Hos­pi­tals want mon­i­tor­ing de­vices and EHRs to com­mu­ni­cate

Modern Healthcare - - NEWS - By Dar­ius Tahir

Nurses at Ephraim McDow­ell Health’s two hos­pi­tals in cen­tral Ken­tucky un­til re­cently had to copy raw data from mon­i­tor­ing de­vices into each pa­tient’s elec­tronic health record. “The nurse would be try­ing to mon­i­tor the pa­tient on the vi­tal-sign mon­i­tor as well as do­ing doc­u­men­ta­tion in the EHR sys­tem,” said Becky Blevins, project manager for in­for­ma­tion sys­tems at Danville-based Ephraim McDow­ell.

That be­gan to change in 2012 when the sys­tem re­tained a soft­ware de­vel­oper to trans­late elec­tronic data from the vi­tal-sign and other mon­i­tors di­rectly into the EHR. The shift sharply re­duced hu­man tran­scrip­tion er­rors. Now, it is “like the cell­phone,” said Dr. An­jum Bux, an anes­the­si­ol­o­gist with Ephraim McDow­ell. “You don’t know how you lived with­out it.”

But the process is still in­com­plete. “Right now, we’re do­ing a pa­per record of the anes­thetic in the OR,” Bux said. The hope is to have the EHR grab­bing the data dur­ing an op­er­a­tion within 12 to 18 months.

Con­cerns about the lack of in­ter­op­er­abil­ity be­tween com- pet­ing EHR sys­tems are ris­ing to the top of the health in­for­ma­tion tech­nol­ogy agenda in Wash­ing­ton. HHS’ Of­fice of the Na­tional Co­or­di­na­tor for Health IT is­sued a re­port last month blast­ing both ven­dors and providers for block­ing the ex­change of data be­tween ri­val EHRs and ri­val health­care sys­tems.

But that re­port ig­nored sim­i­lar prob­lems that pre­vent clin­i­cal-mon­i­tor­ing de­vices such as ven­ti­la­tors and elec­tro­car­dio­grams from com­mu­ni­cat­ing with EHRs. They cre­ate data that in the­ory should pass to the pa­tient’s record. But it of­ten doesn’t hap­pen. In­stead, nurses must man­u­ally tran­scribe the data, in­tro­duc­ing an­other arena for hos­pi­tal er­ror.

That dis­con­nect has cre­ated new op­por­tu­ni­ties for ven­dors sell­ing soft­ware so­lu­tions to link up the non-com­mu­nica­tive sys­tems. Ven­dors also say link­ing de­vices to EHRs will al­low clin­i­cians to mon­i­tor data au­to­mat­i­cally, con­trol­ling drug dosages from afar and pro­vid­ing a record for an­a­lyz­ing and ad­just­ing a pa­tient’s care plan. It can “(take) out any chance of user-en­tered er­ror,” said Jeff McGeath, vice pres­i­dent of soft­ware so­lu­tions for Iatric Sys­tems, which pro­vides one such prod­uct.

Even the more so­phis­ti­cated health­care

sys­tems in the coun­try are fac­ing de­vice-EHR in­te­gra­tion prob­lems.

Con­nect­ing mon­i­tor­ing de­vices and EHRs is likely to be­come a growth busi­ness over the next decade. Tech­nol­ogy re­search firm Gart­ner pre­dicts a 35.5% com­pound an­nual growth rate for de­vices that can com­mu­ni­cate through the “In­ter­net of things” be­tween 2013, when sales to­taled $19.9 bil­lion, and 2020. The first tar­get is en­sur­ing de­vice data flow into the EHR. Roughly 18% of hos­pi­tals have pur­chased med­i­calde­vice in­te­gra­tion soft­ware, McGeath said.

Even the more so­phis­ti­cated health­care sys­tems in the coun­try are fac­ing de­vice-EHR in­te­gra­tion prob­lems. Geisinger Health Sys­tem in Danville, Pa., for in­stance, has in­te­grated its dial­y­sis and anes­the­sia units and plans to in­te­grate data from its in­ten­sive-care unit into its full EHR be­gin­ning this sum­mer. But to­tal in­te­gra­tion be­tween its in­pa­tien­tu­nit de­vices and pa­tient EHRs won’t hap­pen un­til 2018.

The nurses have “been our in­ter­op­er­abil­ity de­vice in­ter­face,” said Jean La Val­ley, a se­nior tech­ni­cal an­a­lyst at Geisinger. Greater in­te­gra­tion will al­low them to de­vote more time to pa­tient care, he said.

Nurses bear the brunt of mak­ing up for mon­i­tor­ing de­vices’ fail­ure to stream data into the EHR. A March 2015 poll com­mis­sioned by the West Health In­sti­tute found that 69% of 526 nurse re­spon­dents be­lieved doc­u­men­ta­tion took time away from pa­tients, and 46% be­lieved er­rors were likely to arise in such cir­cum­stances.

Even when the data make it onto the EHR, they are not al­ways us­able. For in­stance, wave­form data from many EKG ma­chines show up in the EHR as a dig­i­tal pic­ture. For hos­pi­tal ex­ec­u­tives, that’s dou­bly an­noy­ing. Cletis Earle, chief in­for­ma­tion of­fi­cer at St. Luke Corn­wall Hos­pi­tal in New­burgh, N.Y., said the pic­tures are “data hogs” that take up too much space on the hos­pi­tal’s com­put­ers. Dr. John Pirolo, chief med­i­cal of­fi­cer at St. Thomas Health in Nashville, noted the pic­tures are dif­fi­cult for com­put­ers to un­der­stand and an­a­lyze.

The wave­form is­sue cre­ates a small skir­mish in get­ting the data im­ported at all, which re­quires tricky chore­og­ra­phy be­tween de­vices and soft­ware. Few EHR sup­pli­ers have cre­ated easy data in­ter­faces.

Of­fi­cials at St. Luke Corn­wall and Ephraim McDow­ell com­plain early ver­sions of Meditech’s EHR can get only slices of data by click­ing a spe­cific but­ton. Their sys­tems can­not ac­cept real-time stream­ing data. Meditech says it has cre­ated 200,000 in­ter­faces.

Pirolo at St. Thomas Health, which uses Cerner and Athenahealth, notes that ev­ery new piece of mon­i­tor­ing equip­ment re­quires a new in­ter­face with the EHR. “If a new ven­ti­la­tor tech­nol­ogy emerges that pro­vides en­hanced safety fea­tures that we would like to im­ple­ment, we will be forced to rebuild the en­tire mid­dle­ware layer to connect the new ven­ti­la­tor to the EHR,” he said.

Stream­ing data be­tween a wire­less mon­i­tor­ing de­vice and an EHR presents an ad­di­tional headache in hos­pi­tals that weren’t built with wire­less con­nec­tiv­ity in mind. For ex­am­ple, they may have cop­per pipes, which can cause in­ter­fer­ence, or sig­nals are un­able to pen­e­trate deep un­der­ground or through lead-walled rooms. “As pa­tients move from one lo­ca­tion to an­other,” Blevins said, “we need to en­sure that that wire­less con­nec­tiv­ity is go­ing to con­tinue to pick up that sig­nal.” In­cor­po­rat­ing new wire­less de­vices re­quires testing per­for­mance each time, he added.

Prob­lems can some­times arise un­ex­pect­edly. Leaky mi­crowave ovens have knocked com­put­ers off the In­ter­net at Geisinger, for in­stance, said Robert Murcek, the sys­tem’s direc­tor of net­work in­fra­struc­ture.

Com­pli­cat­ing mat­ters is the sheer num­ber of de­vices that need to be herded onto a net­work. Any­one who’s tried to pick up cell­phone re­cep­tion at a foot­ball game will be familiar with the prob­lem: Too many de­vices try­ing to ac­cess a net­work at the same time slows ev­ery­one down, which can pose haz­ards in a health­care en­vi­ron­ment.

Still, soft­ware ven­dors and some man­u­fac­tur­ers are ex­cited about au­tomat­ing many clin­i­cal-sup­port ac­tiv­i­ties that in­volve mon­i­tor­ing de­vices. At a March event, Bakul Pa­tel, as­so­ciate direc­tor for dig­i­tal health at the Food and Drug Ad­min­is­tra­tion, touted the agency’s ef­forts to help cre­ate in­ter­op­er­a­ble de­vices.

The agency has rec­og­nized 25 de­vice stan­dards and has dereg­u­lated sev­eral types of de­vices—most crit­i­cally, med­i­cal-de­vice data sys­tems, which trans­fer and dis­play data from med­i­cal de­vices. The de­vice cat­e­gory was, as re­cently as 2011, in the agency’s Class III—or most risky—cat­e­gory. Pro­gres­sively, the agency has low­ered re­quire­ments for the cat­e­gory. Now it’s com­pletely un­reg­u­lated.

The Cen­ter for Med­i­cal

In­ter­op­er­abil­ity has pulled to­gether many of the na­tion’s largest health sys­tems to serve as a coun­ter­weight to ven­dors who main­tain pro­pri­etary stan­dards that cre­ate the “illusion of in­ter­op­er­abil­ity.”

“The reg­u­la­tory path seems straight­for­ward and pretty clear to me,” said Robert Jar­rin, se­nior direc­tor of gov­ern­ment af­fairs at Qual­comm, prais­ing the di­rec­tion the gov­ern­ment had taken over the past few years. Jar­rin says solv­ing the in­ter­op­er­abil­ity prob­lem will re­quire the co­op­er­a­tion of mul­ti­ple stake­hold­ers, in­clud­ing agree­ment on stan­dards.

But the mar­ket­place isn’t there yet. Buy­ers grouse about a lack of in­for­ma­tion about what they’re buy­ing. La Val­ley, for in­stance, noted that many ven­dors claim to sell “en­ter­prise” wire­less de­vices that will in­ter­act with all the net­work en­vi­ron­ments in a hos­pi­tal. Yet Geisinger’s de­vice-pur­chas­ing ex­pe­ri­ences have amounted to a “school of hard knocks” in terms of learn­ing what would and wouldn’t work, he said.

Some med­i­cal-de­vice ven­dors, mean­while, blame buy­ers for fail­ing to con­duct a care­ful anal­y­sis be­fore pur­chas­ing new equip­ment. Welch Al­lyn’s Se­nior Prin­ci­pal En­gi­neer, Steve Baker, noted that his com­pany rarely re­ceives de­tailed quote re­quests from hos­pi­tals con­cern­ing in­ter­op­er­a­ble de­vices. For ex­am­ple, it’s sur­pris­ing to see re­quests for elec­tronic cer­tifi­cates that can list ev­ery de­vice on a hos­pi­tal’s net­work .

The Cen­ter for Med­i­cal In­ter­op­er­abil­ity has pulled to­gether many of the na­tion’s largest health sys­tems to serve as a coun­ter­weight to ven­dors that main­tain pro­pri­etary stan­dards which cre­ate the “illusion of in­ter­op­er­abil­ity.” It is dif­fi­cult to mix and match de­vices from dif­fer­ent ven­dors, St. Thomas’ Pirolo said.

Hos­pi­tals re­main hope­ful about the prom­ise of get­ting their mon­i­tor­ing de­vices and EHRs to talk to one an­other. It could make hos­pi­tal pro­cesses more ef­fi­cient by us­ing the data to con­duct the equiv­a­lent of time-and-mo­tion stud­ies, Pirolo said.

And clin­i­cians such as Geisinger’s La Val­ley be­lieve more data flow­ing into the EHR will give hos­pi­tals a new tool for de­tect­ing pa­tient de­te­ri­o­ra­tion early on. “What if you could have a su­per­com­puter look at that (data) for an en­tire pop­u­la­tion, even if a doc­tor hasn’t or­dered that a nurse check on that pa­tient?” he said. “This is the next gen­er­a­tion of medicine, not one with less doc­tors, but one that is bet­ter in­formed be­cause some­thing is al­ways look­ing at the data sets.”


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