PDF File: 

HCT2_wp_adler.pdf

3Com Corporation

Communications infrastructures, such as computerized physician order entry systems, in conjunctionwith new workflow paradigms, are making dramatic contributions toward improvingaccess, quality, and efficiency in patient care.

There are many problems currently facing patient care: an aging population; a growing shortage of clinicians, presentday processes that are prone to medical error; and shrinking budgets that are further aggravated by slow reimbursements. Something needs to be done and it needs to be done fast. In this paper we will discuss observations, implementations, and suggestions to prepare patient care communications infrastructures for access, quality, and efficiency within the health care sector.

Access, Quality, and Efficiency

Access – We must provide better access to health care. By the year 2050, more than 20 percent of the world’s population will be over the age of 60.1 Just as the world’s telephony system could not scale without circuit switching systems, the health care infrastructure cannot scale on its current trajectory.

Quality – We must not harm our patients. More than 100,000 accidental deaths per year are estimated to be caused by adverse drug reaction, dosing errors, or breakdowns in commutations and workflow. The shortage of U.S.-based, English-speaking clinicians further aggravates the quality of communications as clinicians from around the world come to the United States with different pronunciations, dialects, and coding conventions.

Efficiency – We must let clinicians treat patients. By 2020, the demand gap for nurses in the United States will exceed 1 million.2 The clinician deficit in the United States has a ripple effect as clinicians from Canada, the United Kingdom, and the Philippines come to the United States. The global mobility of clinicians creates an additional burden on communications (quality) as language and cultural differences take effect.

A Current Perspective

The electronic paint record (EPR) or electronic patient dossier are the spine in e-health deployment. Key interdependencies of the computerized physician order entry (CPOE) system, picture archiving and communication system, emergency department applications, nursing documentation, physician documentation, chart tracking, patient tracking, clinical system integration, discharge documentation, voice dictation, clinician alerts, order entry, quality management, and productivity reports will drive the success of the EPR.

Of the 5,794 AHA-reported hospitals in the United States, KLAS validated 159 U.S. CPOE hospitals, or 2.7 percent, as having some CPOE in use by physicians.3With today’s advancements in both vision and technology, it begs the question: Why is the adoption rate of CPOE so low?

Often cited are the required workflow changes, budget concerns, and change in mindset. According to a recent survey of over 2,000 hospitals in Western Europe, the No. 1 barrier to the acceptance of e-health is the lack of infrastructure.4 A stable, robust, reliable, and secure communications infrastructure will accelerate broader adoption of EPR and CPOE. Figure 1 is an example of a converged communications infrastructure that supports the top trends in e-health.

Figure 1. Converged Communications Infrastructure

Top Trends and Required Infrastructures

Supporting CPOE

Although with limited deployments, CPOE has a bright future with high growth potential. One study reports a 55 percent reduction in serious medication errors following the implementation of inpatient CPOE.5 Three categories of CPOE input devices are offered below:

• Tablet PCs and tablet thin clients (Acer Travelmate series, Xybernaut Atigo, and the Philips 100WT);
• Computers on wheels (Flo, Stinger, and RDP); and
• Heart monitors with thin client portals (Philips Intellivue MP70).

The Green Heart Hospital has experienced early success with their CPOE pilot. The first job was the creation of a common device independent, XML view, of all the hospital applications. This was achieved through a common HL7 interface engine. Whether roaming the hospital, the GP office, pharmacy, or longterm care facility, clinicians are authenticated with 802.1x and sessions are secured through the VPN concentrator. Currently up to 70 tablets, Green Heart favors thin client tablets.

Independent of platform, these wireless entry devices require a communications infrastructure based on a foundation of open standards, reliability, session persistence, and security.

Converged Medical Devices

A hospital that converges medical devices such as cardiac monitors, metered IV pumps, and drug dispensers onto its existing communications network saves substantial staff time and increases efficiency and quality.

When 10/100 Mbps-switched ethernet ports are added by bedsides and staff locations, the patient’s medical device data can connect directly to the patient’s clinicians and administrators. The days of writing readings, routing papers throughout the hospital, or searching for and/or deciphering handwritten records for patient diagnosis, treatment, and billing are gone.

Whether directly connected to terrestrial Ethernet or indirectly connected to the LAN through WiFi or wireless medical telemetry service, the following are a few examples of these devices:

Heart Monitors

• GE DASH 4000
• Philips Intellivue MP70
• Siemens/Drager Infinity Delta

Transducer Fetal Monitors

• Philips Avalon CTS

Infusion Pumps

• Q-Core EFC

In any location where clinicians require more devices, IT staff must add more network ports. Yet in most patient rooms and hospital departments, pulling network cable, or installing a freestanding hub is time-consuming, costly, insecure, and disruptive. Many older buildings have asbestos or brick construction that makes pulling more network cabling or electrical wiring difficult or unsafe. Also, the density in the wiring closet may make adding more switches impractical.

Expensive medical devices and network equipment can be easily misplaced, they are also subject to unauthorized use and abuse. Sometimes devices simply show up on the network, other times they “grow legs and walk off.” The IT staff must know immediately when and where devices are added or removed from the network.

The IT department must be able to quickly solve problems remotely or from the operations center. They also need to instantly locate, isolate, and troubleshoot a networked device from the network or Web.

Medical devices must be connected quickly, and the connections must be reliable. Network traffic to and from life-critical devices and applications must get top priority. IT staff must be able to control which devices and applications are on the network, who has access to them, and the bandwidth the devices and applications receive.

Distance Medicine

Distance medicine leverages access to specialists and enables patients to be monitored outside the boundaries of the acute care facilities:

Radiology – Remotely located radiologists (down the street or halfway around the world) reading and reporting for smaller hospitals or after hours is a proven model for reducing costs and leveraging improving access to radiologists.

Remote eICU – With recent implementations at University of Pennsylvania and Aurora Health, Visicu is backing up ICU departments with off-site intensivists and other hospital personnel to deliver critical care. Through a proactive care model that reduces clinical complications, the eICU solution has been proven effective at reducing mortality by more than 25 percent. The eICU system is powered by the VISICU eVantage technology.

Outpatient Telemetry – Early discharge and a watchful eye on patients with chronic illnesses is another technique that stretches out existing access without having to add more beds. Mobile cardiac outpatient technology has been successfully implemented along the East Coast, where thousands of patients are using Cardionet telemetry service through institutions like Johns Hopkins and the Cleveland Clinic. If vital sign thresholds (set by the clinician) are crossed, the system will trigger an outbound call to emergency services through the analog and cellular phone system.

Managed Care – Equipped with DSL circuits and 802.11g access points the Chorleywood Center in conjunction with the eVital initiative has validated remote patient monitoring in residential care homes.6-7 A European funded project, eVital pilots are occurring in Spain, U.K., Greece, and Italy. The main goal of the eVital project is the exploitation of technology for the provision of remote telemedicine services to patients who are not confined to a hospital.

Clinical Trials – Wearable devices are contributing to the efficiency of clinical trials with regards to speed and economics. The LifeShirt by Vivometrics is a shirt worn by ambulatory patients to continuously monitor and collect data on pulmonary, cardiac, and posture data. The data is uploaded by modem or wireless connection through a PDA. While at school or sleeping, pediatric patients can be analyzed in the comforts of their own home.

Voice and Unified Messaging

Health care voice applications, which may very well be killer applications for health care, can be summarized into two discrete categories: communication and coordination.

Communication

Clinicians need better communications tools that will enable critical calls to find and follow them while diverting nonessential calls to voicemail. Presence-based systems will detect where the clinicians are and where the calls are originating from, thus putting calls through from the facilities where the physician is making rounds and diverting other calls to voicemail.

Coordination

Code Blue – A code blue condition is an example of a diverse virtual team, with different specialties being brought together for the common goal of saving and sustaining life. Hospitals such as the Heart Institute of Sao Paolo University have leveraged their voice infrastructure to not only notify the code blue team, but to coordinate the correct arrival sequence of physicians, nurses, technicians and specialists. Captured data is collected and analyzed by the team, so that they can evaluate their performance in the future.

Virtual Consultation – Prior to surgery, the ENT needs to verify that platelet levels are sufficient. The hematologist has rounds at different times of the day. Surgery is delayed and information is indirectly relayed between these two specialists with the nurse acting as intermediary. A virtual on-the-spot conference call consultation between the nurse, ENT, and the hematologist would save time and improve communication quality.

Appointment Verification – Secondary care physicians and specialists report a patient appointment cancellation rate between 7 and 30 percent. A busy patient may not have the opportunity to speak to the office administrator directly to cancel and reschedule. Patients who have been wait-listed for earlier consultations are informed of the opening appointment too late. An automated appointment verification application enables the patient to reschedule the appointment, spawning an automated outbound call to the wait-listed patient that an earlier appointment has become available. All this is done within minutes with no human interaction. With this type of system, one hospital has reported up to a 40 percent optimization of secondary physician time.

Emergency Broadcast – The commencement of the 21st century has been plagued with natural disasters, disease, terrorism, and war. Health care delivery organizations must be able to mobilize and respond quickly and without hesitation. Bi-directional communications is crucial as the chain of command needs to be well informed to deliver instructions to clinicians and first responders. The communication infrastructure delivers outbound calls and text messages with instructions as to where to report and with whom to check in. The contact list is a real-time database with several contact numbers per clinician, record of specialty, and geographic proximity.

Conclusion

Communications infrastructures in conjunction with new workflow paradigms are making dramatic contributions toward improving access, quality, and efficiency. Medical devices are appearing on the network daily and need to be supported reliably and securely. Successful health care delivery organizations are moving from departmental fiefdoms to common interdepartmental infrastructures that are pooling resources and preserving budget for patient care.

Endnotes

1 United Nations, “Population Aging, 2002.”

2 2000, 2001, and 2002 by the American Hospital Association.

3 KLAS 2004, “Vendor Performance Measurement in 2003.”

4 HINE 2003 Hospital Survey.

5 Bates, D.W., “Effect of CPOE on prevention of serious medication errors,” JAMA 1998.

6 Healthcare 2004 Harrogate, “Providing remote patient monitoring,” Dr. M. Clarke, Brunel University.

7 www.crnettest.arbonaut.com/evital