Connectivity-dongle

I found a blog reader's email in my inbox this morning. It seems not everyone at his hospital is keen on investing in medical device connectivity. He wrote about a near term need for connectivity to a planned EMR. Sadly, medical device connectivity is sort of the Rodney Dangerfield of EMR deployments, frequently an afterthought or put off for some "future phase" mainly due to complexity and cost. What follows is my reply.

Device connectivity impacts EMR adoption in a number of ways. (In no particular order.)

  • User adoption - a jaded observer could view many HIT projects as an exercise in getting one set of users to either change the way they do things, or to take extra steps, for a benefit of other users. Manually entering medical device data into an EMR is widely perceived as "extra work" or "double entry" by caregivers on the floor. This occurs when physiological parameters from devices are manually recorded and then later typed into the record. Automated acquisition of medical device data is perceived as a benefit of EMR adoption by most caregivers, because it's - you know - actually automating an otherwise manual task. Since a big part of the success of an EMR deployment rests with caregivers, medical device connectivity is a big carrot that can engender EMR adoption; of course the opposite (the negative impact of manual entry of device data) is also true.
  • Timeliness of data - a big benefit of EMRs is the ability to get data into the electronic chart as soon as it is available by integrating various diagnostic (e.g., radiology, lab) and medication systems (e.g., an electronic MAR and integration with pharmacy IT). Data from medical devices is frequently overlooked as a source of data with a timeliness requirement. The manual entry of data from medical devices is frequently delayed. Caregivers are frequently interrupted in their tasks, and the act of entering the data into the electronic record can be delayed by minutes or hours. Which brings me to the next issue:
  • Missing data - as caregivers write down medical device data (on scrap paper, their scrub suit or hand) they sometimes get distracted and lose that scrap paper or forget. Consequently, that data never makes it into the electronic record. Over 50% of point of care diagnostic tests are never recorded in the patient's chart, let alone an EMR. There is a lower rate of missing data for vital signs data.
  • Poor data quality - the inherent weaknesses of paper charts include illegibility of entries, entries that are incomplete or not made, transposed data, or accurate data entered for the wrong patient. Without automating the acquisition of data, an EMR really only improves illegibility. Thus manually recorded device data that is keyed into the EMR can result in transposed data or data entered into the wrong patient's record. Medical device connectivity eliminates these problems, just like an interface to your lab system.

All of the above issues become more important as patient acuity increases because the higher the acuity, the more device data that's generated. Hospital patient acuity is increasing, as reflected in the hospital trend to increasingly monitoring patients outside of conventional monitored units (ICU, telemetry, step down, etc.).

I can think of two additional drivers for medical device connectivity:

  1. The Joint Commission's new National Patient Safety Goal for the identification and response to patients with a deteriorating clinical condition (goal 16) necessitates that hospitals tighten up the completeness, timeliness and accuracy of vital signs data (and in some cases, increasing the frequency). Research has shown that vital signs capture is pretty poor in many hospitals (more on this later). Medical device connectivity will help maximize the quality and timeliness of your vital signs data.
  2. Starting next year, CMS will not reimburse for certain adverse events. These "hospital acquired conditions" are all preventable and many focus on infections. While care practices like ventilator toilet will minimize these infections, high quality medical device data (along with lab data) will allow your staff to identify infections most quickly. Since CMS will no longer reimburse you for the costs to care for these infections, the sooner they are identified, the sooner they can be treated - minimizing the financial loss to the hospital. (More here and here.)

For data and references to put around the above, there are a number of sources (besides the links embedded above). Vital signs vendors with device connectivity features like Welch Allyn (Connex) or Sensitron are the best source for data on the incidence of missing, delayed or inaccurate manual data. I would talk to both vendors to increase your pool of data.

Another source of information (one that I forgot to mention to my reader) includes studies on pervasive short falls in vital signs documentation. This was one of the main topics at the 4th annual Rapid Response Systems: Teams Systems for Safety conference. You can access the conference presentations here. This presentation by Gary B. Smith MD provides specific data on the completeness and accuracy of typical vital signs records.

But medical device connectivity justification is really the easy part. The lack of standards and vendor's obsessive pursuit of proprietary end-to-end solutions can make connectivity very expensive at best, and confusing and hard to use at worst. It's easy to get painted into a corner by proprietary systems, or forced to adopt a mosaic of systems from vendors who only provide part of the solution. And due to the cost, not to mention the pervasive use of medical devices, implementing connectivity must be done in phases over time.

A good connectivity plan is based on a thorough needs assessment that encompasses current practice and future plans for HIT, telecommunications, medical device purchase/replacement, and care delivery processes. Initiatives like continuous quality improvement, improving patient flow, and extending patient monitoring into new clinical areas all impact connectivity requirements. Then all of this must be distilled into a set of requirements used to create a phased connectivity plan.

The next challenge is to address vendor variability. Besides details about what and how vendors do what they do, you have to try to take into account their roadmaps, or future product plans - otherwise you might end up with a plan to use products that you can't buy from anyone.

The end goal of all this is a connectivity roadmap for your hospital that takes into account planned funding, anticipated changes in the needs assessment areas mentioned above, and vendor variables all laid out in a timeline. Now you're ready to put together a capital budget for phase one.

So, hopefully I've helped with articulating the need and justification for medical device connectivity. And just like I told me reader, if you've got questions, let me know.

If you gain the momentum to move forward with connectivity in your hospital, and you'd like some help let me know. I can provide targeted feedback and advice, come in and do the whole thing (assessment, connectivity roadmap, system design, and vendor selection) turn-key, or anything in between.

Pictured right is a serial cable dongle typically used to connect legacy medical devices that don't have network connections.

UPDATE: Health Data Management reports that Applied Digital subsidiaries Verichip and Digital Angel are working with sensor company Receptors LLC to create an implantable glucose sensor that transmits data using a passive RFID scheme.