Web site surveys can be amusing, and one on Mobile Health Data's site today caught my attention. Here's the set up (it's not eally a question, is it?):

Enabling medical devices, such as infusion pumps, electrocardiograph machines and glucometers, to wirelessly send data to a patient's medical record or to a physician:

Why wireless? Well, unless you're in the OR or ICU with gorked out patients and dedicated devices, you're going to go wireless. Wireless best fits the inherently mobile nature of hospital care: medical devices connected to patients, care givers and support staff who constantly circulate, and patients who transit through (too many) care units and departments during their stay.

When thinking of integrating medical devices, the first two I think of are spot vital signs monitors and continuous patient monitors. Patient vital signs are taken several times daily. The problems with manually documenting vitals are legend; indecipherable handwriting, data in the wrong chart, vital signs written on scraps of paper (hands, scrub suites, etc.) that get forgotten, and the sometimes considerable lag between readings and when they get into the chart. This is a problem; now add an EMR -- now everything must be written down and then typed into the electronic chart, and cries of "double entry" and "extra steps" arise. So, spot vital signs monitors probably represent the greatest amount of data that makes it into the patient's chart.

Continuous patient monitoring is being used more and more outside the ICU and Telemetry. One driver is the increased emphasis on pain management. When therapeutic intensity is increased (in this case increased pain meds), there must be a related increase in surveillance. Reducing nurse to patient ratios is one way to do this, as is adding ECG and SpO2 monitoring. Hospitals that have foregone increased surveillance have experienced sentinel events.

Another driver is what's called the variable acuity care model (aka, flexible monitoring, universal bed, flex bed). This care model keeps the patient on their medical service unit and varies the nurse-to-patient ratio and related therapies and surveillance (monitoring) as the patient's condition changes. Typical ranges of acuity go up to high dependency or Telemetry units, just short of the ICU. Hospitals are using this approach to relieve patient flow bottlenecks in the ICU, Step-down or Telemetry units. Finally, some hospitals are making wireless patient monitors available in units outside the ICU simply to improve patient safety.

Wireless diagnostic devices, especially the two mentioned in the survey, are great examples. Wireless enablement of these devices gets data into the chart much quicker, without the risk of data entry errors.

Sending medical device data to physicians is a non-starter; an alert about that out of range lab test yes, the 15 arrhythmia alarms the patient had in the last 45 minutes, no. The unsung hero in all this is the person directly responsible for the patients care and safety 24/7, the caregiver. Communications at the point-of-care is incredibly chaotic and disjointed. Many life critical alarms are still audible alarms annunciated solely at the bedside by the device itself. Much of the coordination of care (especially when patients start to crash) is done with unreliable pagers, overhead pages and phone calls to roles ("on-call respiratory therapist") rather than individuals. The amount of meaningful automation and technology to support caregivers is miniscule compared to that provided for patient accounting, medical records and diagnostic departments. The adoption of an EMR on its own will make little difference. Is it surpising that past and current IT investments have had little impact on patient safety?

Here are the survey choices (the results when I took the survey are in parentheses):

  • Still too expensive to implement in routine clinical care (5%)
  • Doesn't offer a secure enough mode of transmission for clinical data (10%)
  • Could help save time and improve patient safety (50%)
  • Could also be used to help monitor patients from their homes (35%)

In the scheme of things, the cost to integrate medical devices is but a rounding error in measuring the cost of an EMR. However, there are several hidden costs. Some vendors insist hospitals provide separate network infrastructures for their medical devices. Medical devices communicating "life critical" data are a new application for most hospital IT shops, but the SLAs required for an EMR are virtually identical to those required for medical devices. Getting IT to the place where they offer up-time, latency and support coverage for "life critical" applications is part of good EMR implementation planning.

If people bought cars like most hospitals buy medical devices, we'd all be driving much older cars. Consequently, when looking to integrate devices many hospitals are told that the older devices or system they have must be upgraded to support HL7 integration. Ca-ching. Another hidden cost is the proliferation of point solutions. If you're not careful, you can end up with multiple infrastructures, HL7 interfaces, and numerous gadgets for your nurses. Fortunately there are enterprise solutions to
these challenges, they're just not widely known.

Protection of ePHI (electronic protected health information, i.e., patient identifiable data) is far from insurmountable. Although HIPAA rules for both privacy and security apply to medical devices, most hospitals are not in compliance. Here's a gut check question: has your facility had all of your medical device vendors complete a Manufacturer Disclosure Statement
for medical device security? Ever heard of such a thing? If the answer to either question is "no" you've got some homework to do. (Let me know if you need any help...)

It was heartening to see that the majority of survey-takers recognize the benefits of medical device integration.

Finally, home monitoring is a completely different kind of application from EMR integration. Rather than caregivers as users, home monitoring must be patient friendly. The available networks and their technical characteristics are considerably different from hospital networks. There are also different parameters that must be monitored that are managed differently in the hospital (e.g., the weight of a patient with chronic heart failure). Finally, home care applications are chronic disease monitoring systems that provide patient feedback, patient monitoring and alerts (to both patients and physicians). If there are any systems that are sold and used in both inpatient hospital and home care I'd like to know about them.

Medical device integration is a critical (and often overlooked) part of EMR planning. To be successful, any plan must take into account many more considerations beyond getting an HL7 feed into the EMR. Multiple stakeholders include nursing and biomedical engineering must be engaged. Putting together a successful plan requires going across traditional hospital silos, and an in depth understanding of point-of-care workflows, medical device connectivity and device vendor offerings and product strategies. In this area, there is no such thing as a "one shot" plan; multiple phases over a period of years will be required for you to reach your ultimate goal. And great care must be taken to avoid "throw away" purchases and to ensure that caregiver productivity is enhanced rather than degraded. If you'd like a little help, let me know.

Take the survey yourself, and let me know what the results were when you took it.