What with all the effort required to get everything plugged together and talking, it is easy to forget that medical device connectivity is really about workflow automation. In other words, providing everything "connects" and works, the question of how it works becomes critical. The October 2008 issue of 24x7 has a story by yours truly on workflow along with some suggestions on how to deal with workflow.
The complexity and costs of implementing a medical device system that uses specialized peripheral devices, applications and systems integration with third party applications can add considerably to the cost and time required to install and implement such systems. This seriously impacts one of the most common tools providers have for evaluating vendor's products.
The on-site evaluation is becoming a weak link in the conventional equipment evaluation process when complex systems are under consideration. An on-site evaluation can certainly reveal how effective the medical device itself may be in a specific clinical environment. This evaluation tool breaks down with purchases that require additional peripherals like personal data assistants or computers on wheels, application software installations, and, especially, systems integration with other hospital information systems. All of these components—that extend beyond the actual medical device—come at considerable expense and time required for systems integration. The result is frequently an on-site pilot that represents only a small fraction of the total system under consideration, leaving the buyer in the dark as to how the complete solution would perform in their environment.
The consideration of workflow associated with medical device systems is presently not receiving a lot of focus in many hospitals. The IT department looks at workflow for their conventional HIT applications. And nursing is focused on policy and procedures associated with caregiving - including IT and medical devices - but this rarely gets down to a detailed assessment of workflow. All of this provides an opportunity for clinical engineering to add value:
In response to the growing impact workflow is having on the ultimate acceptance of equipment purchases, many hospital biomedical/clinical engineering departments have an opportunity to step in and leverage their clinical focus to better account for workflow in vendor selections. An appreciation of the value of workflow is growing. Hospitals are increasingly interested in improving workflow through process reengineering methodologies like Lean and Six Sigma.
The story goes on to propose use cases as a tool to capture, assess and manage workflow at the point of care. Industry utilization of use cases is growing as vendors and health care providers both look for tools to define requirements and ensure that resulting solutions result in workflows that are improvements over previous manual processes. As we all know, medical device connectivity can easily result in workflow that is a step backwards as far as end user productivity and workflow is concerned.
The main portion of the story describes the components of a use case, and how to create them.
As medical device, connectivity and software vendors zero in on the point of care, workflow will be an increasingly important issues. A complicating factor is the tension between vendor's preferred strategy of proprietary end to end solutions, and clinicians (increasingly impatient) need for patient centric solutions. Use cases will be an important tool for both vendors and providers to assess workflow at the increasingly interconnected point of care.
I recently read your article in 24×7 on the Challenge of Automating Workflow. I found it to be an excellent article and a concept that I hope to implement here at Stevens Hospital. You are correct that historically the “dog and pony show” has been the method of product evaluation in the hospital and with its limitations it is fast becoming a method with a lot of drawbacks. The least of which is that nurses can see the product but not use it and a lot of times doctors do not even see it before it is installed.
We recently purchased a telemetry monitoring system for the hospital. Although we did not go into workflow in the depth you describe, we included it in evaluating the purchases we made. We have a limited budget and wanted to make the most economical yet practical decision about the monitors. We gathered a group of biomedical engineers, doctors and nursing staff who would ultimately be involved in the purchase and use of the equipment. We looked at the acuity of the patients involved in the nursing unit and using workflow considerations we devised a plan where the monitor capabilities we purchased were flexible and defined by the acuity of the patient. If a patient had high actuity they resided in the intensive care unit with the highest level of monitoring. If they were less acute they could reside in a room with a lower level of monitored parameters, and so on to levels of acuity that could be monitored by telemetry. This allowed us to purchase monitors for each room but to tailor our purchase of multiparameter modules to fit the patient’s acuity - ECG, 3 pressures, cardiac output/ ECG, NIBP, SPO2, etc.
Now each patient can reside in a room without being moved from that room and the level of monitoring can be tailored to their acuity by changes in the monitoring parameters. Rather than having a traditional ICU/Progressive care/Telemetry unit, we have a Cardiac Care unit that encompasses all of these parameters. We are starting this unit in November 2008 so we will see how it works , but this is the first time we have not used the “dog and pony” method.
I have first-hand knowledge of the power of workflow technology from my wife. She is a production supervisor at Fluke Instruments in the Fluke Networks Division. When she first started at Fluke Instruments their production method was the “old school” methods of producing orders on a hit and miss schedule and smoothing the bumps with excess inventory. The production people batched and there was no real connection between production, shipping and planner / buyers.
Recently Fluke was purchased by Danaher Corporation and they introduced Japanese production techniques in their production lines. They are very involved in workflow analysis of the production cells, kaizan of cells methods, and just in time control of parts , inventory and shipping. The turnaround in their production and efficiency has been amazing to see.
I have been a biomed for 28 years and I see the healthcare field is very far behind in not only information technology but workflow analysis. Nursing staff demands for patient care have restricted their participation in workflow analysis but informal use cases would be an excellent place to start. Automatic charting systems are only just starting to be introduced in this hospital and there is no connection between these and stores ordering and inventory or central service functions like at Fluke Instruments, and no connectivity between medical devices to any great degree. Remote monitoring of the performance of medical devices is only just starting and that is usually large radiology systems like the MRI and cath lab.
The computer in my Audi measures and controls more sensor inputs and device performance than any piece of medical equipment I maintain in the hospital.
This is an excellent article and I thank you for it.
Rick, thanks for your kind words.
It’s interesting how your hospital’s assessment of workflow led you to implement what others would call “variable acuity” care delivery. This approach of bringing the care (and monitoring) to the patient, rather than transferring the patient from unit to unit, is an interesting analog to the changes in the manufacturing floor at Fluke.
Transfering patients between units adds a full day to their length of stay. Too many transfers equals a high average length of stay (ALOS).
Further, patient flow bottlenecks in critical care units (usually from too many inappropriate admissions) are a major contributor to ED diversions and hospital patient flow problems overall.
You’re right about both the value of workflow and use cases, and the need for hospitals to let loose of some of their traditions and embrace a bit more change.
I would guess that about one third to half of telemetry monitors are really used for monitoring higher acuity patients as opposed to arrhythmia monitoring of cardiology patients. There is clearly a growing market for a patient worn monitor that avoids the clinical complexity of ECG waveforms and arrhythmia alarms, and provides parameters more suitable for low acuity patients who need patient monitoring.
The Welch Allyn ProPaq LT fits this niche, as does a product in development by Triage Wireless (both past clients).