It’s All About Workflow

Okay, it’s not all about workflow, just mostly, as you’ll see.

A while back Ann Farrell was nice enough to bring an interesting paper to my attention. Titled, “Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety” the paper is a fascinating read for several reasons. The authors studied barcode medication administration systems (BCMA) at 5 hospitals, and identified 15 types of workarounds and 31 types of causes of workarounds. This paper provides the most detailed and comprehensive description of product and implementation shortcomings centered on the point of care that I’ve ever seen. It’s devastating. Really.

So what’s this got to do with medical device connectivity?  Two words: workflow and barcodes. Medical device connectivity is the automation of workflow through the integration of medical devices and information system. Likewise, BCMA is the automation of workflow through the use of auto ID (barcode labels and scanners) and information systems. With connectivity, attention centers on the connection; with BCMA, attention centers on the barcoding. Where should the attention be focused? Workflow.

Workflow is the Rodney Dangerfield of point of care systems. Everyone, manufacturers and clinicians both, focus on the tangible stuff, like serial cables and network connectivity or barcodes and readers. The invisible stuff, like water is to fish, is the workflow that occurs at the point of care. There are two key workflow data points that are required for a well designed product. First is capturing the complete workflow process in which the technology solution is to be used.

Framing the workflow should extend beyond the scope of the actual product, so that everything flows well at both the initiation and end of the workflow. Whether you’re a provider looking to define requirements for a vendor selection process, or a manufacturer developing a new product, use cases are an ideal tool for capturing workflow. Use cases are easy for non-engineers (product managers, application specialists, clinical analysts) to understand and use and can be structured to provide engineers with something that can easily be translated into software specifications.

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National Patient Flow Survey – 2008

A little over a year ago I wrote about a patient flow survey underwritten by StatCom. This past fall, StatCom published their survey for 2008 (registration required). Some interesting changes were reflected in the latest survey.

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.

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Why Wireless Connectivity is Different

Wireless changes everything …

I have been watching the evolution of wireless bedside medical device connectivity for several years now. It is now fairly common for medical devices to communicate wirelessly and most hospitals now have the requisite Wi-Fi networks installed and operational. In fact, the saturation point of WLAN adoption in US hospitals has been reached as the numbers are quickly approaching 90% of all US hospitals.

But this posting is not about Wi-Fi or other wireless technologies used in medical devices. Rather it is about additional connectivity considerations beyond the actual wireless connection of the device to a network. Regardless of the wireless connection technology or standard used, wireless changes everything when it comes to connectivity.

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Barcoding and Patient Context

One of the most important areas of connectivity, and one that frequently does not receive the attention it deserves, is establishing and maintaining patient context. Historically, connected devices identified data by location – tagging data with a bed or even port number – rather than the actual patient name or ID. Because patients are frequently moved during an episode of care – not to mention ambulatory – data that is only tagged with a location presents risks of misidentification. In an effort to improve positive patient identification, data is increasingly tagged with a patient identifier.

Besides patient safety, patient context also greatly impacts medical device workflow. (Medical device connectivity is workflow automation through the integration of medical devices and information systems.) How a vendor implements patient context can have a big impact on usability and customer acceptance.

Patient context requirements can vary, based on the type of medical device in question. What is not variable is the requirement to reliably establish and maintain context. Mobile applications (like smart pumps or patient monitoring) where the device may go in and out of network coverage while constantly in use present special challenges. This compares to a fixed or portable medical device, like a dialysis machine or diagnostic ultrasound, with an episodic use case during which neither the device or patient is moved. Another variable is whether the application is life-critical. Continuous patient monitoring and many alarms (e.g., smart pumps and ventilators) are life-critical applications with a higher threshold of requirements. This contrasts with connectivity for documentation like with point of care testing or spot vital signs capture. In all cases though, patient context must be safe and reliable. The above issues just help define how many hoops you have to jump through to be safe and reliable.

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