless sensors and a gateway.
Monitored parameters include: blood pressure, heart rate, SpO2, ECG
rhythm, and possibly temp. You might notice these parameters extend
beyond traditional ambulatory BP monitoring. According to the press
release, the Advance BPM platform could target three additional market
segments; a low-cost product for cardiac disease management; a 24-hour
ambulatory monitor; and an in-hospital monitor. According to Robert
Murad, Triage Wireless CMO, the product platform might also monitor patients with CHF, sleep apnea, pneumonia and cardiac
arrhythmias.
Wireless sensor-based monitoring is a pretty hot area right now (here's an example). The company has applied for 16 patents on their
technology. No word on whether they've signed licensing deals with any others holding broad IP in this area, like the Besson patent (scroll down to the bottom of the post). You can read more about Wireless Sensors by clicking the category in the left column.
The product consists of a disposable wireless sensor, a gateway device
(presently a PDA with Bluetooth and a CDMA mobile phone radio),
Qualcomm's QConnect provisioning system and NOC, Sprint's CDMA
wireless wide area network, and web based client apps for the physician
and patient both. The following use case comes from the press release:
- A comfortable patch sensor is worn during a patient's sleep and
day-to-day activities and makes continuous, cuff-less measurements -
A mobile device receives data from the sensor and wirelessly sends information to a secure website
-
The website provides prescribing physicians with comprehensive information for the diagnosis and management of hypertension
The availability of off-the-shelf gateways (i.e., PDAs with both
Bluetooth and CDMA wireless phone), existing reimbursement, and 75
million people with high blood pressure, makes the outpatient remote
monitoring market an attractive first step. Both continuous monitoring
for acute conditions and alarms will be difficult to implement over a
wireless carriers network (dropped connections, dropped packets,
latency, etc.). The cost of running continuous monitoring on a wireless
carrier's network could be prohibitive if there is not a flat rate per
month plan available.
A product targeting hospital inpatients would probably require the
development of a gateway that includes a WiFi radio rather than CDMA, a
new server and client apps. The press release mentions integration with
HIT apps, but does not mention any HL7 interface.
According to serial entrepreneur and CEO Matt Banet, they plan to go to clinical trials in January at Scripps. Distribution is not set, but they're tending towards an indirect distribution channel.
Changes in Critical Care and the Variable-Acuity Unit
Critical care units (CCUs) are an important part of any hospital. Typically, between 8% and 12% of a hospital’s beds are devoted to some form of critical care (about 3% outside the US), which consumes half of an institution’s direct patient care budget; CCUs are expensive.
A standard indicator for hospital patient flow problems are ED diverts and boarding. In 2004 46% of all hospitals reported going on ambulance diversion; that percentage goes up to 69% for urban hospitals. Similar data for 2001 shows the rates of diversion at 62% and 79%; this represents some improvement, but not much. The leading cause of this patient flow backup: lack of critical care beds (2001 and 2004, 43% and 39% respectively). While the number of ICU beds grew 26% between 1985 and 2000, the problem still exists.
In addition to constrained capacity, there is also a problem with over utilization. Critical care areas see a high degree of inappropriate admissions that take beds away from truly critically ill patients. In one study, “11% to 34% of patients admitted to the ICU in the past two quarters alone did not meet the severity and intensity measures, justifying admission to the ICU.” An inappropriate admission to ICU, being the most expensive, can produce significant unreimbursed costs to the hospital if the payer deems the admission inappropriate. With capitated patients, a hospital gets just so much per admission. Even if the patient met criteria for admission, it is prudent to treat the patient with what he/she needs, no more and no less. An ICU admission might be too much. In most cases, these inappropriate admissions end up in CCUs (especially Telemetry and stepdown units) because they require patient monitoring or a nurse-to-patient ratio that is higher than that available in general care areas.
It is unlikely that hospitals will build their way out of this problem. Well over half of US hospitals have negative patient care margins, and ICUs are expensive to build and deliver care ($2,674 per patient day).
The “acuity adaptable” room is a concept that has been gaining ground as a strategy to relieve pressure on critical care areas. Health Facilities Magazine has an article on trends in CCU construction and leads off with a discussion of variable acuity or universal beds. The term “universal bed” (universal room or universal unit) is traditionally defined as private patient rooms equipped to the standards required for critical care. Here’s an explanation from the article:
Universal room construction involves equipping private patient rooms to the standards required for critical care, under the assumption that as the patient recovers, he or she will be permitted to stay in the same room while the trained staff rotate. Nurses’ stations are positioned immediately outside the patient room with patient viewing windows, electronic charting and digital information–one nurses’ station per two private patient rooms.
This I think is misguided. Building out a meaningful percentage of patient rooms in this way would create a greater number of expensive ICU-type rooms that would only be used as critical care rooms for a portion of the time they are in use. If the nurse-to-patient ratio is maintained at 1:1 or 1:2, HPPD (hours per patient day) costs would also equal the ICU. These rooms could be even more expensive than traditional ICU rooms if current “state of the art” recommendations of additional nursing stations and amenities for family members are included.
Nor is the implementation of “universal beds” simple to implement:
Though architects and administrators have embraced the acuity-adaptable configuration in many settings, it is most appropriate in critical care, where the desired nurse-to-patient staffing ratio is maintained at 1:1 or 1:2. It is far less efficient in medical-surgical nursing units, where the nurse-to-patient ratio may be 1:4 or 1:5.
The challenge for providers is successfully staffing the acuity-adaptable model. Critical care nurses require specialized training and possess specialized skill sets. What happens when one of the two critical care patients becomes less acute? The critical care nurse, positioned outside two universal rooms, is now faced with caring for one critically ill patient and one lower acuity patient, which is inefficient and expensive.
The description above seems to recommend an approach of providing a greater than necessary level of care in the most expensive setting. This seems a non-starter given today’s health care costs, the state of hospital finances, reimbursement pressures, and changing patient
demographics.
What is needed is the creation of true variable acuity units that are different from both critical care and med/surg units. The guiding philosophy of such a unit is to deliver the appropriate level of care in the least expensive environment. This approach preserves both patient safety and hospital finances. Typical variable acuity unit policies include:
- Critical patients (that meet admissions criteria) continue to be cared for in ICUs
- The variable acuity unit replaces some or all traditional Telemetry, high dependency and stepdown units
- No special construction or build-out is required, but appropriate patient surveillance and alarm notification is required
- Admissions requirements are defined for the variable acuity unit, and revised for other units (and enforced!)
- Variation of patient acuity supported by a variable acuity unit ranges from a high dependency or stepdown unit to general care
- A nursing staff with a broader mix of skills is required, i.e., some critical care nurses and some med/surg nurses
- Patient assignments and nurse-to-patient ratios will be driven by either patient acuity or workload and vary by patient
- Multi parameter patient monitoring is available in the unit
- Appropriate meds and therapies (IV, vents, etc.) are available on the unit
The goals of the variable acuity unit are to:
- Allow patients that do not require 1:1 or 1:2 nursing care to bypass CCUs
- Allow patients to be discharged from the ICU more quickly and placed in an appropriate and lower cost setting
- Reduce readmission to the CCUs when patients require greater clinical surveillance or intervention
- Provide greater continuity of care, as patients are transferred less between “specialized” units
- Reduce LOS, mostly as a consequence of fewer transfers
- Free up CCU beds and significantly reduce ED diversions and boarding
This past May, an editorial in the Am Journal of Critical Care called for fewer ICU beds in the US, observing that many patients who are placed in an ICU to receive a little extra care and observation could receive the care they need in a unit with a lower but appropriate level of management. A variable acuity unit is a thing unto itself, not an ICU with lower acuity patients nor a med/surg unit with patient monitors. The creation of a flexible acuity unit, as opposed to a universal unit, provides significant financial and clinical benefits.
Planning for Hospitalists
The adoption of hospitalist programs is one of a number of proven methods to improve patient flow. Hospitals & Health Networks has a good overview on things to consider when contemplating the use of hospitalists. Here's an excerpt:
Some of the most common needs regarding service include:
- Managing admissions on behalf of the physicians, which improves their lifestyle and allows them to focus on outpatient volume.
- Providing prompt, attending physician services to patients without
regular physicians and often without insurance or financial resources. - Providing on-site, 24/7 physician coverage to hospitalized patients.
Some of the most common needs regarding care management include:
- Efficient use of resources, resulting in a decreased cost per case.
- Improved patient satisfaction due to increased physician presence.
- Improved quality of care due to the physician's increased familiarity with hospital procedures and processes.
- Improved compliance with order sets and standards of care.
- Improved throughput, better capacity management and decreased length of stay.
- Improved ED performance due to facilitated admission procedures.
Baylor To Deploy Self-Service Kiosks Throughout Network
Baylor Health Care System signed a three-year contract to license
Galvanon Inc's MediKiosk solution at all of its affiliated facilities.
Baylor will roll out Galvanon's self-service kiosks to automate the
patient registration process at its entire network of hospitals,
primary care centers, rehabilitation clinics and ambulatory surgery
centers. The contract follows a successful pilot program at Baylor's
Sammons Cancer and Breast Imaging Center (also a reference site), where patients use Galvanon's
MediKiosk to check-in for appointments, enter or verify demographic
information and make co-payments.
[Hat tip: Dail-E News]
Mobile Phone Vendor Update
Verizon and PatientKeeper announce
that the PatientKeeper platform can now be accessed through Verizon's
wireless network. Each wireless carrier's wireless network is somewhat
proprietary, so IP based applications must be tested (and sometimes
tweaked) to run properly. Whether this announcement means anything more
that test and validation on Verizon's network is not clear.
In other news, Sprint announced that they'd completed their acquisition
of Nextel. They passed up a perfectly good new company name (Sextel)
for Sprint Nextel Corporation — boring. Nextel has traditionally been
strong with contractors using their “push-to-talk,” a feature that for
many years was unique. Numerous hospitals have also acquired Nextel
microsites and use the handsets for internal communications.
Sprint has made one of the earliest and biggest pushes into the health
care market, and is the first and only carrier to implement Qualcomm's
third party provisioning system (called QConnect). This allows vendors selling products
with embedded radios to directly provision their customer's devices on
the Sprint network. This self-provisioning system eliminates 2
objections medical device vendors have to using wireless carrier
networks. By allowing vendors to provision their own customer's devices
on the carrier's network, they can maintain a more direct client/vendor
relationship, keeping the carrier at an arm's length. Wireless carriers
provide notoriously poor provisioning service, so the vendor can
provide their own service to their customers.
Qualcomm's been shopping this capability around for a couple of years,
but I'm not aware of any device vendors signing up. Nor have I heard of
any other carriers offering this service. As remote monitoring for
chronic disease gains adoption, services of this type will eventually
be adopted.
UPDATE: I talked with the CEO of Triage Wireless today and learned that his company and CardioNet are both using Qualcomm's QConnect capability (press release). More on Qualcomm's efforts in health care here.
From a coverage standpoint, Sprint probably has the third biggest
coverage footprint (after Verizon and Cingular). Their support of
QConnect was probably the key factor in signing up Triage and CardioNet
to their network.
