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.)

Delta Controls monitors building boilers, air conditioning, lighting and other basic building systems. Like with WatchMate, a user at a computer display has been replaced by automated notification through ConnexALL. Also like with WatchMate, alarms are received by appropriate staff more quickly and reliably. Unlike with WatchMate, interactions and dependencies among building systems can result in multiple subsystems generating alarms on the same change in conditions — essentially duplicate alarms. The ConnexALL system analyzes these multiple alarms and filters out duplicate nuisance alarms.

The Siemens fire control panel monitors both elevators and fire alarms. The application and benefits are similar to the building systems automation system. Because ConnexALL is integrated with both the building automation system and fire control panel, alarm analysis and management takes co dependencies and interactions between the two system, consolidating alarms and reducing nuisance alarms.

Their legacy alarm monitoring solution for these three systems was custom engineered and was no longer supported by the original vendor. The system only consolidated  alarms in a central location (the switchboard) but alarm notification remained a manual process. Alarm escalation was dependent on a switchboard operator monitoring alarm notification success and responses to alarms, and escalating alarms manually. And of course, if the switchboard operator was busy or not present, alarms could be missed. Because alarm management was completely manual, auditing alarm responses was difficult, at best.

A variety of notification devices were contemplated. Many wanted to use pagers, but their pagers were not two way pagers and thus could not ensure alarms were received by the device or send back acknowledgments from those responding to alarms. Many users Blackberrys, wireless phones and desk top phones. Everyone’s desk top computer also has a client application that pops into focus when an alarm condition occurs.

Grand River Hospital’s lessons learned were the importance of weekly team meetings and the proper involvement with the vendor. Due to the impact of automating (and thus changing) workflows, getting all the operational issues and changes worked out and agreed to prior to implementation is essential. In their case, the Facilities department didn’t want to be responsible for alarms, they liked having the switchboard having this responsibility. Once they understood that ConnexALL would automate the alarm process they were agreeable. Issues like this are important to work out as early in the process as possible.

They ended up having to reconfigure their building automation and fire control systems during the implementation. They didn’t realize that a comprehensive assessment of alarm notification would result in decisions to optimize the other systems to improve overall processes.

Susan Bisaillon, with Trillium Health Centre leveraged ConnexALL for a house-wide process reengineering effort in a hospital new-construction project, the West wing project. The new wing is designed for decentralized care, rather than the conventional large central stations on large nursing units (30-40 beds). The new wing has 12 bed pods, 3 pods per floor. Each pod has what is effectively a mini central station, with more technology at the bed side. Computers on wheels located outside patient rooms are used by staff rather than workstations at the pod, or mini central stations. This minimizes time at the central station and provides caregivers more time at the bedside.

The underlying concept driving the design and implementation of the new West Wing was patient centered care. A big part of this was leveraging technology to realize a more patient centric view. The existing hospital has stand alone (that is, not integrated) wireless LAN, phone system and nurse call. The new building has combined wireless VoIP phones and wireless LAN from Cisco, and the nurse call is Rauland-Borg — both are integrated using ConnexALL.

In a decentralized nursing environment, relying on the central station as a hub for workflow automation does not work — there is no central station, and nurses spend little time at the decentralized pods that replaced central stations. As a result, workflow changes included the move of nurse call  from central stations to calls dispatched by ConnexALL directly to the caregiver’s phone that is responsible for that patient.

They evaluated Ascom, Blackberry, Vocera and Cisco 7921 phones. They had a cross functional team evaluate the phones. The evaluation was accomplished in a two day beauty contest. There were 60 participants, 6 two-hour sessions where vendors presented their solutions and how they would perform in specific scenarios. The hospital chose the Cisco 7921 IP phone.

Interestingly, while the Blackberry was a popular device among caregivers, the hospital could not justify the monthly cellular bill that came with them. Until Research In Motion, the maker of the Blackberry, figures out a distribution channel for enterprise Wi-Fi deployments, they will see limited adoption in hospitals.

The hospital ultimately chose to support 2 devices: Blackberry and the 7921 Cisco handset. The carrier cost of the Blackberry was the barrier to adopting this device for the nurses.  They use a plastic sleeve on the Cisco phones to improve ruggedness, make them easier to clean and protect the plastic from the detrimental effects of disinfectants. (After the presentation, there was some discussion about the potential for an increased risk of infection from the phone sleeves, an issue that will require more study.)

Besides the integration of their nurse call with the new phones, ConnexALL also drove large automated displays that replaced manual white boards to reflect patient status, staff assignments, attending physician, etc.

Trillium did a pilot to ensure integrations worked and were configured properly for optimal workflow. The pilot served as a major shake out for the wireless LAN. There were a lot of wireless LAN issues. The wireless LAN was engineered for wireless data. The addition of wireless VoIP represented a major change in performance requirements for which the initial network was not designed.

Not surprisingly, they found they had to reengineer their wireless LAN to realize sufficient performance for their new application. After initial problems during the pilot, their Cisco VAR (value added reseller), FlexITy, did a comprehensive site survey and revised the wireless LAN (upgrading existing access points,  adding and moving access points) to achieve the required performance. There are presently no medical devices on the wireless LAN. The issue for them is, “what devices need to be wireless to facilitate patient centered care?” And when the time comes, the hospital will be well served to review the specifications for any wireless medical devices, do another site survey, and reengineer their network as needed — before the pilot.

Nurse managers on each unit are responsible for developing a process for managing, deploying and retaining wireless devices. So far only one Blackberry has disappeared. Another customer in the audience noted that they’d lost 30 phones out of their ED. While many of these phones don’t work outside the facility, they can be sold on eBay and other places.

A lot of effort went into preparing the staff in the new units for the differences in the care environment (especially no central stations), the new workflows, and new devices — automated display panels, phones, COWs, etc. Human factors engineers were also brought in to ensure proper body mechanics.

With the implementation of more direct and efficient communications, Susan noted increased communications between patients and the interdisciplinary team. ConnexALL is used to integrate messaging to caregivers assigned to individual patients, backup caregivers, and MET team for responding to patients with a deteriorating clinical condition.

The new technology has created a more quite care environment. Communications, nurse calls and alarms are communicated directly to the responsible caregiver without disturbing patients and coworkers. Patients have noted the more quite environment, and are complimenting nurses at a higher rate than in the existing hospital units.

Susan notes that they’re still on the learning curve with ConnexALL and working with mobile technology. Staff is still making some adjustments to the decentralized care delivery model. Staff sometimes feel isolated, especially at night.

Throughout the project hospital leadership was very supportive, a critical success factor according to Susan. All the vendors involved collaborated effectively. The planning and implementation teams met weekly to discuss strategy, planning and evaluation.

Loookin to the future, they want to integrate telemetry and their PBX. The next big project is to retrofit the units in their existing hospital. Those units will retain their central stations, but they will use the same technology as was deployed in the West wing. Longer down the road, they’re working on EMR adoption and broader more comprehensive workflow automation.

Farrah Hirji with Markham Stouffville Hospital spoke on The LEAN Evolution at Markham Stouffville Hospital: Transforming Care. After an introduction to LEAN fundamentals, Farrah launched into the application of LEAN at her hospital and the results they have realized. Their hospital was built to serve about a population of 100,000 but they serve almost double that.

Their incentives for embarking on LEAN were a rapidly growing population (24% in past 3 years) and the resulting need to improve throughput, and also the need to improve patient safety and outcomes.

Culture change is required for success with any focused process reengineering methodology. LEAN is a continuous quality improvement methodology that identifies and eliminates muda (Japanese for waste) in processes. Muda is any activity that uses resources without creating value. Most importantly, it is the patient that defines value.

The major tools are the process, implemented with people, post-it notes and butcher paper to do affinity grouping and process documentation to document the initial state. From this a value stream analysis is done that results in a strategic improvement plan. These tools are used within a specific framework called a Kaizen. A Kaizen event is a 7 week cycle centered on a major 5 day Kaizen event. The first day of the Kaizen documents the current state. Day two does rapid experiments considering process and workflow changes. Day three is focused on defining implementation changes. Day four is centered on trails and testing and creating standard work. The last day is a review and briefing the rest of the hospital staff.

Markham Stouffville targeted the ED for their first LEAN project. Their initial changes included the creation of a Rapid Assessment Zone, EMS protocol, and volunteer greeter. The result of these changes reduced triage to physician assessment interval, reduced ED LOS, and fewer patients left without being seen. In Canada, ED wait times are publicly reported, and these changes have helped the hospital meet their provincial performance targets.

Success factors: a balance of top down and bottom up innovation, collaborative leadership, and treating front line staff as the experts in the work being done. LEAN and Kaizen are cross functional teams, and this process creates the expectation of the need to change — sort of a built in change mangement process. They’ve also adopted the “Vegas” rule: whatever’s said in the Kaizen meeting, stays in the Kaizen meeting. A further technique, the “Gemba” walk takes the team to where the actual work is done and places them in the patient’s perspective. They can also see what their colleagues in different roles have to deal with and how they get their work done.

Typical change in health care takes 6 to 18 months. LEAN results in a much quicker time line, with immediate measurements of results to optimize and reinforce the positive change. The challenge is of course, resistance to change. People also ask why front line staff are making the changes. Hospital’s traditional silo organizational structures are also a barrier. Front line managers need to understand how to manage in a LEAN environment; they no longer call all the shots, but faciliate a broader group process for planning and realizing positive change.

The requirement to collect real time data to measure initial states and documents the impact of changes is a big issue. Without operational data, the LEAN process can’t analyze the current state, nor test and verify that new processes are an improvement. Finally, some operational data is needed going forward to ensure that reengineered processes don’t slip back into the comfortable old way of doing things.

LEAN thinking needs to be integrated into everyday patient care.

Farrah next laid out how to get started in LEAN process. The first things needed are a change agent and lever. This is typically a new requirement imposed on the department or oganization. An executive sponsor is also critical. This is someone who will provide appropriate commitment and “head banging” when required. Physician involvement is important, if difficult to achieve. Use an external consultant to facilitate the initiation of the project. Sustaining positive change is key; follow up meetings and audits are essential to sustaining change. Steal shamelessly from other organizations who have dealt with similar problems or implemented interesting innovations. Develop a long term strategy for transforming your organization.

Brent Maranzan from Thunder Bay asked about gaining physician involvement. Brent presented on Monday, describing how they improved OR workflow. Farrah described a couple of techniques. First she nicely but persistently asked for physician involvement. The catalyst for physician involvement in her project was letting physicians know that improved ED throughput would allow them to see more patients, and thus increase their income.

Getting started in LEAN: a very few hospitals have the luxury of their own process improvement department. At Farrah’s hospital, senior management wanted to try the LEAN methodology. Farrah also had a personal interest in LEAN techniques and was quickly drafted to lead this effort. LEAN process improvement is only part of Farrah’s full time job. Their hospital heavily relies on line staff to implement the LEAN process.

Markham Stouffville is not a GlobeStar customer; Farrah was invited to present based on GlobeStar’s recognition of the necessity of changing workflow to realize operational improvements — whether facilitated by technology or not.

Closing Thoughts

As the conference came to an end, several thoughts came to mind. Messaging middleware deployments are usually point to point types of purchases. They’re focused on a small portion of the organization. Such systems are of modest scope, complexity and cost. The rub is that automating workflow through improved messaging is a need that spans the enterprise. Consequently, manufacturers in this market segment have enhanced their products and repositioned them as enterprise wide solutions. While they may still be implemented in a department by department or application by application fashion, an enterprise architecture is more cost effective and is easier to manage than a series of disparate messaging products.

It also struck this observer that there are several market segments targeting the point of care that may eventually merge into one market. These markets include nurse call, wireless phones, real time location systems, patient flow optimization applications, messaging middleware, and medical device connectivity. Much of the meta information used by these systems is common, and there is a frequent tussle between niche vendors as to who will control things like nurse to patient associations and patient to device associations. Workflow automation that impacts direct care, care coordination, therapy delivery and point of care diagnostic testing frequently bleeds across these niche markets, creating additional systems integration work for vendors, and additional complexities for buyers.

The challenge for vendors is to figure out the best ways to position and sell their solutions. While these solutions are highly flexible, hospitals want to buy solutions rather than tools. But when your product can be configured or implemented in many different ways, to create a variety of solutions, do you try to market each solution separately? Or is it best to offer a tool that can be used to realize several solutions?

Hospitals are even more challenged than vendors. There is almost nothing at the point of care that can be changed without impacting something else. The increasing overlap and integration between these six market segments has transformed a simple phone or nurse call decision into a broader workflow automation decision that impacts existing and future systems used at the point of care. Hospitals that don’t consider this new complexity, and think longer term will end up foregoing important workflow automation or face unanticipated costs in replacing or upgrading something they recently bought.

Of course supporting all these market segments, and more, is the enterprise network — specifically the wireless network. There is a general lack of appreciation among both buyers and sellers that wireless LANs must be designed to meet the specific requirements for the application at hand, whether it be wireless handsets, indoor positioning systems, or wireless medical devices. Some of these repeated site survey and reengineering costs can be mitigated with longer range planning. But in any event, a realization is needed that with each change in networking requirements, there must be a change in the network.

What impressed me most about the case studies presented by customers at this event, was their ability to apply the capabilities of the ConnexALL system to their operational requirements in thoughtful and creative ways. Sometimes this was done with the full support and involvement of GlobeStar Systems. More impressively, this was sometimes done by the hospital on their own.

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.

Another complication is the pervasive silo organizational structure in health care. Both providers and vendors have long had stove piped organizational structures. Groups not used to working together have to collaborate on things that cross both products and silos. Medical device connectivity should be common across product lines from the same vendor (a standard approach across vendors is needed but a different kind of problem). Workflows should be patient centric and common across the different products and departments in the hospital.

Another cause of the above problems is the way most health care providers make purchase decisions. Decisions are often made to solve the immediate problem, with no regard to the fact that everything at the point of care is connected. A solid RFI/RFP process is worthless if insufficient consideration is given to the full range of needs that will impact the entire planned life of the product.

A common victim of insufficient needs assessment is medical device connectivity. Many hospitals are looking at this for automated documentation into the EMR. Besides the obvious complications of spot versus continuous data, wired verus wireless devices, and dealing with legacy devices versus new(er) devices with built in connectivity, there are broader complications. Connectivity is also used for alarm notification. Another wrinkle is improved support for wireless medical devices and the significant requirements they can create for the enterprise network. Decisions based on the immediate need (like connectivity for EMRs) result in future unanticipated costs to replace technology that met initial requirements but can’t meet the requirements that arise in 18 to 24 months.

Vendor’s don’t have the luxury of starting from scratch every time they plan a new product release. They design their products so that future features can be built on previously developed features, rather than reworking major portions of the product to support new features. To do this they use roadmaps, both for entire product families and individual products, to visualize all the moving pieces and how/where they fit. Vendors use this to look ahead and figure out what future capabilities are best acommodated in advance.

The key take aways from the keynote were 1) break down the organizational silos to acquire and manage systems at the point of care, and 2) use roadmaps to look at the bigger picture and coordinate technology management at the point of care.

New Product Release Announced

The 6 market segments mentioned above are breaking down. Increasingly vendors in each niche are looking at broader market requirements and extending their value proposition outside their traditional market segment. Examples include Ascom and their Unite messaging middleware, and nurse call vendors Rauland-Borg and Austco automating workflow. GlobeStar is also following this trend.

GlobeStar used this user group meeting to launch Version 4.0 of ConnexAll. (It’s interesting to note they didn’t choose to launch 4.0 at HIMSS.) The big new features in this release are:

• High availability configurations (active/passive ConnexAll server clustering)
• Location based services (location as a new data element and event trigger with rules engine and scripting)
• Voice integration client (inbound IVR and text to speach nofication to any telephony device)
• Health care informatics client (extends workflow automation through HL7 integration with rules engine and scripting)
• Database input client (extends workflow automation with rules engine and scripting connections to external databases)
• New reporting capabilities (mostly custom reporting)

Don Hennessey, product marketing and Raul Sinimae, senior software engineer talked about the new location based services and how they enable identification of the locations of objects in real time. This provides accurate location of the object during an alarm (when you really want to know where someone or something is located) and the ability to generate new alarms based on location. These can include things like staff duress notification, patient wandering, infant security, or access control to an area. This was done in conjunction with the introduction of the concept of “class” into the system, especially classes of employees.

They’re already working with AeroScout, CenTrak, Ekahau and Versus — and are looking to integrate additional indoor positioning system vendors. Interestingly, ConnexALL can integrate with and fully support multiple different positioning systems to provide a common application overlay that encompasses different positioning vendors in the same enterprise. An adjunct to LBS is the ability to grab images from IP security cameras, and send those with an alarm to staff. Images can be acquired in a variety of ways (stills, series of images, timing relative to event) and store them in a database for inclusion with messages and retrospective review.

ConnexAll takes positioning data from any vendor’s RTLS system, blending that information into their messaging and alerts. They can also receive data from tag buttons or slide switches. Butttons can be used for a variety of ways. It seems to this observer that the absence of a user interface on the tag to manage button use limits the value of tag buttons. Besides location, the system can trigger an event based on a tag being in motion, or when a tag is not moving for a certain period of time.

Clinical Tracks

After lunch two customers presented their experience using ConnexALL. Brent Maranzan from Thunder Bay Regional Health Sciences Centre talked about OR and Hospital-Wide Bed Status Management, and Bill Burley presented Reducing Wait Times in the Emergency Department: A patient Access and Flow Initiative at London Health Sciences Centre. Both were great examples of how lines are blurring between niche products (like SIS and Tele-Tracking) and an application with a more enterprise wide perspective.

Thunder Bay has MediTech that is responsible for admission and discharge transactions, ConnexALL is responsible for the workflow automation between. They’ve expanded out of the OR and are starting to manage bed turnover house wide. Pre sugical delays have been reduced, and patient care in the OR and staff/patient satisfaction have improved.

Bill Burley described the situation at LHSC. Their ED length of stay (LOS) was 5.4 hours, 5% left before being seen, 2.8 hours bed turn over, 6% of discharges by 11 am, and 37% discharged by 2 pm. They’re a Cerner IT shop, have Cisco 7929 and 7921 wireless VoIP phones, and ConnexALL. The first task they tackled was patient transfers from ED to admitting unit, and then bed management.

Their original admit/transfer process had 15 steps involving 7 different people. With just these two areas of focus, they shaved 3 hours off their average admission time, reduced patients who left before being seen fell to 2%, and LOS fell 17% shaving an hour to 4.5 hours.

Interestingly, nursing came to Bill who repurposed their ConnexALL system to include these ED applications. The capital costs for the hospital was zero; operating costs covered both existing hardware and systems, in addition to Bill’s time.  Further, this was not an application that GlobeStar used to sell their system to the hospital. Faced with the operational problem, Bill simply applied what he knows about ConnexALL’s capabilities to solve the problem — although they did bring in a consulting firm to reengineer the admit/transfer workflow. (The consulting firm spent 4 months gathering observational workflow data, then the hospital took 2 weeks to configure the solution.)

They use Cerner for ADT and EMR, and use ConnexALL for admissions messaging into multiple separate buildings and  Next phase they’re going to integrate Cerner and ConnexALL and

After the break Jose Manuel Teixeira with Hospital do Divino Espirito Santo in the Azores, talked about their implementation. They have used ConnexALL for 2 years, integrating nurse call, risk notification, managing patient transport (i.e., porters), on-duty team notification, and building monitoring. For tracking patient visits, ConnexALL prints barcode tags at admission and scans the card upon discharge. They also use it for messaging in the outpatient clinic to increase throughput. He showed several displays representing user interface dialogs created by the hospital to automate various messaging workflows.

Down the road, the hospital is targeting nurse call integration, accident alarms, blood bank monitoring, server farm monitoring, and on-call team messaging. These projects are awaiting product upgrades or the replacement of products reaching end of life. The hospital’s implementations to date include 2,000 callpoints (what GlobeStar calls events that can be both real and virtual, and paired activation/cancellation events).

Teresa Ferreira talked about their use of ConnexALL at the Azores Center for Volcanology and Geological Risk Assessment. The Azorres archipelago is made up of 9 vocanic islands located where three major tectonic plates meet. They currently have 16 active volcanos. The risks associated with this environment include earthquakes, vocanic erutions, landslides and tsunamis, which can occur individually, in combination, or all at the same time.

ConnexALL is used to integrate seismic, geodetic, geochemical, air quality and meteorological information systems and real time data acquisition.  The applications include support of prevention and forecasting of geological hazard, provide information to the Civil Protection department, and contribute to public awareness. ConnexALL reads the acquired data and generates the appropriate messages, alerts and alarms based on rules in the ConnexALL system.

OR Special Interest Group

Looking at the application of technology that’s used in health care in other industries can be most interesting.  These case studies offer a different perspective on technology application, workflows and problem solving that may be directly or indirectly into health care — sort of lateral thinking writ in real life. This application incorporates technical advisory (system failure notification), watch (alerts generated based in increased risk), and restriction/evacuation alarms.

After the official agenda ended an informal group met to discuss OR workflow. Some participants use ConnexALL in the OR, some have the system implemented in other areas of the hospital, and others are potential adopters. One scenario described was were an emergency initiates communications into the OR for some sort of emergency response. The group talked about potential ways to implement this workflow.

The involvement of surgeons in workflow optimization was noted, as was the difficulty in getting surgeons involved in almost anything.

Poorly implemented wireless LANs came up as a common barrier to adoption. It was noted that users frequently blame the application provider for what are symptoms of wireless LANs that are poorly designed, implemented and/or maintained.

Another interesting topic was how hospital’s traditional system acquisition process was poorly suited to the kinds of problems tackled by ConnexALL, like OR workflow automation. Brent Maranzan noted that, “You can’t just decide you need to buy an certain type of product, and then you’re done after it’s installed and running.” This goes back to my keynote where needs assessment is as important as the RFI/RFP process, and that roadmapping is needed to look at the bigger picture (because, you know, everything is connected).

Disclosure: I do not accept consulting engagements to write blog posts about a company or event. The blog is a noncommercial endeavor, focused on improving knowledge and awareness in the industry. GlobeStar did engage me to develop and present their keynote. Separately, GlobeStar and I agreed that they would cover my expenses so I could stay to the end of the meeting. GlobeStar gets exposure through my blog, I have an opportunity to learn more about what’s going on in the industry, and you, dear reader, hopefully learn something from the resulting blog posts — a win win win.

UPDATE: You can read the posts for day two here, and day three (and closing thoughts) here.

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.

The Root of the Problem

When considering the cause for poor patient flow, executives blamed poor communications 67% of the time. Poor scheduling and resource utilization (36%), and things like a lack of beds and staff (36% and 34%) rounded out the causes of poor patient flow. It would be interesting to know if there was any data that would shed light on just what “poor communications” meant to the executives surveyed.

I suspect that the lack of quantitative data mentioned above might somehow be conflated with poor communications. But communications is clearly the culprit when the silo organizational structure of hospitals is considered in light of the need to coordinate patient flow across multiple silos.

Crossing Silos

One challenge the study highlights is a problem with almost any solution targeting the point of care, building consensus among all the stakeholders. The survey noted that 76% of hospitals have committees targeting patient flow and capacity, up from 64% the year before. Almost any automation or new product used at the point of care impacts multiple stakeholder. The mish mash of meds administration, bed turn over, bedside charting, computers on wheels, wireless phones, nurse call, alarm notification — it’s all interrelated, you can’t make a decision about one without impacting another. And of course any decisions made impact nursing, medical staff, environmental services, biomeds, and other ancillaries requires participate and buy-in from each group.

Increasingly hospitals are organizing cross functional teams to look at these multi faceted problems. Of those with patient flow committees, only 54% reported that committee recommendations were implemented (and we can assume that only a portion of those implemented were successful – although this was not reported). Again, progress was indicated when comparing the 2008 implementation rate to the 43% rate for the year before.

Technology to the Rescue

Being a vendor who, you know, sells things, StatCom asked a lot of questions about technology. What they referred to as tracking technologies might better be termed visibility technologies. Only 12% of hospitals show waiting times or patient progress to patients or their families. Those that do, use information accessible on computers or phones (calls or voicemail) by a wide margin – 70% and 67% in 2008. Grease boards (29%), digital displays (19%) and mobile devices (12%) lagged considerably. The leading technologies (computers and phones) were used by humans to convey that information to patients and their families. Technologies with the lower adoption levels convey this data to patients and families directly. I’m surprised hospitality paging isn’t used more for communications to patients and their families.

No self respecting survey would omit a look at new technologies under consideration. Here the number one technology to help track patient status is bar coding at a whopping 62%. A distant second at 38% is patient tracking software, then tablets/PDAs (33%), RFID (29%), and inpatient scheduling software (23%). With bar coding at almost double the next closest choice, this seems to be indicative of the unrealistic expectations that continue to surround the technology. It’s as if bar codes – by themselves – will save us from meds administration errors, improve patient flow, and who knows what else. This list of technologies – a category of application software, computer hardware, and another auto ID technology (RFID),  describes the components of an overall solution rather than competing ways to do the same thing.

If the market’s success with bar coding on smart infusion pumps and point of care meds administration systems are any indication, this should be the last choice for tracking patient status.

In an increasingly crowded market, any vendor sponsored survey has to look at what sets them apart from their competitors. StatCom is lucky to have some meaningful differentiation. While other vendors consider thinking like hospitals an advantage, StatCom has looked to other industries for new ideas and techniques that will improve patient flow. Their value proposition is “real time, proactive coordination of resources to pull patients through the care process.” This contrasts with the more passive approaches of visibility or monitoring. I’m surprised they didn’t add bed management to the list, although it probably would have scored an embarrassingly low percentage.

There’s a lot of great data in the survey. Be sure to download your own.

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.

FierceHealthIT notes a new CDC study on ED overcrowding – it’s getting worse.

The 32 page report is fuel for the American College of Emergency Physicians lobbying efforts to get congress to, “create a commission to study the ED overcrowding problem. Under the terms of the ACEP-backed bill, hospitals would have to report to HHS on how many patients are boarded in the ED, and how long they’re boarded.” [Patient "boarding" is the practice of placing patients in hallways, usually in the ED, where they wait for an inpatient room to become available. Patients commonly wait for hours, and sometimes more than a day, on a stretcher parked in a hallway.]

Ambulance diversion data is tracked by hospitals, regional and state hospital associations, and sometimes the state. This data is not available to the public or most state health agencies. Given how bad ED diversion is, I’m not surprised hospitals want to keep this data private – especially the worst offenders. Data on patient boarding is tracked less often by hospitals and to my knowledge, is not tracked across hospitals by associations.

Public reporting of both diversions and boarding would provide an important customer service metric and patient safety indicator and should be available to prospective patients. It is too bad that such a requirement must be forced on the industry by government.

You can download your own copy of the CDC report here (pdf).

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.