The vast majority of hospitals are organized like this, where their resources are divided based on (rarely met) assumptions about patient volumes. The alternative approach is to admit patients to their “on service” unit (orthopedics, oncology, med/surg, etc.) and rather than tranfering them to a higher acuity unit if their condition deteriorates, medical equipment (usually patient monitors) and staff are brought to the patient. Bringing the equipment and clinical expertise to the patients, rather than the reverse, has numerous benefits.

In addition to improving patient flow throughout the hospital and reducing patient safety errors, the universal floor has allowed staff members to spend more time with patients, making for a more comfortable patient stay.

Hat tip to StatCom’s Going with the Patient Flow e-newsletter, a great source for patient flow related stories.

According to Brenda the implementation of ConnexALL was initiated to better align with their hospital’s patient and staff safety goals.  After installation they were able to consolidate much of the management and interaction of these three event driven systems into an automated and consolidated system using ConnexALL. Specific benefits included, improved reliability, managed group notification, reduction in manual interventions, automatic alarm escalation, increased mobility (no sitting at a workstation or watching a panel), quicker decision making, and a consolidated auditing capability.

WatchMate is used for wandering, patient elopement and infant abduction. The hospital’s security is based on the premise that it’s easier to contain (a potential security situation) than retrieve, and that it’s easier to catch someone in the act than is to try to find them after the fact. WatchMate provides notification to a user at a workstation. The hospital used  switchboard operators to monitor WatchMate, since they’re usually at their desks. They had to recognize the alarm, look up who to notify, and ensure that notification is made. Now, ConnexALL automatically receives alarms, notifies appropriate staff, ensures alarm delivery (including necessary automatic retry), and escalates alarm notification when necessary. (After some googling, it seems that GlobeStar integrated with WatchMate even though the product is no longer sold by the manufacturer, Xmark.)

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The messaging middleware market is transitioning from middleware to an enterprise application. GlobeStar has been in the business just over 10 years. Unlike Emergin, who started in paging messaging,  GlobeStar got their start in the 1990s integrating Austco nurse call and Nortel’s Companion (the first wireless phone system in North America). Over the years, the company (and the market) have evolved from a single nurse call/phone integration to a platform supporting many different systems and devices both on the input and output sides — and incorporating workflow automation through rules, alert initiation, and escalation.

The conference kicked off with introductory presentations from David Tavares, CEO of GlobeStar; Dr Teresa Sustelo, President of Centro Hospitalar de Lisboa Central (a large multi hospital system); and Dr Miguel Correia, Regional  Secretary of  Health, Azores. During his opening remarks, Miguel Correia noted the broad applicability of improved messaging. He spoke to the extension of messaging systems to tracking and eventually orchestrating complext processes and tasks. This is a vital requirement in health care delivery.

GlobeStar’s technology has been applied outside health care too. They monitor automobile painting production lines and “man down” systems in mining. Miguel Correia mentioned that they’re using ConnexAll in CO2 monitoring at volcanos in the Azorres. Now they’re moving further into workflow automation.

Keynote Presentation

My keynote presentation theme was, “everything is connected” and contrasted this with provider’s tendency to only focus on the immediate problem — or what they think is the problem.

Putting the health care IT market aside, the point of care market is divided into 6 separate market segments: wireless phones, patient flow applications, medical device connectivity, messaging middleware, nurse call, and real time location systems (RTLS), not to be confused with indoor positioning system infrastructure vendors like Sonitor and CenTrak. For some time, buyer’s haven’t been able to buy a product from one of these segments without impacting one or more of the others. Connections to medical devices, and the nurse-to-patient assignment process are common points of contention.

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Of those surveyed (n=237, 59% of which were C-level, 19% directors) a number of findings jumped out. First, a large majority (89%) said their hospitals have poor patient flow - by itself not particularly surprising. Market adoption of bed management applications showed a 12% increase over 2007, going from 48% to 52%. It struck me that around half of the execs admitting to poor patient flow in spite of already having bought a patient flow solution (albeit a limited “bed management solution”).

More than Bed Management

There are a number of conclusions one can draw from this incongruity. As noted in my post last year, a lack of solid quantitative operational performance data makes improving patient flow difficult. You have to be able to measure it before you can manage it, as they say.

How care is delivered also impacts patient flow. Critical care units (ICU, telemetry, high dependency units) are a common patient flow bottleneck. This bottleneck results from inappropriate admissions where attending physicians want monitoring for patients that don’t really meet the admission criteria for the unit. Implementing variable acuity units, where equipment like patient monitors and staffing levels are allowed to float with a patient’s acuity, can improve the ability to deliver the appropriate level of care without incurring the overhead found in a typical critical care bed.

Another conclusion one might draw from hospitals with bed management software that still claim poor patient flow, is that these applications have been poorly implemented. The likelihood of implementation issues is reinforced by this quote from EVP of client services for StatCom, Ben Sawyer,

Healthcare executives say overcoming behavioral patters poses the greatest challenge [to realizing patient flow improvements], followed by resistance to change…

Bad habits and laziness on the part of hospital staff would be inexcusable. But most everyone I’ve met in health care wants to do the right thing. They just don’t want to have to do their already demanding jobs in addition to extra work created by poorly designed or configured workflow.

Finally, while many patient flow vendors have options to sell bed management by itself, but most of them have solutions that offer far more than just bed management. Frankly, bed management is the easy part. (more…)

Qualcomm released a new 3G chip that supports both EV-DO (Verizon and Sprint) and HSDPA (AT&T and T-Mobile). This will result in radio cards that will run on either technology and provide the greatest choice in selecting carriers.

The chips are apparently targeting laptops and should appear in new laptops by the second quarter of 2008.

The latest technology to join the 3G alliance is WiMax, which the Qualcomm chip (called Gobi) does not support. In the US, Sprint is the first carrier to announce plans to deploy a nation-wide WiMax wireless network.

Pictured right is Qualcomm's QSC6240 chip with integrated radio
transceiver, baseband modem and multimedia processor - together with
power management functionality into a single chip for WCDMA (UMTS)
and HSDPA handsets.

A recent survey of ED docs indicates that they believe that ED overcrowding is getting worse. From the Modern Healthcare story:

In a survey of nearly 1,500 practicing emergency physicians, more than 80% said crowded conditions in their emergency departments had increased either slightly (40.2%) or significantly (42.4%) in the past year, according to a recent poll from the American College of Emergency
Physicians. In the study, conducted from Aug. 28 to Sept. 19, nearly 67% of respondents cited “not enough staffing and/or resources” as their leading concern about patient care.Other top concerns included decreased throughput in the emergency department because of boarding patients (65.4%) and long wait times (65.3%). Also, 40.4% of physicians said their emergency-care environment has overcrowding and that access to specialty physicians and similar practice issues is a concern, but not yet a crisis.

Of those who responded, 703, or about 47%, said they had experienced a patient suffering as a result of crowded emergency rooms, while 200 said they had experienced a patient death for this reason at some point.

First off, while quantitative percentages are quoted extensively, this is really just a survey on the opinions of emergency room physicians. As noted a couple days ago, actual operational data is much harder to come by. Certainly the emotional assessment of front line physicians on ER overcrowding has value, but it is certainly not scientific.

Caveats out of the way, it is likely that ED overcrowding is indeed getting worse. Certainly there’s no doubt emergency room volumes are increasing. The major cause of this overcrowding, “not enough staffing and/or resources,” is frustratingly vague - but then the survey is based on opinion rather than operational data. Are they talking about staffing and resources in the ED, outside the ED in downstream areas, or both?

The survey hints rather strongly at both the causes and potential solutions to reduce overcrowding. Overcrowding due to boarding patients in the emergency department was noted as the second major cause. Boarding patients - parking them on gurneys in hallways while they await a “soon to be available” inpatient bed - results from down stream patient flow bottlenecks. Building a bigger ED won’t help with that problem.

Another story, noted by FierceHealthcare, describes a 2006 study showing that increasing ICU beds reduces ambulance diversion and increases hospital revenue. The study, done at Oregon Health and Science University Hospital and published in the Annals of Emergency Medicine (abstract), includes some interesting data.

• Based on 10,301 adult ED patients in 2002 and 2003, the average hospital revenues per patient were $4,492
• Each hour spent on diversion cost the hospital $1,086 in lost revenue
• An increase of staffed ICU beds from 47 to 67 beds reduced time on diversion by 63%
• The hospital gained $175,000 in additional monthly revenues through reduced time on diversion

Since critical care and telemetry represent the most common patient flow bottlenecks that result in ED overcrowding and diverts, the outcome of this study is expected. You too can calculate the cost per hour of revenue lost due to emergency room diversions - to provide one more reason why those units that won’t take your patients should buck up and start carrying their weight.

Solving your ambulance diversion problem by adding ICU beds is perhaps not the best approach (but it is by far the most expensive). OHSU is sort of ICU-crazy, with a 1:2 ratio of “special care” beds to med/surg beds (155 critical care beds to 311 med/surg beds). This compares with another Portland metro hospital, Providence St Vincent. At virtually the same number of beds (466 for OSHU, 450 for St V’s) St Vincent as 7 critical care beds for every 54 med/surg bed (94 critical care beds to 356 med/surg beds).

Implementing variable acuity units at your hospital can go a great way to eliminating critical care patient flow bottlenecks. The capital cost to implement variable acuity units (or universal beds) is much lower than building more ICU beds. The rub is the management effort to retool the impacted nursing units and getting buy-in (and compliance) from your medical staff. But then, nothing is easy.

As an aside, using the American Hospital Directory (found in the Resources tab under Important Web Links), I created a spreadsheet that compares beds, LOS, total patient days, gross patient revenue, etc. While there are many differences between the hospitals, like LOS, it is interesting to note that St Vincent’s revenue is 4 times the gross patient revenue at OHSU.

UPDATE: I tried to find an email address for the principal investigator, John McConnell, for the study I quote above, but was unsuccessful. If you know John, I’d love to chat with him about his study (not to mention all those ICU beds). Thanks!

Hospital IT shops can be very keen on single vendor solutions - sometimes to the point of accepting significant shortcomings in parts of the vendors comprehensive offering. This tendency applies to networking in spades. Certainly you need central management, but you assume the AP and controller vendor has all the answers at your own risk - as Duke learned.

Certain vendors are taking this to extremes, offering hospitals WLAN site surveys and recommending the replacement of any technologies that don't sport their logo. Hospitals have received “advice” to replace $300,000 wireless patient monitoring systems because they weren't validated for that vendor's APs. The justification for these recommendations is that I just bought a new 30' sailboat third party systems can't be integrated into our enterprise solution. (If a vendor offers to do a free site survey of your facility, by all means take them up on it - just be sure to have someone else review the findings and offer a less biased assessment.) “And the story sounds so great, “Implement our solution and it will fix itself when it breaks and protect itself when security policies are breached.” Who wouldn't want that?“

In addition, as much as big market leaders would like to believe that single vendor
solutions are the new “best of breed,” we live in a multi vendor world.

Unlike commercial office space, or an open warehouse, the WLAN environment can be extremely challenging. Putting all your eggs in one network vendor is fine when all you're doing is supporting portable users moving from room to room charting or administering drugs. But when you start adding things like wireless VoIP, indoor positioning or wireless medical devices - with truly mobile users crossing subnets - look out.

Be sure to read Bruce's post, he's got some great recommendations.

UPDATE: Here are some previous posts on WLAN issues: Cisco Stumbles in Health Care, and Cisco Wireless LAN Technical Issues - Update.

According to a survey by CHIME, more hospitals are reducing restrictions on cell phones.

As I noted on the Biomed Listserv this week, RF interference is a fact of life and cell phones are but one contributor. Regarding RF interference risk, cell phone's will never be proven to be perfectly safe - but then neither will hair dryers, florescent light ballasts, microwaves, and elevator motors. The key is risk management.

Sadly there's no link to the actual report on CHIME's web site. (You'd think they could have found a corporate sponsor for the study, and then published it in support of their advocacy for effective use of IT in health care and as a service to the industry - that is why CHIME exists, isn't it?)

Vocera has successfully competed in health care against a a number of much bigger competitors. Their unique offering has gotten good adoption, but they will have to continue to innovate to maintain their market position, let alone grow. It will be interesting to see what direction Zollars takes the company.

Lots of discussion centered around the evolving role of biomeds and clinical engineers and the kinds of training they might need in the future. There were rumblings from some in the ACCE who wanted to hold their annual meeting at HIMSS next year rather than AAMI. There certainly is a life-critical systems role that needs to be filled, and clinical engineers could fill that role. To this observer, it seems that clinical engineers will slowly become marginalized if they do not move in the “systems” direction. Even biomed techs will need IT skills to manage and support increasingly complex and pervasive medical device systems.

During the GE sponsored breakfast, there was a session on managing RF in your hospital. Reportedly the perennial “WMTS versus ISM” debate reared its tired ugly head. For many reasons mentioned here in the past (just google “WMTS” in the search box on the left colum). The WMTS bands will never have the bandwidth or (more importantly) the management tools to support more than a small portion of the wireless medical devices in a hospital. Only the usual suspects can even afford to develop the prorpietary radios required for WMTS, which is why 802.11 has seen so much uptake with device vendors.

But the inherent limitations of WMTS do not make 802.11 a slam-dunk. In fact, recent experience has highlighted the need for more rigorous RF engineering, wireless LAN design, and ongoing RF and network monitoring to ensure a reliable network. Hospitals are perhaps the most hostile environment for wireless networking. When it comes to networks, hospitals are faced with both selecting a hardware vendor that best meets their needs and a VAR (value added reseller - the indirect reps used by IT vendors to sell their products) who really knows what they’re doing. Only the best VARs can design and install a reliable network that supports all the big apps: data, wireless VoIP, positioning, and medical devices.

In a nod to presidential politics, “It’s the workflow, stupid.” To most, connectivity is about extracting data and moving it some place else. The real objective is to automate workflow - and how connectivity is implemented has a huge impact on what workflows it supports, and ultimately the usability of the system. A fundamental piece of this workflow is patient context, the association between a patient, their medical devices, and the data that comes out of them. Patient context remains a concept that’s poorly understood by most users and vendors. Many still try to fudge patient context by associating the patient to a port number or bed location. Guess what? Patients move, and mobile devices especially, must establish patient context in the device itself to be safe and effective. I would love to see some of the fantasy-based risk analysis and mitigation documents done for certain connectivity features that I saw this week.

All of this gets to another big change reflected in this weeks conference. Stand alone embedded products are evolving into real systems that extend functionality way beyond the box itself. This “systemization” of medical devices requires some changes in thinking. No longer can you focus on building safe and effective boxes, and after the fact plugging them together with other stuff and be sure the result is still safe and effective. Nor can you manage and support interconnected devices simply by maintaining the device - the entire system must be configured and maintained as a whole.

One of the good things to come from the increased involvement of IT in device connectivity is their insistence on a test system to support the “production” system. They do this with all their software systems. An indicator that connectivity is an afterthought is the total absence of test fixtures for an integration lab. Another symptom is the scarcity of such labs in hospitals and the limited capabilities of most manufacturers’ verification labs. As systems grow and become more complex, hospitals will increasingly demand support for these labs - in the absence of test fixtures, that means customers with clout will insist on indefinite loaners so they can effectively maintain their systems.

During the ACCE Clinical Engineering Symposium Saturday morning, Bridget Moorman referred to medical device connectivity as “brittle.” I know more than one person had an epiphany upon hearing that term. Any change, no matter how small, along the chain from medical device to target computing device renders the device interface inoperable. Device firmware changes, pin-outs, cable connections, terminal server configurations, network configurations, and interface configurations - on either side of the interface - all result in failure. Planning for these interfaces (hopefully by the vendor before product development) must take this brittleness into account. At the very least, customers must be able to monitor their connectivity all the way to the device, not just a server or terminal server.

Finally we come to FDA regulatory issues. I met an FDA representative in the exhibits. She works on the Issues Management Staff, a tiger team that addresses patient safety related issues that reach a point where they must be dealt with. Can you guess one of the simmering issues that may soon become an Issue? That’s right, medical device connectivity. Much of the current regulatory framework (both vendors regulatory strategies and how the FDA manages the process) is based on standalone medical devices, and “oh, by the way, it gets plugged into all this other stuff to do… stuff.” We can expect to see regulatory perspectives shift increasingly to a systems view, especially when multiple vendors are involved.

The contortions many vendors go through to avoid FDA regulation is a symptom of this spreading systemization of medical devices. While the FDA has a responsibility to ensure safety and effectiveness, they are also responsible for accomplishing their mission in a way that doesn’t drive undeserving vendors out of business or stymie the development of innovative solutions that promise even better safety and effectiveness. Don’t expect them to accept the status quo for long. I ask everyone who’s skirting the regs if they are committed to building a quality product, and the answer is inevitably yes. All it usually takes to get a 510(k) is compliance with a basic quality system (the FDA’s Quality System regulation) and 60 days for the FDA to process your 510(k) paperwork. And yet the reticence to be regulated suggests that things like prototype code makes it into finished products all too often.