So What's Wrong with USB Connectivity
Reader Bernard Farrell (who's got a terrific diabetes oriented blog) ask about my recent slam on USB connectivity for medical devices.
crude and poorly suited for most medical device connectivity applications and
should be eclipsed by Ethernet and wireless LANs.” Given how successful USB has
been in the camera and MP3 device marketplace, why do you see it as 'crude'? It
may eventually be replaced by wireless, but I don't think this will happen until
wireless boards are as cheap as USB is right now. Anyway, I'm just curious here
and I've love to know more.
Medical device connectivity is all about workflow, not just getting data out of a device and into some software application. At one extreme you have the user look at a device, manually record the data, go to an information system, pull up the appropriate patient and key in the data, indicating the time the data were “acquired”. This process is obviously labor intensive and prone to many types of errors.
The best kind of connectivity is that which becomes invisible, requiring the minimum intervention on the part of the user. The best connectivity at the present time is wireless where the user easily establishes patient context at the patient attached device. Data is then acquired automatically (the frequency and specific data elements) according to a predefined protocol or configured by the user. While attached to the patient, the device system manages the connectivity and patient context (not a trivial task in some use models) and notifies the user only when there is a problem requiring manual intervention. Finally, when the device is removed from the patient, the patient context and data connection are broken down, freeing system resources for other patients and connections.
USB connectivity is “crude” in that most of the manual steps outlined above are still manual; the USB only eliminates the need to manually record and enter data. The user must still be in the presence of the device to extract the data (via the USB drive), and must convey it over to the receiving computer, pull up the correct application, indicate where the data is to go, and properly identify the patient. The two problems here are staff productivity (and the likelihood that data collection will be late or not occur at all), and the risk of attributing the data to the wrong patient. Those are two big problems, both of which could result in an adverse event.
There are other forms of “crude” connectivity that suffer from similar productivity and safety problems. Connectivity that does not establish patient context in the patient connected device (common with serial interface connections) has patient identification risks. The device docking approach used by many point of care diagnostic devices runs the risk of delays in getting data into the chart – or possibly never getting into the chart. And wired connectivity of any kind is a frequent victim of forgetfulness, yanking sockets out of walls and/or damaging cables as devices are moved while attached to the network.
Connectivity also impacts the patient. Wearability, mobility, and patient comfort are affected by the quality of the connectivity implemented by a device. Poor implementations can result in false positive alarms, leads-off situations, and extra work and hassle toileting the patient. Even open heart patients are encouraged to start waking shortly after surgery, and a portable device that's not wireless is, well, silly.
To all of this, you can add my previous observations on the data security risks posed by USB connectivity. Pictured right is another snazzy USB drive, known as the stick.
Data Archival and Migration: Another Dirty Secret
The other day, PACS guru Mike Gray wrote an interesting post on disaster recovery. Between the HIPAA security requirements and Sarbanes-Oxley, hospitals have little choice but to archive data and store a copy off site. Mike takes the concept of backing up data a step farther:
to create a reasonable Disaster Recovery solution, why make that second
copy a duplicate of the semi, not really 100% DICOM-compliant version
of the study data created by your existing PACS? Why not avoid the
“disaster” of data migration and make that second copy a 100%
DICOM-conformant copy of your study data? What I am suggesting is that
you redirect your Disaster Recovery dollars into an second, standalone
“archive” solution, most likely from a different vendor, who can
demonstrate/guarantee that this second copy is accessible to both the
current PACS and the next PACS, and the one after that. There would be
no need to migrate the data, when you change PACS!
Make your Disaster Recovery solution a PACS-neutral solution, and avoid the very predictable disaster of data migration.
In the diagnostic imaging world, DICOM provides a reasonably high level of interoperability between vendors' imaging modalities and PACS. However the vast majority of PACS make extensive use of what DICOM calls “private” tags and other non standard ways to represent data. This makes migrating data from your old PACS to a new PACS from a different vendor problematic. This pernicious form of vendor lock-in represents a hidden cost that is born by providers when they replace systems. It can cost between one quarter and a third of the cost of your new PACS to migrate the data from your old system. The migration process takes months which frequently delays new system deployments. Yikes.
Now think about data migration and your EMR or CPOE system. Could you implement a new clinical system without access to data that was in the old system? Sadly there is no DICOM equivalent for non-image oriented clinical information systems, so migrations can be much more complex. Migration is not the kind of thing usually asked about by providers during a vendor selection process (let alone needs assessment). And don't count on vendors volunteering to raise the subject.
Hospital Uses Premise Patient Flow Application
The Syracuse Post-Standard profiles a Premise Corporation installation at St. Joseph's Hospital Health Center. The story has a nice lead in that set's the stage for Premise's patient flow application:
Monitoring the flow of patients and bed availability in a
busy 431-bed hospital like St. Joseph's Hospital Health
Center, in Syracuse, is akin to managing flight traffic at
an airport.
Patients are constantly arriving, departing and
transferring. About 50 beds turn over every day. Rooms need
to be cleaned after each patient leaves. Any misstep along
the way can set off a domino effect of delays, creating long
holdups in the emergency room for patients waiting to be
admitted.
Until recently, St. Joe's managed this complex process
with scraps of paper and color-coded magnets on a
6-feet-by-4-feet wall board in its admitting department. The
scraps of paper contained patient names and room numbers.
The magnets identified patients with conditions like
allergies or contagious infections.
“If a magnet fell off the board, you'd have to
remember exactly where that magnet came from,” said
Kimberly Murray, the hospital's director of surgical
services. “Of if you took a patient label out of a slot
to check some information, you had to make sure it got back
to the correct slot.”
After spending nearly $500,000, a year to implement the system, and training 1,600 employees, the hospital went live.
The program at St. Joe's lets staff analyze the
hospital's capacity at any given moment and forecast
what traffic is likely to be later in the day.
“The biggest benefit of this is it can get the right
patient to the right bed in the shortest time frame
possible,” Murray said.
Hospitals nationwide are under increasing pressure to do a
better job of orchestrating patient flow. Long waits for
beds can force emergency rooms to divert incoming ambulance
patients to other hospitals, delay medical care, anger
patients and hurt hospital finances.
The old system at St. Joe's relied on numerous phone
calls between staff on patient floors, the admitting office
and the housekeeping department. If housekeeping wasn't
notified right away of an empty bed, the dirty room would
not get cleaned right away, even though there might be a
patient in the ER waiting for it, according to Murray.
“Now it happens almost instantaneously, in minutes as
opposed to sometimes hours before,” she said.
Information about patients and bed status is continually
updated. This task used to be handled by employees in the
admitting office. Now every nurse in the hospital is
responsible for entering information into the electronic bed
board in real time.
The system shows the rooms being cleaned and in what order
dirty rooms are scheduled for cleaning. The queue can be
changed at any time if a more pressing need for housekeeping
arises on another unit.
The system also has much more patient information, such as
whether the person has special needs or is awake a lot at
night and could be disruptive to a roommate.
[Hat tip: iHealthBeat]
Impact of Remote Monitoring Still Inconclusive
Published studies about studies are sort of a “gimmie” in the academic world – you don't really need to do any research per se, but simply analyze research done by others. This new study titled, “Systematic Review of Home Telemonitoring for Chronic Diseases: The Evidence Base,” is a study of studies. From the abstract:
These inconclusive findings and lack of focus on “cost-minimization analysis” remind me of the discussions among physician/researchers at the Rapid Response Systems conference I attended earlier this week (more here and here).
It seems that many of these remote monitoring solutions are more caregiver productivity tools rather than new and unique therapies. Solutions like these make poor subjects for traditional double blind randomized control trials. Similarly, clinician-lead studies on remote monitoirng are all about outcomes like mortality and morbidity, virtually ignoring “mundane” issues like productivity or impacts on the cost of care delivered. Perhaps the ratcheting down of home health reimbursement rates (see below) will serve to swing the focus to the operational side. Certainly providers and patients both would be well served by improving the delivery of care in patient's homes.
Pictured right is the home health productivity tool chronic disease management system, Health Buddy from Health Hero Network.
[Hat tip: iHealthBeat]
CMS Set to Ratchet Down Home Health Reimbursement
The feds prepare the next phase in their transformation of the health care industry with the release of proposed new Prospective Payment System (PPS) rules published May 4th in the Federal Register (I found the proposed rule using the Justia search engine mentioned yesterday). The Home Care Automation Report reports:
industry it would do almost since the inception of the Home Health
Prospective Payment System (HH PPS) in October, 2000. After permitting
home care providers seven years to fully learn the system, enjoy
reasonable profit margins and invest in efficiency tools such as
technology and training, CMS is beginning to ratchet payment rates
downward, exactly as was done with hospital DRGs in the 80's.
I spent some time looking at remote monitoring and home health care delivery several years ago. The vast majority of home health care agencies were not interested in adopting point of care technology that was not reimbursed, regardless of how much it might improve productivity and lower costs. From my occasional exposure to this market since, that attitude has not changed much. It would seem that in the near term, home health agencies will have little choice:
providers to cut costs. By ratcheting payments down, only those who
find ways to economize will survive.
Perhaps downward reimbursement rate pressures will spur technology adoption that will reduce the cost of care delivery – like remote monitors that cut down on required caregiver home visits – without CMS reimbursing for the actual use of the technology.
In a more, ahem, rational market, providers would be constantly innovating to reduce costs in light of capitated reimbursement. In fact some industries are quite adept at reformulating themselves in response to changing markets. To all of our frustration, health care is not one of those flexible and constantly changing industries. While the science of medicine is always innovating, the business of delivering health care has a strong aversion to change.
Pictured right are some of the ViTel Net home monitoring devices, shot at last summer's Healthcare Unbound conference in Boston.
