I'm at GlobeStar System's annual user group meeting this week, in Lisbon, Portugal. Attendance is about 150, equivalent to last year's meeting.

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.