Digital Hospital and the Internet of Health Things
“Digital disruption accelerates competing ideas even as it facilitates the entry of a previously impossible number and magnitude of ideas.” – James McQuivey, Digital Disruption: Unleashing the next wave of Innovation.
Governments worldwide are keen to reign in the unsustainable rise in healthcare costs. Consumer expectations are also on the rise. Payers and providers are trying to respond to these expectations measuring up to improving quality and outcomes, patient satisfaction and bringing down costs. There are initiatives for integrated delivery, service innovation, wellness and taking care to the patients.Healthcare is in the midst of a perfect storm. Some Hospitals are seeing in-patient revenues steadily decline in favor of outpatient revenues- with some surgical procedures now done on an ambulatory basis. A Cancer center estimates an over capacity of available beds by over 40% and is seriously considering leasing an entire wing to other hospitals.
Value based pricing models require:
meeting a variety of quality metrics,
improve patient experience
Innovate on service delivery especially for chronic care patients. Reform needs a focus on population health management.
Change brings with it disruption as well as creative business models. Some systems are contemplating setting up Ambulatory care centers - ambulatory surgery, primary care, urgent care, ambulatory ER, Labs, Imaging, dental, pharmacy all under one roof- a care construct that that does not carry the cost overheads of current Acute facilities.
There is disruption and innovation happening from the outside. American Well, MD Live and other similar models aims to disrupt Urgent care. CrowdMed takes the concept of Clinical conferences to diagnose difficult conditions and makes the process virtual as well as crowd sourced by specialist medical professionals. Cohealo aims to improve asset utilization by sharing of expensive diagnostic devices among facilities.
Healthcare providers are looking at ways and means to take costs out of the system - reducing waste, managing operations process and workflows; a complex multi-dimensional change management of strategy, structures, systems, process and people. Payers are becoming payer providers, not surprising the healthcare space is seeing a high degree of mergers and acquisitions. There are initiatives to drive:
operational efficiencies, process and workflows optimization
transformation of patient experience
ensuring financial sustainability
information interchange among their systems as well as non integrated delivery networks
Is Digitization and Digitalization the answer? Is there a benefit?
A McKinsey study estimated efficiency gains of 7.5%-11.5% from adopting existing digital technologies in one OECD country
A GE and Deutsche Bank IoT study indicated a 1% increase in operational efficiency could result in a $63B savings to the Healthcare providers in the US.
In June 2014 Ponemon studied the impact of inefficient communications in Healthcare. (Imprivata Report on the Economic Impact of Inefficient Communications in Healthcare) In a survey of over 400 Healthcare providers in the US about the communication process during three clinical workflows : patient admissions, coordinating emergency response teams and patient transfers the impact was approximately $1.75 Million per US hospital or over $11 Billion industry-wide.
Impacts to Process, Workflow and Operational Efficiencies:
Healthcare is an event driven environment. Events are triggered when new information is generated. This information can be generated through patient observation, a lab result, an E Mail or a notification – a STAT order- in the EMR system, a nurse charting or an alarm from a monitoring device.
This information arrives and lies trapped in an EMR or an E Mail system- this passive information is also open loop in nature. Alarms from a monitoring device are transmitted to an appropriate destination without patient context. Delays in accessing and processing the information creates downstream delays in workflows. Some of these delays can be compounding impacting performance and outcomes.
Once the Information is accessed by a care team, a resource flow for patient care is initiated. There are challenges, even with best intentions, new delays occur. Collaboration between Physicians or between the physician and a nurse or a pharmacist or the lab is often delayed because of poor communication tools. Time is lost locating people or finding people to locate people. There are delays in tracking assets- charge pumps, gurneys, wheelchairs, portable EKG machines.
The flow of resources that are not synchronized has an impact on patient flow, length of stay and other operating metrics. Ponemon in their study estimated:
A patient admission on an average takes 51 minutes of this 65% is waste
An emergency rapid response takes 93 minutes of this 43% is waste
A patient transfer takes 56 minutes of this 63% is waste
Digitization along with Digitalization or aligning technology to the business or clinical process promises to help in eliminating some of this waste.
The Technology enablers driving Digitization initiatives:
Video has the potential to replace traditional dial tone communications, becoming the collaboration channel of the future. Video along with secure texting is akin to face to face collaboration and can convert any passive interaction into an active one.
Video is being integrated into EMRs and patient portals for clinical or patient collaboration, in Contact centers for care coordinators to interact with patients, in lobbies in Kiosks for check-in, signage and way-finding, virtual concierges for help in any corridor, for physical safety and security, in OR’s for transmission of procedures for education, in corridors for crowd management and security. The use cases for videos are broad and diverse – a good video architecture will pay in the long run.
Smartphones are replacing conventional wired and wireless handsets. Omni-channel collaboration features - voice, video, text on mobile workforce smartphones will mitigate many a collaboration issue in a dynamic mobile healthcare environment. A robust wireless network with appropriate RTLS technologies can enable a variety of use cases- way-finding, locating assets, locating patients and people, understanding workflows and creating optimized process and workplaces.
The Cloud offers CAPEX and OPEX optimization opportunities- contact centers in the cloud, wireless management through the cloud, collaboration through the cloud, integrating delivery networks through the cloud, vendor neutral image archives, productivity applications in the cloud - just a few examples.
Machine learning, cognitive computing is being integrated into the clinical workforce. IBM Watson in collaboration with leading providers such as Medtronic, Under Armour, Memorial Sloan Kettering are implementing a variety of use cases that will allow clinicians to practice at the top of their license.
Oculus Rift and other virtual reality technologies with 360-degree camera content is enabling the implementation of a variety of immersive use cases in clinical care as well as training and education.
EMR’s have largely been designed for episodic care- data is trapped in the EMR, but with newer data representations as in Fast Healthcare Interoperability Resources (FHIR) there is hope of achieving semantic interoperability of health data allowing friction free information interchange among integrated networks.
Medical grade consumer devices both for diagnostics such as portable smartphone integrated ultrasound or monitoring devices- wearables that track SpO2, Blood pressure, Blood Sugar allow a care team to monitor patients remotely and proactively intervene bringing down re-admissions and improving outcomes.
A Framework for the Digital Hospital and the Internet of Healthcare Things:
A digital hospital relies on the network as a foundation to drive healthcare services and business transformations- improving access, quality and outcomes. Technology solutions should enable, differentiate and define the business strategy as well as improve workflows and the processes clinical and business throughout the healthcare system. At the same time, they should assist with improving business and clinical outcomes as well as transform patient and workforce experience.
Path to a Digital Hospital- some requirements, some barriers and some wins
Enterprise architecture- secure the foundation for digitization to succeed : A large healthcare system has a regional organizational structure. Each region is autonomous and takes independent decisions on their ICT investments. There are no corporate standards- as a result they have over 7 different EMR systems, a variety of PACS systems and their networks are multi-vendor diverse with no standard architecture. They have wireless from different vendors, they have video from Microsoft, Vidyo and Cisco. They even have grey market infrastructure in their environment. The infrastructure is fragile - breaks down too often. They have tried to break fix, outsourced the network but are yet to see a resilient network. They have now assembled a team to develop an enterprise ICT architecture that is aligned to business needs.
This is not the story of one enterprise alone, hospitals that have grown organically or inorganically are seeing similar infrastructure issues. The foundation for a digital hospital is a solid, secure enterprise architecture.
Providers need to create a single IT Governance and change management board that should be tasked to take decisions to create standards, define policies and guidelines and drive architectural disciplines. The ICT infrastructure may need an overhaul to create a resilient, agile and highly secure infrastructure- the foundation for a smart hospital.
Once this happens process and workflows can be optimized, operations enabled and new transformational services created.
Security: Hospitals are under increased attack from malicious ransomware as well as viruses. Devices in the network- especially clinical devices- many of them on legacy obsolete operating systems such as Windows XP are susceptible to compromise. Some of them even have exposed USB ports, a potential for introducing malicious Trojans, viruses, ransomware. The network and the bio-medical devices should be secured with a comprehensive security architecture that provides protection and the ability to detect and respond as quickly as possible in the event of an attack.
Building Management Systems: Bringing the building management systems- Lighting, HVAC, Energy Management, water onto the IP network saves operating expenses. At the same time patients have control managing their environment, lighting, heating or cooling relieving pressure on nurses or technicians from having to perform those tasks giving care teams more time to the care of patients. Agents can keep an IP controlled elevator available for patients moving from rooms to ORs or other parts of the hospital.
Physical Safety and Security: A physical safety and security network using IP Video cameras and smart phones with push to talk functionality provides both CAPEX and OPEX savings. One hospital aims to leverage security video analytics, to provide information on congestion and help care team move patients on gurneys through least congested corridors. With the Building management system, also on the IP network they will have the ability to centrally control and have an elevator ready to take the patient to the appropriate floor.
Mobility and RTLS: A hospital is perimeter fencing with wireless with an objective to know when a patient has entered the facility and initiate the check in and meet and greet process. Wireless with
RTLS is also driving innovation and operational efficiencies in Healthcare.
Celebration Hospital in Florida ran a few experiments with RTLS. Nurses, Doctors and patients were provided RFID tags and movement data analyzed. A series of studies were conducted on the movement of staff and the result was used to make flow changes as well as coach nurses on workflow. A nurse or a physician could, from the spaghetti diagram of their movement, understand how their day looked like. The information provided enough insights to redesign the spaces on a new floor to optimize movement. Tracking patients allowed a better coordination between the PACU and the OR.
Another hospital is taking the wireless footprint to the patient’s home enabling resources to be delivered virtually as well as providing new functionality to nurses visiting patients. Visiting nurses have access to the EMR or are able to Telehealth from the patient’s home and bring in a specialist, nurse or language translator.
A good real time location requires a robust network infrastructure. Tracking equipment is different from tracking infants (for infant tracking precision is needed as well as the area has to be zoned to ensure that infants are not moved outside the secure zone), guest wireless has different needs to the wireless network needed by a patient with a portable wireless heart monitor. The use case defines the need for the RTLS technology and the infrastructure requirements. Clinical grade and in-room (infra-red) tracking needs a different technology than use cases that need limited certainty (LF or Low Frequency or BLE) or approximate location (WiFi).
Unified Communications and Video: A robust unified communication with voice, secure text and video enables care team collaboration among each other as well as with patients and their families. Smartphones such as iPhones and iPADs are making inroads into Hospitals.
At one facility nurses use iPhones to collaborate. The system provides secure texting as well as provisions the iPhone automatically once the nurse swipes his or her badge. Physicians get their communication environment in the examination room- their RFID tag is used to provision the badge to authenticate. When the physician leaves the room the communication system resets the credentials. The Contact center also has omni-channel capabilities allowing Agents/ nurses to have conversations on patients preferred channel-phone, video, text or through the web.
A hospital system uses smartphones to consolidate the diverse channels of inefficient communications enhancing communication workflows, online directories allow smarter collaboration, training such as Ebola preparation was now provided virtually and recorded, with a mechanism to track who all had taken the training; presence, chat, click to voice features provided smarter workflows. Other use cases for bed management, clinical collaboration are now possible. A good UC foundation architecture also enables a Telehealth implementation at scale.
Nemours, HCA and other facilities have set up self-check-in kiosks in lobbies to manage the queue at the concierge desk. By extending the check in facility through an App provides another option to shorten the concierge queue. One facility is planning to perimeter fence the hospital. As a patient drives in an HTML page shows up on the patient’s smartphone encouraging him or her to check in. For patients who would like to check in at the desk a virtual concierge supporting various integrated hospitals provides the same capability.
Alerts and Alarms: Perhaps one of the biggest benefits of a robust Unified Communications architecture with smart phones is the ability to communicate effectively while sharing context simultaneously. Healthcare is event driven and events have triggers. Many a times these triggers are passive and open loop in nature. A stat order by a physician does not alert a nurse. An alarm from a monitor can be transmitted but lacks context. Middleware technologies such as from Vocera provides capabilities to pull information from the EMR and other systems and combine it with the patient monitor signal for forward transmission. Alerts and alarms are propagated to smart phones with patient context – the room, the clinical context (age, condition, medications etc.) This allows a richer collaboration and significantly improves process performance as well as clinical outcomes. Escalations can be set up if an alert is not responded to in a defined period.
Clinical Logistics: Nemours Children Hospital in Orlando has implemented a novel clinical logistics system that is used to monitor patients in the Orlando as well as Delaware hospital from a single location, remotely. Built like an airport control tower, signals from patient monitors are brought into a centralized control room. Separate screens display EPIC EMR information with an acuity index. A paramedic monitors patients 24x7 from the control desk. The paramedic can video into the room in Orlando or Delaware, if he or she notices an issue and can have a conversation with the patient or family as well as alert a nurse. Nurses can initiate a rapid response by pressing a RRT button on an iPAD like device at the patient’s door. The paramedic also can initiate an emergency rapid response. The paramedic is like a second pair of eyes supporting the clinical staff on the floor. This allows the floor nurses to spend more time taking care of patients. Another hospital is in the process of implementing a similar logistics system but extending the capabilities to include transfers, bed management, locating assets and asset management from a centralized control location. The aim is to drive better operational efficiencies allowing care teams to spend more time with patient care and improving clinical outcomes.
Telehealth and Home-health: Outcome based models require access to patients in any setting, in the hospital or outside the hospital-the perimeter of the hospital as a result needs to shift to where the patient lives. Mercy Health in St. Louis, UPMC, Kaiser Permanente, the VA have programs at scale for Telehealth and Home-health.
Mercy Virtual is a Telehealth initiative where 600 plus virtual co-workers remotely monitor up to 500,000 patients through the Engagement@home program. This has resulted in 50% reduction in preventable re-admissions and 60% fewer septic shock deaths in patients being treated remotely.
A healthcare facility estimated that managing a non-compliant Diabetic patient costs the system over $27,000. Chronic diseases such as Diabetes, COPD or cardiac conditions require proactive care coordination through virtual platforms with embedded analytics and a patient App. Medtronic plans to deliver a service for diabetic patients with an ability to reach care to a patient and proactively intervene before a potential episode. IntelliH has a diabetic care coordination platform that is now in clinical trial at two facilities one in Florida and the other in California and is showing some promise with diabetic patients. A trial in India will extend the management of diabetic as well as CHF patients.
AI – Machine Learning and Virtual Reality: Medtronic partnered with IBM to build a cognitive computing platform to manage diabetic patients. The system tracks patient glucose from a continuous glucose monitoring device and can predict a hypoglycemic episode nearly 3 hours before onset, potentially saving the patient from a debilitating episode. Similarly, Watson Oncology, built in partnership with Memorial Sloan Kettering Cancer Center, has trained Watson to sift through patient records, diagnostics, Omic profiles, cohort patients from a registry with similar characteristics and systems, research papers and medical literature supplemented with how oncologists diagnose to identify and recommend a treatment plan or clinical trial. IBM Watson also can assist a radiologist to make reading from images. Machine learning will play a big role in future Healthcare settings.
Virtual reality has been used in healthcare for several years now for treating PTSD patients as well as medical education. I was privy to a recent demonstration from a stealth startup building a training solution for Healthcare. The 360 camera view images with the immersive solution allows a trainee to view any procedure from the perspective of any of the resources in the OR.
Connected Hospitals: Some states such as New York are encouraging Healthcare facilities through its DSRIP program, to build integrated delivery systems. This would bring together acute, Sub-acute, urgent care, skilled nursing, homecare, clinics as a single virtual unit with interoperability of patient data. Similarly connecting ED’s in a region or trauma centers in a region provides a much better way to route patients in the event of a major calamity – an earthquake or a tornado or a terrorist incident. Some thought leaders are looking to create Connected stroke centers for better patient management.
Focus Areas : The road to digitization and digitalization can be challenging:
Create a vision of what the hospital of the future would look like and communicate that to all stakeholders. Functional areas will need added attention:
Systemic: The absence of an enterprise architecture with an ICT infrastructure that has grown organically will not stand up to the demands of digitization.
Decisions in the past have been department focused rather than the enterprise focused, with little or no governance. All technology decisions should align to the needs of the business and should contribute to improving business metrics and patient outcomes. Solutions should be driven by enterprise needs not departmental needs.
Data drives decisions- that data lies in silos of the healthcare eco-system. Enable semantic interoperability of that data so that anyone providing care has a 360-degree view of the patient.
Process: Process should be examined to eliminate lean waste.
Technology should seamlessly be built in to support the process. As an example, providing an IP phone at the point of care is a need but with a little systems integration provisioning the phone automatically for a care team member is an example of a seamless friction free solution fitting into the clinical process.
Similarly collecting all patient information at the point of care or delivering information at the point of care are examples of solutions that supports the clinical process.
Transmitting patient monitor signals along with the patient context from an ICU or an in-patient room to a remote specialist saves time, drives operational efficiency as well as potentially improves outcomes. In the event driven environment automatic event notifications should be pushed to the appropriate resource in real time rather than them having to pull that information passively. Where needed process should be redesigned and technology should “integrate” into the solution without requiring unnecessary workarounds or involve hefty learning curves.
Functional: For a brown-field hospital digitization is a journey. There will be several competing initiatives:
New services such as chronic disease management with initiatives for virtual care,
Consolidation of EMR’s or Datacenters
Patient experience initiatives such as way-finding, Intelligent parking or lighting, in room entertainment and patient engagement solutions
Operational initiatives such as IP enabled building management, integrated delivery networks, supply chain integration, intelligent work-space, clinical logistics, intelligent contact centers, asset tracking and management or physical safety and security
Process improvements for check in or registration, discharge process, multi-disciplinary team collaborations, workplace experience improvements, ED patient flow, OR operational efficiencies
The hospital should have a formal governance process to prioritize these based on the value and ease of implementation of the initiative. For each of these initiatives a value driver tree and benefits should help in building the ROI of the initiative or the use case.
Human: Any new initiative comes with change and change has to be managed. Change can impact strategy, structures, systems, process and people and each of these require management. Change requires the involvement of people directly impacted. They or a few- change agents- need to be involved at the outset at the design stage not at the implementation stage. This may take them away from the day job for some time.
Having nurses or physicians wearing RFID tags is a cultural change and has been resisted at some facilities. But that simple change has the potential to improve workflows and drive operational efficiencies. To make that change requires crossing that cultural bridge (or chasm). Start small with pilots that show success. Success can overcome rigidity- success drives success.
Digitization properly implemented brings potential benefits:
Business Agility and in a fast-changing environment this could provide competitive advantages. It allows the creation of new services and capabilities
Patient Experience builds on the improved infrastructure allowing creative initiatives focused on patient experience and help drive comparative advantages as well as improved brand image
Better workplace allows the retention of a workforce as well as attract skilled workforce to the system
Operational efficiencies help in driving better patient outcomes
A better brand, a better image attracts new patients increasing the top line and operational efficiencies help in reducing costs
A resilient, scalable enterprise architecture provides the framework to create integrated delivery networks
A manageable, robust infrastructure designed with an architectural framework can be secured to prevent malicious attacks as also to respond proactively and in a timely manner before, during and after any breach.