The following are some notes from some of the more interesting presentations - be sure to keep scrolling, this is a long post! I’ll follow this up with a post on my presentation at this year’s conference, “How the Network Effect Impacts Adoption of Healthcare Unbound Technologies,” and a wrap-up post.

At 8 am Monday morning, Teri Louden kicked things off. She started her career at Baxter Travenol in the 1970s. Referring to The Graduate, Baxter’s innovative technology of the day was plastic IV bags. Today, things have come a long way from plastics to Healthcare Unbound.

There have been few breakthrough industry segments over time - disease management, home infusion therapy, outpatient surgery - and Healthcare Unbound (HU) is an important pioneering new industry segment.

Teri prognosticated that many of the really breakthrough solutions in health care will come from companies outside of health care - mentioning Intel, Qualcomm, and other electronics and communications companies.

Using CardioNet as an example, Teri described how a new type of solution presents substantive challenges for adoption and effective use. The CardioNet value proposition was unique and required new ways of selling, patient use, and reimbursement.

She introduced Vince Kuraitis and David Kibble, and their topic: The Personal Health Information Network (PHIN): Opportunities and Implications for Healthcare Unbound

The Personal Health Information Network (PHIN): Opportunities and Implications for Healthcare Unbound

Vince introduced the topic with a classic example of the network effect, phones. He asked, what is the value of a single phone? The health care industry is currently the equivalent of two phones representing one to one solutions. The real value comes to the fore when many phones are interconnected, allowing users to contact many other users whenever they want. (more…)

Designing for the unforeseen: preparing your facility for evolving technologies

Presenters: Barrett Franklin and Sudhakar Nagavalli of KJWW Engineering; Valmik Thakare, Christner; and Dennis Minsent, OHSU.

Major trends that they see:

• Diagnostic imaging - portability
• Monitoring/connectivity
• Integration
  • Clinical information systems
  • Video capture
  • Communications
• Transparency (RTLS)

Diagnostic imaging is moving out of conventional settings into surgery, procedure rooms and intensive care. This impacts workflow and consequently, workflow automation. Imaging is becoming an enterprise application, going beyond distributing images on an enterprise basis to include image acquisition anywhere and any time.

Patient monitoring is transitioning from disparate stand alone systems to an enterprise system. This creates specific infrastructure requirements, encompassing wired and wireless networks. Raising patient acuity and an increasing trend to spread higher acuity patients out to their medical services has increased the need for pervasive monitoring capabilities.

Integration was grouped into 3 different applications. Integration started in the operating room, and this trend evolving into a unified enterprise system. There is a growing requirement for disparate systems to work in concert, including: patient monitoring, ventilators, infusion pumps, defibrillators and information systems. This gives rise to challenges in defining a coherent network infrastructure. (more…)

GE Breakfast Symposium

Presented by Elliot Sloan and Leanne Cordisco, the symposium presented a vision of the future of the biomedical engineer. Elliot started off, describing how we got to where we are.

“May you live in interesting times…”

The issue that started all this - biomedical engineering - was electrical safety. Ralph Nader’s shocking expose on a rash of hospital patient deaths from electrocution stirred both the public and the industry. Nader’s shameless self promotion consumer advocacy resulted in congressional hearings, new FDA regulatory authority, and the creation of the biomedical engineering role in hospitals.

Then in 1977, the big issue was gas safety. Changes like DISS standard gas fittings, O2 low-pressure cutoffs and PO2 monitoring were the result. Already the interactions between systems of systems were creating risks that resulted in use errors, patient injury and death.

Classic systems engineering was first applied to solve anesthesia deaths in 1991. The need for systems engineering has only grown over the years, as complexity affects multiple systems in unexpected ways. (more…)

The theme of this year’s Clinical Engineering Symposium (and also the title) is: Capturing the Heart and Mind of the Clinician — The Art and Science of Human Factors for Medical Systems.

Ed Israelski, the Human Factor Program Manager at Abbott, talked about the application of human factors to the design of medical devices. He presented a basic framework for incorporating human factors engineering (HFE) into the product development cycle.

He noted that the importance of developing quantified usability objectives, and through testing prototypes (both product models and user interface simulations), to improve usability and safety through design iterations.

The FDA design history file is required to include HFE in the design process, but does not proscribe specific methodologies for implementation. Consequently, most HFE efforts in medical device product development are very limited. You can read more, including a survey on medical device vendor software engineering methods, in this report (scroll down to the sub head, A Survey of…) from last year’s conference Improving Patient Safety through Medical Device Interoperability and High Confidence Software. (more…)

The following is a continuation from the the Improving Patient Safety through Medical Device Interoperability and High Confidence Software joint workshop last week in Boston. I’ve got a bunch more notes that I’ll be tweaking and posting this week. This next bit is from a panel discussion that described the need for high confidence systems and interoperability. The panel was introduced by co-chair Julian Goldman.

The foundation for any quality product is requirements. Inadequate or incorrect requirements mean not just a lousy product, but one that could be unsafe or unreliable. This panel discussion targets the clinical need driving high confidence systems and interoperability.

A market for any kind of product is made up of both producers and buyers, each with their own responsibilities. Device vendors (and to a lesser degree, HIT vendors) have not demonstrated much command of either a good understanding of the workflows that occur around their devices, or a mastery of workflow requirements gathering. To achieve success with medical device interoperability, one must have high quality requirements.

At the same time, buyers are responsible for actively shaping demand and motivating vendors to build the best products possible with the right features. Healthcare providers must demonstrate a market for interoperable systems in order to provide vendors the motivation (and eventual financial return) on more comprehensive requirements gathering efforts.

The expectation is a phased market implementation, with medical device connectivity first, and then interoperability between devices, and between devices and systems. Such advances must support clinically meaningful use-cases. Standards can be used to mitigate risk and support interoperability, but they have yet to mature sufficiently to make connectivity or interoperability easy: a classic “chicken or the egg” conundrum.

The Clinical Needs panel included:

Jeff Cooper PhD, Anesthesia Patient Safety Foundation
Sandy Weininger PhD, FDA
Jennifer Jackson MBA, CCE, Brigham & Women’s Hospital
Jim Philip MD, Brigham & Women’s Hospital
Steven Dain MD, University of Western Ontario
Jim Fackler MD, Johns Hopkins
Moderator: Julian Goldman MD

Cooper’s introductory remarks went to his motivation for participating in the APSF and his interest in medical device interoperability. He described two experiences, the son of friend who went into respiratory arrest on a PCA. In another experience, a friend was in the hospital and he saw first hand what is the best and worst (disruption in care, interrupted communications) in hospital care.

“Hospitals today are not safe – if you go into the hospital, take someone with you. One of the biggest problems is that technology advancement has outstripped the infrastructure (how the technology is deployed and used) to ensure safety. The technology with perhaps the biggest potential impact on patient safety is the interoperability of medical devices.”

After Jeff Cooper described the need, Sandy Weininger, noted some accepted approaches to developing high confidence systems. Looking into the future, he also offered some rhetorical questions on creating safe and effective systems.

“Absolutely Safe,” how do you define it? How do you implement it? In reporting to the FDA (users voluntarily report, and manufacturers have mandatory reporting) they receive more than 100,000 reports per year. The FDA estimates that that figure represents just 2% of actual incidents. Of the fraction of events that the FDA does receive, they are hard to analyze and understand.

Best practices for interoperability and systems integration include:

• Clinical requirements are necessary to understand what a complex medical device system is intended to do
• “Interoperability” must be described using rich set of scenarios/use cases
• Must address safety, security, effectiveness
• Look at current clinical challenges and hazards, mitigations, future solutions and new risks

Given that this whole interoperability thing extends way beyond the actual “medical device,” Sandy went on to note the legal definition of a medical device:

An instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article, including a component part, or accessory which is intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease, in man or other animals, orintended to affect the structure or any function of the body of man or other animals, and which does not achieve any of it’s primary intended purposes through chemical action or on not dependent upon being metabolized

Device vendors, systems integrators and hospitals should study this definition.

Weininger also asked some important questions, like, “How do you enable innovators (who lack the resources to create their own vertically integrated systems) to contribute innovations that work safety?” and “How do you validate a system that is greater than the sum of its parts?”

He contrasted how one builds a conventional medical device with additional factors that should go into the broader scale systems resulting from interoperability and systems integration. The issue is a systems engineering challenge that requires the involvement of numerous specialties. This is not new – aviation is a great example. The best solutions require a multi disciplinary approach. These skills include control systems design, operations research, safety engineering, reliability engineering, interface design, cognitive systems engineering – human factors, in addition to communication protocols and security engineering.

Risk analysis is essential to designing a safe system. Weininger suggested the IEC 60300-3-9: Risk Analysis of Technological Systems standard as offering a good methodology for risk analysis.

Another important factor is the proper identification and description of requirements. Two common approaches are clinical scenarios and use cases. Clinical scenarios are descriptions of the current clinical situation and related problems identified from clinical stories, adverse event reports, near misses, etc. Use cases are a detailed look at a specific part of the clinical workflow. A work flow may not be required for a use case, but is helpful for examining human interaction.

Weininger wrapped up asking, “so, when is a system validated?” The answer with a stand alone embedded system medical device is unambiguous. When medical devices and information systems are combined, the answer is much less clear.

Jennifer Jackson discussed the recent popularity of ethnographic analysis for capturing medical device requirements. But even with these expensive and supposedly sophisticated requirements elicitation techniques, Jackson noted that providers are really struggling with good connectivity solutions in the absence of solutions from vendors that meet their needs.

The vast majority of connectivity solutions fall short, considerably short of safe and reliable systems needed by hospitals that are easy to use, and easy to maintain and support. One of the key reasons for this is a dearth of good requirements.

Jackson described clinical engineers as the interface between medical device vendors and regulators on one hand, and nurses and physicians on the other.

She noted that medical devices have traditionally had a 7-10 year lifespan. With the adoption of general purpose computer components into medical device systems, this length of time is falling. Vendor software updates (especially those driven by operating system patches or connectivity problems) are most problematic. The need for software updates is very unpredictable, and software releases frequently take 6 to 12 months – way too long. Vendor suggested workarounds place considerable burden on providers as they retrain users to the new operation, and because workarounds usually require some new manual steps that can introduce user error and lower productivity.

Current interoperability options are typically proprietary end-to-end systems. This is good because a single vendor provides quality and design control, and there’s a predictable market for the vendor. For customers, there is limited choice and “best of breed” is reduced to “what we have to offer.”

Jackson also noted a structural weakness that was a theme of the conference: that interoperability is usually a post-planning, post-market thought. Consequently, the solution is usually compromised by:

• Unreliable performance, slow (and too frequent) software updates
• Poor vendor ability to support integrated systems
• Poor design with multiple points of failure that are – what do you know, prone to failure.

Jackson used an example of a ventilator-patient monitor alarm integration project they did in an ICU. The layout of their ICU inhibits the ability to hear ventilator alarms.

The solution from the vendor was “dongle-ware,” an external module that connects to the serial port on the back of the device. This approach works most of the time, but the interface is brittle with many links in the chain of connectivity that can render the interface inoperable.

Jackson described currently unmet connectivity requirements in a slide generously titled: Interoperability Tomorrow. In this scenario, vendors have a real competency in systems integration, providing software updates in a timely fashion, with technical support that understands general purpose computing environments in addition to medical devices and clinical environments.

Even with improved vendor execution, we’re still limited to what the device will output (not everything), and the interface still represents multiple points of failure in the system. This current state of connectivity adds unplanned costs to installations. The costs for interfaces are expensive (plus cabling costs), and the hardware required takes up a lot of space (often unallocated at the design stage).

Kaiser has estimated simple EMR connectivity costs at $10,500 per bed. Not including CE/IT labor to configure, support and maintain the integration.

The perfect solution uses a standardized interface language embedded in the medical devices. No dongles. Systems integration, clinical and technical support tools are incorporated with other utilities. No dongles. And these capabilities are offered as part of the basic connectivity offering, rather than positioned as optional, higher cost features.

The cost to retrofit their hospital is prohibitive. The cost of moving forward when purchasing new technology is also very high.

Jim Philip MD, MGH, is a clinical anesthesiologist and the director of bioengineering at Brigham & Women’s Hospital. His contribution to the panel discussion was a case study highlighting the potential benefits of high reliability and interoperability.

The case is a laparoscopic cholecystectomy on a middle aged female with no other medical problems.

Preparation included:

18 Gauge IV catheter
Monitors applied and connected
ECG
NIBP (q 1 minute)
Oxygen saturation (Pulse Oximeter)
Airway Gas Sampling and monitor for
Oxygen
CO2
Agent

Anesthetization:

Sodium Pentothal for Induction of general anesthesia
Tracheal tube inserted under direct vision
Inhalation anesthesia administered via Anes Delivery System
Moderate-duration muscle relaxant (Vecuronium 4 mg)
18 F Gastric Tube passed via mouth
Stomach emptied of gas and liquid

Abdominal Insufflations (where they inflate the abdomen for visability):

GI Surgeon, trained in laparoscopic surgery, division director, began surgery
15:28:16, BP 128/66 and pulse 90 / minute,
Minute Ventilation = 5.7 L/min, ET pCO2 = 30
Veris Needle placed in the abdomen for insufflation
Trochar with self-retracting incisor
Scope inserted

Monitoring Observations:

15:29:20, the NIBP monitor failed to record a blood pressure
15:29:40, peak inspiratory pressure (PIP) rose as peritoneal pressure was raised with insufflation
15:30:00 minute ventilation (VE) = 5.7 L/min and constant 15:30:40, pulse oximeter failed to record SpO2 or heart rate
but pulse was palpable
15:31:00, end-tidal CO2 fell from 30 mmHg to 18 mmHg, heart rate constant at 90 / minute, peripheral pulse not palpable, carotid pulse weak.

Clinical Communication:

15:31:00
Anes: “was there was bleeding when you inserted trochar?”
Surgeon: “a tiny bit”
Anes: “If there was bleeding, would you see it?”
Surgeon: “No, not able to visualize”
Anes: “I think you have major bleeding”
Surgeon: “What should I do?”
Anes: “Cut now
Surgeon to Scrub Tech: “knife”
Surgeon Action: Incision
15:31:10

Action:

15:31:10 Abdominal Exploration Incision
Surgeon Observation: Blood poured out, 2 L in suction
Surgeon Action: Finger on palpable site of bleeding Aorta
Call for Vascular Surgeon to assist
Surgeon: ”How the ‘h” did you know that?”

Anes: “That’s why we monitor carefully and continually and try to integrate it all”.

Resuscitation:

15:31:20 Anes Action: Call for help (more IV)
3 L Lactated Ringers solution over 10 minutes
Albumen 75g
15:45:03 NIBP = 44/31, ETCO2 = 24 mmHg
2 U Packed Red Blood Cells, more late
15:47:20: pulse 117, NIBP = 83/47, ETCO2 = 24
15:50:00 ABGs: pO2= 468, pCO2= 37, BE=- 4, Hct=13%
16:05:00 NIBP = NIBP = 100/60
Event declared under control
17:00:00 Emergence with patient awake and alert

Resolution:

PO Day 2 Ileus resolving
PO Day 4 Patient discharged home, alive and well

Philip noted that until they could detect the problem and make the diagnosis the patient was at considerable risk. Here’s a summary of the time line:

15:28:16 Event
15:29:20 First sign
15:31:00 Diagnosis
15:31:10 Definitive treatment
00:02:54 Event to Treatment
00:01:50 First sign to Treatment
00:00:10 Diagnosis to Treatment

This clinical scenario (which would be a worthy addition to requirements for an anesthesia system) demonstrated how lots of data and integration was used to achieve a good outcome. Much of this data was integrated in a particular monitor that was developed just for this kind of situation at Partners. This monitor is no longer made and not available. Data integration from multiple sources and presented in an integrated way is essential. Hospitals can no longer afford to build their own systems of this type, and universal interoperability is required and desperately needed to bring these capabilities the broader market at large.

Steven Dain MD, Director of Anesthesia Informatics at the University of Western Ontario, provided a historical perspective to interoperability. Back in 1990 he was asked to write a program to collect blood pressure and heart rate from an NIBP monitor every 2.5 minutes, and SpO2 from an oximeter every 10 seconds and put it into an Excel spreadsheet. Easy, right? After this character building experience, he wrote the paper: Anesthesia Monitoring and the Computer Interface: The Need for Standardization of Communications Protocols.

The NIBP monitor had an RS232 interface, but the SpO2 device was a custom interface and required a clinical engineering project to get access to the data link.

Dain asked, “What’s changed in 14 years?” Not much. We still have proprietary electronic interfaces; it is still difficult to connect medical devices; expensive custom software is needed for each device; and there are still no usable standards for the electrical interface, syntax or semantics.

There have been lots of standards committees: the International Electrotechnical Commission (IEC) committees and working groups, ISO TC Health Informatics, ISO TC’s for medical equipment, IEEE, SNOMED, MSHUG, HL7, IHE, IOTA, HIMSS, WHO, and various national agencies and standards bodies (see Kolodner’s presentation). But these groups are often working in isolation, and frequently at cross purposes.

In addition, past attempts at medical device communications standardization have proven unsuccessful. There has also been a lack of a multidisciplinary needs analysis and use scenarios. And even with ethnographers, efforts to completely understand the complex clinical environment in which healthcare providers work have failed.

In addition to the above, Dain suggested that a multi disciplinary approach is needed to design, manufacture, sell and support interoperable systems. Most vendors lack the core competencies to provide effective connectivity and interoperability solutions – still.

With his clinical and vendor experience, Jim Fackler MD, intensivist Johns Hopkins, offered a different perspective. He noted that, “Dr Kevorkian does not hold a candle to what I can do as a participant in the current health care delivery system.”

Fackler went on to describe the hostile clinical environment in which he and his peers provide care. Patients are surrounded by myriad medical devices, where nothing talks to anything; alarms are simple threshold alarms, that don’t know where they come from (based on variable locations of equipment). He showed photos of his clinical environment where as many as 350 data elements can come off of each patient – in a unit with a total of 26 kids.

A fundamental problem with patient safety in hospitals is the fact that humans can only handle 7 things at once. This bit of ground breaking research, known as cognitive psychology, dates from 1956. And one bit of information is the amount that we need to make a decision between two equally likely alternatives. It is no wonder patient safety is in the state it is, when the clinical environment exceeds to known human limitations.

More recent research looking at what differentiates chess masters from mere mortals reinforced the findings in the study from 1956. The chess masters research found that adults could memorize and then recognize random patterns as well as masters, but that chess masters recognized patterns of chess pieces at a much higher rate than adults. Part of physicians training is to turn them into something like a chess master so they can recognize patterns of symptoms to make a diagnosis.

The ability to correlate and process data in the head is best in surgery where there is a 1:1 anesthesiologist to patient ratio. In an NICU like Fackler’s, the ratio goes up to 1:27. I private practice the ratio averages 1:5,000. Is it little wonder that more should be done to improve the clinical environment?

The first line of care and vigilance in the hospital is the nurse, who receives little or none of the “chess master” type training received by physicians.

Interoperability complexity increases as scope of patient and care delivery grows. For example, when a weight scale used for home monitoring breaks the patient can’t go to Bed Bath and Beyond for a new one.

Questions to the panel:
What is needed to drive the adoption of interoperability standardization? Capitalization versus standards imposed on the market. Providers must demand change when buying new products and systems.

Plea to industry – you will create proprietary systems with artificial intelligence providing decisions support. You will be automating exactly what we have now, but physicians don’t have the data they need now. Without putting all data into a “bus” that is interoperable, the potential to impact patient safety and outcomes will be severely limited.

Used aerospace as an analog to medical device industry. Suggesting that aerospace has a small number of large integrated vendors pr0ovide most solutions. False assumption – aerospace has many small subcontractors and contract engineering services companies; all large aerospace systems (like a new plane or even new major components) are constituted from many sub contractors and contract engineering shops, under the management of a general contractor. In fact, unlike medical devices where subcontractors are hidden from the market, aerospace projects are very open about the many subcontractors that participate in a project.

Someone in the audience who was in aerospace before health care noted that airplanes are very complex, like medical device systems, but unlike medical devices they are not reconfigurable – they are integrated once over 10 or 15 years of development.

It was suggested that the industry was at a tipping point where manufacturers developing and maintaining large and unwieldy proprietary systems could give way to multi vendor interoperability with a focus on core technologies. This would allow medical device vendors to compete on what they’re best at, rather than the general purpose computing systems used to provide connectivity.

Open source software on standard platforms was noted as a potential solution (for both vendors and providers) that had yet to be mentioned.

Yesterday I was asked for some quick impressions of this year’s HIMSS. Now that I’ve had a bit of time to digest the event, here’s what I came up with. First, this show was much more of a business development/business alliance oriented show. Many vendors were openly partnering and had products in each other’s booths, brought together by their efforts to bring to market broader solutions that meet market requirements. These alliances frequently revolved around connectivity.

• First Vocera came to market (a few years ago) on the strength of a health care targeted wireless communicator, and has done well. This year Ascom was the first established phone company to take that step with an almost full blown point of care system integrating wireless phones with nurse call, medical devices and more. Ascom now represents a competitor to both Emergin and their wireless phone competitors.
• Two new wireless patient monitors were introduced at HIMSS using 802.11b (the GE Dash and Spacelabs SL2400). The adoption of ISM/Wi-Fi over WMTS for wireless patient monitoring is significant, and reinforces the trend away from that proprietary narrow band.
• GE showed near real time fetal monitor surveillance (AirStrip OB) on smart phones – with a 510(k), no less! (check this photo)
• PDAs and tablets lost much of their cache this year – there were lots of laptops and integrated computers on COWs (computers on wheels), AirStrip OB on smart phones, and while not an exhibitor, there was buzz about the OQO handheld computer. (check this photo)
• Welch Allyn was the first major vital signs monitor vendor to release a wireless vital signs monitor for data integration into EMRs (the new Spot) – a couple years behind Stinger Medical. Also of note, Welch Allyn licensed Wellogic’s server software for their wireless vital signs monitor. Clinical servers are neither rocket science nor a trivial effort, what with role based access support, CCOW, RADIUS/LDAP integration, HL7, remote access (i.e., a web server), data storage and high availability. So far, not a single medical device vendor has launched a decent server - until now.
• Integration middleware vendor Emergin was in over a dozen booths - most of the smart pump vendors, patient monitoring, nurse call and wireless phone vendors, and a few HIT vendors.
• This was also a year for refining product strategies for patient flow application vendors - in particular, StatCom and Awarix have moved beyond (and in different directions from) bed management to help out more broadly with hospital care delivery.
• On the imaging front, this was (if not the first) the largest presence of cardiovascular information systems (CVIS) shown at HIMSS. Agfa/Heartlab, Witt Biomedical, McKesson/Medcon, ScImage were all there – and maybe a couple I missed.
• All the smart pump vendors (Cardinal/Alaris, Hospira, Baxter, B Braun) showed progress in moving past the first generation of wireless features.
• RFID was hot hot hot at HIMSS this year. In apparent agreement with my post that RFID is not a product, many RFID vendors introduced software applications - mostly basic patient flow apps. RFID also presents an interesting issue for device vendors – for the slackers who don’t embed a Wi-Fi radio into their device, should they embed some kind of tag technology?
• Finally on a related topic, wireless network infrastructure also got some buzz. GE formally introduced their deal with MobileAccess, InnerWireless repositioned themselves at the show (rolling out their RFID solution and dropping the “leaky coax” part of their solution), and lots of wireless LAN vendors – Cisco, Aruba, Trapeze, Symbol and Meru.

Whew. Pictured above right are two of the Godfathers of Connectivity: Arnaud Houette of Capsule Technologie, and Brian McAlpine with Emergin.

Did you run out of time too? I needed two more days for all the info I was hoping to get at HIMSS this year. This year a few of the publicity firms scheduled me for meetings with key people at a number of companies. To my interviewees, thanks so much for your time - it was probably a departure from interviews with a publication. Once I’ve written the post, it will be your’s (and your customer’s) turn to continue the conversation via comments.

While in a coffee line, I said to one CEO in passing that I was looking forward to visiting their booth. I was told they were expecting me and to, “take my best shot.” Of course I was planning to take pictures (and got some great ones), but then wasn’t sure what they meant. Analysis and opinion, along with product details, should be expected, but there is no malicious intent. Thankfully, I don’t pick the winners, the market does. And while I make no excuses for passion expressed in the interest of customers and especially their patients, I guard my independence and neutrality regarding vendors or technologies carefully.

Days three and four reinforced the business development nature of the show. Many of the press releases around this year’s event were about alliances and solutions created through the efforts of vendors working together. I remember seeing one very cool demo given to about 8 people - all vendors, not a white badge in the crowd. Emergin is a great example of this, and the RFID vendors were emulating their strategy. Even companies like Welch Allyn were in a half dozen other vendor’s booths.

Last year I spent more time posting from the show but didn’t do any follow-ups afterwards. This year I will be dribbling out HIMSS posts over the next several weeks. Contrary to what some might think, this blog is not my business; it’s more a compulsion or maybe an obsession (no interventions, please). I have a lot of consulting work right now and have little time available to blog. The cynical among you might think this is a strategy to drive up site traffic; you would be wrong, they are just the unintended consequences of being busy.

At right, I caught up with Matthew Holt with Tuomo Rutanen of Ekahau talking RTLS.

An old friend, Jim called today to bitch (in the nicest of ways) about the HIMSS show blogging done by yours truly and others. I also got a request from Dale H.

…could you blogger-attendees blog something about how HIMSS itself went, for those of us who couldn’t make it? I wasn’t able to get away for this conference and want to hear what people have to say about the emerging technologies presentations, especially the “connected consumers”, “trading spaces”, “staying connected”, “natural language processing for healthcare”, and “personalized medicine” talks.

Since us bloggers (with the exception of Neil Versel) are not traditional journalists, we’re here for other reasons - research, education, networking, and prospecting for business. Dale, hopefully you will find some posts from other bloggers whose interests more closely match your own. One of the great things about blogs is that they can be very narrow in their interests and still find readers - which is certainly the case with this blog. Jim teased me and my blogging peers about writing (too much, perhaps) about meeting each other. Admittedly, that was one of the high points of the show for me, meeting Shahid, Matthew, Enoch, Will and others. Last year, the only blogger I met was Neil Versel (and it was nice to see him again), but I’m sure next year it won’t get quite the play it did this year. An even bigger pleasure for me was meeting the folks who read this site.

More than once I talked with a vendor who pointed out an error or omission in a post about their product or service. A blog is a conversation; this site includes comments for a reason. I whip the content for this site out pretty quickly, and count on you the reader to respond with your opinions, observations, corrections and clarifications. If you’re not okay with misstatements or omissions about your company, institution, product or area of interest then join the conversation. Over time this blog’s become more of a two way street, and I’ve gotten some great comments from readers from which we’ve all learned something new. Keep it up!

You’ve probably noticed more photos on the blog. That’s not a calculator on my belt, it’s my digital camera. I took many product shots this year, after asking permission, of course. I will be posting them to my photo blog on Buzznet (where comments are also encouraged). I will link to the photos in my posts, and you can find the latest 10 photos thumbnails in the left hand column (just scroll down). Like the rest of the site, the photos are copyrighted, but feel free to use them for any non-commercial use as long as they are attributed to Medical Connectivity Consulting. Some photos will include this site’s URL, so I can get a little free advertising when you vendor-types use them for competitive product presentations. Commercial use of photos or content can be arranged - just drop me a line. If you’ve got product shots (especially on a white background) I’d love to use them. At right is my “reality” shot similar to the one that graced HIMSS06 web site.

So, back to this year’s HIMSS. I spent a lot of time last year at the sessions, and found them to be at a beginner or intermediate level. I learn more about technologies and applications by talking to knowledgeable vendors. Unfortunately, most of the vendors I visited were staffed by people lacking in much real knowledge. There are some very big strategic changes impacting the HIT market, and I was struck at the number of vendors that didn’t really know what business they were in (or are in the “wrong” business). Successful growth companies tend to be very strategic; mature established vendors seem to lose that strategic vision over time, becoming tactically oriented. The companies with a real business strategy were obvious, and a distinct minority.

A number of other bloggers have noted the significant costs for vendors to exhibit at HIMSS (or any show). The preparation and execution of the vast majority of vendors at the show - simple things like what’s new, key messages, value propositions and short positioning statements - was abysmal. I quickly tired of the blathering and frequently had to ask these questions myself. An effective trade show is more than showing up and chatting up visitors. I found the few “telemarketing types” - they guys that catch your eye, and start talking as you pass their booth - less irritating than the many people who were just taking up space in their own booths.

Okay, I’m a little late on my show updates. Tim at HIStalk has been much better with his daily updates, as has Will at the Candid CIO. I went to a lot of the educational sessions last year - they presented at a beginner or intermediate level, and the best part was the questions and meeting the speaker. Since this year’s sessions are all online (and on CD) I decided to give up the questions, skip the sessions and stick to arranged meetings and trying to find engineers or product managers in vendor booths. I’ll review the educational sessions after the show - I can always call a speaker, tell them how much I liked their presentation and ask my questions later. Pictured at right are two of the San Diego Convention Center greeters, very friendly and helpful folks - some of them even wear white gloves.

My day started with getting stood up for breakfast; although we did get to chat for a few minutes before our next meetings. Later I hooked up with Shahid Shah, The Healthcare IT Guy, and Matthew Holt of The Health Care Blog and hit some exhibitors. I even met a fellow Connectologist that afternoon. Later, George Hill of Leerink Swann & Company, was nice enough to invite us to a reception he was having at the Fleming Steakhouse where we chatted about the industry and speculated on the future prospects of various vendors - Andy Eckert, CEO of Eclipsys even made a brief appearance.

I took lots of pictures of products, which I’ll be posting to my Flickr photo blog (click on the thumbnail photos on the left bar).

Lots of companies are refining their business strategies and growing the business. There don’t seem to be any new product categories getting much mindshare. It also seemed that RFID, or real time location systems (RTLS), were getting a lot of attention. I was struck by how many companies don’t get some of the fundamental changes going on in the market - more on that later.

Today I hit the booths and got to talk to some great folks about strategy, markets and underlying technologies. I’ll be posting for weeks about these meetings, and some of the things I learned. I ended the day today meeting Arnaud Houette, CEO of Capsule Technologie. Arnaud is one of the godfathers of Connectologists, and we had a very interesting conversation.

If there is an overall theme to this show, it is business development. It seems that everyone’s doing deals to gain connectivity, interoperability or a new feature. Everyone it seems has an API and SKD (software developer’s kit) to facilitate integration. The RFID vendors dominated the API theme, as did many operational workflow application vendors - and as last year, Emergin dominated the messaging integration middleware space.

Good night.

More interesting news dug up at the show today. Ventilator vendors don’t seem to get the whole connectivity thing yet. I think they’re spoiled by only having to serve up a serial interface to monitoring vendors in the ICU. Even a non invasive vent for use outside the ICU had no more than a serial port.

I went by the LifeSync booth today. They’ve gotten some adoption for their wireless ECG electrode system. They have a very interesting implementation that shows the basic requirements for wireless sensor based monitoring. You can see the electrode harness that provides reduced noise and false positive alarms, and the patient transceiver (on the right arm). This wireless rig connects over Bluetooth (1.1, class 2) with a monitor transceiver that is connected to the monitor. As I took his photo, one of the many female bystanders told him to smile. I cut his head off, to which he said, “I’m used to that.”

I saw some pretty cool examples of device and software integration today. At the Philips booth, I got two very interesting demos. First was an alarm management and notification demo (using Emergin again). There was a software client that managed caregiver-patient assignments (with 3 levels of escalation). Patient alarms were distributed to VoIP wireless phones from Cisco. And here’s the cool part, the handset displayed a 6 second ECG waveform (along with patient name, room number, and type of alarm). The caregiver can also accept or refuse an alarm, causing the system to escalate to the next caregiver. Later I saw a Philips/Baxter prototype integrating the Colleague infusion pump with a Philips MP 70 patient monitor. The integration supported establishing patient context and the 5 rights for meds administration, using the patient monitor as the workstation. All the resulting data is sent into the EMR. The Baxter pumps talk to their server, which talks to the Philips server. On the Philips side, the Portal feature is required, using a Citrix server. Philips plans to release some version of this as a future product. There are some very interesting comparisons and contrasts between the Emergin/Cisco/Philips alarm notification product (which is released) and the Philips/Baxter project.

With all the hoopla about WMTS, it is interesting to note that both GE and Philips use 802.11 FH (frequency hopping) for their wireless multi parameter patient monitors. I asked them both if they were going to switch to WMTS, and they both said no. You should know that 802.11 FH has been discontinued; Proxim discontinued their product last year, and Symbol’s last buy is this year. All the vendors using this technology have made “last time buys” from their vendors, and as one said, the question is how much of their last time buy inventory they’ll have to write off when they go to a new radio.

Could Handheld Products’ Dolphin 7900 beat out Symbol’s PDAs for clinical use? I heard one user that was getting 11 hours of continuous use out of their 7900 (that’s with WLAN and bar code use) vs. 2 hours from a Symbol device. Both devices are ruggedized and water resistant (conforming to IP54).

UPDATE: It seems that the alarm notification on the Cisco phone shown in the Philips booth is not released. They are going next to clinicals and shooting for a release before year end.