AAMI 2007 – Day Two, Afternoon
The IHE PCD crew presented Meeting the Challenges of Integrating the Healthcare Enterprise. Didi Davis from HIMSS, kicked things off describing the IHE organization, what the IHE does, and how they do it. The IHE takes established standards and through collaboration with interested providers and vendors results in a series of “integration profiles” that specify how to configure multi vendor interoperable systems. Each integration area of focus, or domain, has a framework of standards designated to support the workflows and resulting integration profiles for a specific domain. Examples of domains include cardiology, eye care, IT infrastructure, patient care devices (PCDs), radiology, and more.
The process starts with use cases that describe workflows. These worflows are subsequently implemented across multi vendor systems using the standards framework for that specific domain. The resulting integration profiles are tested at an annual “conectathon” every January in Chicago, and demonstrated at Inteoperability Showcases held at RSNA and HIMSS, and then published for use by vendors, systems integrators and providers.
Another key message was the need for providers (buyers) to include requirements for interoperability and standards in the products that they buy.
Next up was Steve Grimes, VP of Enterprise Resource Planning at Technology in Medicine, talking about the convergence of medical devices and IT. He described the trends driving medical device integration with IT. Steve also outlined many of the benefits of this integration:
- Access to, comparison and analysis of rich set of clinical data from variety of sources that can be used to provide preemptive care
- Automatic charting of data to the electronic medical record (EMR)
- Closed loop systems … i.e., outputs from diagnostic devices (e.g., heart rate monitors & pulse oximeters) affect inputs on therapeutic devices (e.g., infusion pumps)
- Patient alarm management
- Asset tracking (i.e., RFID)
- Remote device management
- Monitoring data flow integrity & continuity
- Error code monitoring & remote diagnostics
- Software upgrades
After a review of specific devices being integrated, the resulting integrated medical systems were described. As the systems become more sophisticated, in their effort to improve patient safety and productivity, these systems can become more complex and expensive. As we get more dependent on these types of systems, when they fail it has a significant impact on patient care. This evolution has brought together IT and Biomedical engineering, frequently resulting in a clash of cultures.
Providers must assume a systems engineering role when adopting “home grown” system or multi vendor solutions. While single vendor solutions may be preferred, an increasing number of these systems cross product categories for which there is no single vendor solution. Historically, these systems have been adopted under the radar as a isolated systems. The complexity of these systems, and their impact on patient care, necessitate an strategic enterprise approach to ensure security, safety (like eliminating single points of failure), and manage infrastructure and costs.
The convergence of IT and medical devices are inevitable, and requires coordination between IT and biomedical departments. Clinical engineers can contribute to bridging these two very different departments, and provide a strategic systems vision that spans traditional IT and biomed domains.
Chis Riha, exec director of clinical systems engineering at Carilion Clinic Health Systems. He described the IT realm, with a review of different health care information systems.
Ray Zambuto, President Technology in Medicine, spoke in the IHE Patient Care Device (PCD) Domain. He ran down the history, starting with an IHE provider survey that indicated medical device integration was the second most popular area (50%) for future IHE efforts. Here’s the PCD’s charter:
The Patient Care Devices Domain is concerned with Use Cases in which at least one actor is a regulated patient care device. The PCD coordinates with other IHE clinical specialty based domains such as medical imaging.
Ray then laid out the workflows the PCD has tacked over the first three years. Another survey was done in 2006, asking for device priorities. The top 5 devices were vital signs reporting devices (EMR integration – 72%), continuous patient monitors (67%), ventilators (49%), anesthesia systems (44%), and infusion pumps (43%). Vendor priorities lagged considerably behind user’s interests – the biggest lag with vendors was vents at 21%. Ray described the profiles proposed for 2007:
- Patient identification – estab patient context and binding ID to data stream
- Device – enterprise query
- Point of Care (PoC) real time plug and play integration
- Home telehealth (remote monitoring)
Throughout Ray emphasized the need for providers to participate in the IHE PCD efforts. As someone who’s participated in the past, I can say that vendors are considerably over represented, and provider requirements, perspective, and priorities are sorely needed. “Decisions are made by those who show up!”
Questions: how does the groups work take place? There are two basic groups, the planning committee and a technical committee. Occasional face to face meetings (3 or 4 for each committee) are held for major planning and review efforts, with the rest of the work done via bi-weekly teleconferences and email. You can read technical work done to date by the PCD here. When a vendor says they’re involved in IHE, be sure to ask them for their conformance statement – these are not a certification, but documents their successful participation in a connectathon.
One byproduct of the IHE effort is increased transparency regarding what connectivity and interoperability a vendor’s products have – in a concise and detailed document. On the flip side, participating vendors are increasingly using their IHE participation as bragging rights and competitive advantage over vendors who do not participate.
AAMI 2007 – Day Two
The day kicked off with a two part session on “Applying Real-Time Integration in the OR.” The presenters started with “blood and guts” anesthesiologist, Warren Sandberg. He noted that the surgery department has limited – and frequently constrained – resources. He described the value of extending data beyond the location
What Sandberg’s describing is more than audio visual data (combining images of displays from various cameras and device displays), but data integration that allows for the rearrangement and massage of data to better manage clinical care delivery.
Mark Meyer compared and contrasted the differences between the value of surgical video alone and video with real-time data from patient connected instrumentation combined with operational (procedure, personnel) and clinical data (relevant history, allergies, etc.). A large screen display may be able to aggregate all the data in an OR, but an important requirement is to provide different views of the data, based on roles or what the user’s trying to accomplish.
The system Meyer’s uses at Mass General is from LiveData. This system acquires data (not just images) into a comprehensive “recording” that captures a complete record of each case. The system also captures positioning data of the patient, staff and equipment. The system can also create data trends from data aggregated across all patient connected devices, and display different screen formats based on reaching certain milestones in the surgical case. The data is all archived, and takes about 50 MB per case.
Conventional full disclosure systems are proprietary, run on a proprietary network, very costly, and are unit based (rather providing an enterprise architecture). The LiveData system captures data from multiple vendors with a goal to improve throughput and patient safety in the OR.
Next up, Phil Brzezinski, VP for Healthcare Systems at LiveData. He was inundated with questions about their system (as presented by Sandberg and Meyer) before he even had a chance to present. The 50 MB figure above does not include digital video – video generates a huge amount of incremental data. He notes that while other HIT apps may collect most of the same data, buyers must ensure that they can get access to the data in the form and at the time in which it serves the greatest good.
LiveData’s initial market was the electrical power distribution industry, where they created dashboards for utilities. Back in 2003 and 2004 they did their core research, looking at medical devices – the data generated, data formats, interfaces, etc. They also spent considerable time within the surgical environment gathering requirements.
Visual integration: “Using the clinical workflow at the point of care to determine the optimal display of patient data, images, communication tools and ancillary information to maximize quality and efficiency of care.” This is much more than just a “picture.” Their value proposition:
- Improving patient safety and productivity (thus improving throughput and utilization),
- Improving communications and coordination between departments,
- Leveraging IT investments by extending and synthesizing the data from multiple systems into new information, and
- Gathering data critical for “quality of service” payments.
In the realm of patient safety, LiveData helps reinforce Joint Commission safety protocols. The system also improves situational awareness and facilitates safe patient hand-offs.
All of the data in the LiveData dashboard comes from other systems – nothing is entered into LiveData. A common display configuration may include staff which is updated by scheduling apps, positioning systems and other sources. The patient data includes basic demographics, orders, allergies, etc. The central portion of the display is tabbed to follow case set-up, briefing, intraop, closing, debriefing, and protocol. Users are able to note when logistical problems crop up for later analysis. on the right is the progress log and a summary of cases for that room for the rest of the day. An example was also show where the day’s schedule was laid out horizontally along the bottom of the display along a time line. The system provides team communications: coordination, awareness, cooperation, and communications.
The LiveData Historian is the archive module, allowing for retrospective playback and analysis of procedures for process optimization. The archive module can provide specialized displays that match video of the case with any other data that occurs in time sync.
Phil presented a brief vision of the “visually integrated” hospital as a lead in to how LiveData systems are configured and delivered to customers. There are 6 key components:
- Data sources and mappings
- Workflow description and definition
- Custom user interface or workflow
- IT and Biomed integration for security and system maintenance
- Image routing and management choices
- Facilities
They start the process by identifying data sources and mapping relationships. The actual system configuration is completed, along with data mapping. A rapid prototyping process is used to enable customers to confirm the configuration, and rapidly arrive at an optimal system configuration.
Guess what? Vendors who are already established in the OR are not really keen on the integration that LiveData is providing. This is the common reticence vendors feel when presented with solutions that move beyond the conventional end-to-end proprietary product strategy. Some vendors may claim provide many of the same capabilities as LiveData – caveat emptor. Hospitals will have to push their vendors to support an integrated vision. You must insist your vendors support standards and process unification efforts. Demand open systems at a lower level of granularity – in other words, integration between complete systems is frequently ineffective; integration between sub modules is frequently necessary for meaningful integration. When looking at vendor solutions, consider vendors outside the list of usual suspects to include open source and innovative startups.
Questions: LiveData has yet to deal with a company that is not willing to share integration data, although some vendors are not ready technically for this, or are limited in what they’re really willing to share. The LiveData system does not replace anesthesia record keeping system, but integrates with them to get data, drive the dashboard, and track workflow. The LiveData system will integrate with a third party audio visual integration system from vendors like Stryker or Storz. A question of customer readiness shed light on the fact that LiveData customers are currently “early innovators” who already have high levels of automation. Less automated hospitals look to LiveData to do more than integrate existing data, and help with basic automation too.
Warren Sandberg finished these two marathon sessions with an indepth view of the financial issues (and ROI) that revolve around care delivery – using the OR as an example. Today’s reimbursement environment is rife with highly detailed mundane documentation requirements in order to realize optimal reimbursement. Any “up coding” where codes that reflect higher than normal clinical complexity must be appropriately documented – “if it’s not documented you didn’t do it, even if you did.” Pay for performance (P4) is increasingly adding to the “mundane documentation” requirement for physicians and caregivers. Sandberg’s presentation demonstrated how they used an anesthesia information management system and some additional systems facilitated the consistent capture of this detailed documentation as required be the case and payor. The financial impact was significant at MGH.
The benefits of this improved documentation included a significant financial impact, as well as reductions in LOS and improved patient outcomes. As reimbursement becomes more entwined with patient safety and outcomes (e.g., P4P), systems for billing, department operations, logistics systems,other clinical information systems, and medical devices will become more tightly integrated. LiveData is positioned facilitate this integration.
