Benjamin Kanter MD FCCPCMIO, Palomar Health
Partner, Escondido Pulmonary Medical Group
Disclaimers:Co-developer – MIAA mHealth PlatformConsultant – AirStrip TechnologiesChief Medical Officer – ConversePoint, Inc.
Special thank you:Michael Haymaker, Director of Healthcare Industry Marketing for the Americas, Cisco
Debra LevinPresident and CEO, Center for Health Design (www.healthdesign.org)
Palomar Pomerado Health• 3 Hospitals • 2 Skilled Nursing Facilities• 5 Outpatient Health Centers• Ambulatory Surgery Center• 4 “ExpressCare” Retail Facilities
PPH by the Numbers
• 3600 Employees• 750 Physicians (all private
practice)• 560 Volunteers• 28,000 Discharges• 19,000 Surgeries• 90,000 Emergency Visits• 850 Square Mile Health District• 2,200 Square Mile Trauma District• The Largest Public Health District
in California by area• Primary service area of >500,000
individuals and growing• A Magnet System (hospitals and
SNFs)
Palomar Medical Center Escondido Research and Technology Center
• 1,200,000 sq. ft. hospital complex includes:– Inpatient (Distributed Nursing Model)
• Acuity Assignable Rooms 168• Medical/Surgical 192
– Women’s Center Beds (phase 2)• Labor & Delivery 20• Postpartum/GYN 44• NICU 16• Pediatric 16 Total Beds 456
– Diagnostic & Treatment• Interventional Platforms 6• Surgery 12• Emergency Dept. 56• Imaging Rooms 18
– Women’s Outpatient Center
Opened August 19th 2012
Prop BB
Passed November 2nd, 2004 w 70% majority
496M toward constructing the new campus
Seismic retrofit requirements A general obligation bond
measure requiring a 2/3 majority for passage
Hospital, Emergency Care, Trauma Center Improvement
Evidenced Based Design “…the process of basing decisions about
the built environment on credible research to achieve the best possible outcomes”
Sadler BL, Berry LL, et al. Fable Hospital 2.0: The Business Case for Building Better Health Care Facilities. Hastings Center Report 2011;13-23.
Goals for Quality Improvement» IOM goals :
Increase safety Efficiency Effectiveness Person-centered care Quality of care Timeliness
» IHI quality improvement efforts: 100K & 5M lives
campaigns Innovation
communities
» Quality Improvement Foci People Process Technology Physical
Environment!!
A Better Building facilitates the physical, mental, and social well-being and productive behavior of its occupants.
Credibility of Evidence
» Improve Safety » Improve other dimensions of qualityEBD Research shows a well designed environment
can improve safety and quality of care
Reduce nosocomial infection (airborne)
(contact)
Reduce medication errors Reduce patient falls
Improve quality of communication (patient staff)
(staff staff)
(staff patient)
(patient family)
Increase hand washing compliance by staff Improve confidentiality of patient information
Improve overall healthcare quality and reduce cost
Reduce length of patient stayReduce drugs (see patient safety)
Patient room transfers: number and costsRe-hospitalization or readmission rates
Staff work effectiveness; patient care time per shiftPatient satisfaction with quality of care
Patient satisfaction with staff quality
Credibility of Evidence
» Reduce Patient Stress
» Reduce Staff Stress/ Fatigue
EBD research shows that the physical environments helps to reduce patient stress
Reduce noise stressReduce spatial disorientation
Improve sleep Increase social support
Reduce depressionImprove circadian rhythms
Reduce pain (intake of pain drugs, and reported pain) Reduce helplessness and empower patients & families
Provide positive distractionPatient stress (emotional duress, anxiety, depression)
The physical environment impacts staff outcomes
Reduce noise stress Improve medication processing and delivery times
Improve workplace, job satisfaction Reduce turnover
Reduce fatigue Work effectiveness; patient care time per shift
Improve satisfaction
Ulrich, Zimring, et. al; “A Review of the Research Literature on Evidence Based Design”, HERD Journal, Spring 2008
% o
f Res
pons
es
Flexibility
Develop facility infrastructure that can readily accommodate long-term changes in medical practice, equipment and technology
Develop a patient room and nursing unit
design that can flex between various acuity levels
Deploy a modular approach to planning
where appropriate (similar sized rooms that can change over time)
Distributed Nursing Model
Operational Challenges
Gardens/Mobility Monitoring Communication Location
Distributed nursing Communication
IHI 2x2 findings Nursing ratios
BYOD environment Multiple new remote clinics
Telepresence
Technology-Enabled Rauland-Borg Responder 5
Nurse Call System
Patient StationCorridor Light
Nurse Station Console
Duty Station
PC ConsoleStaff Terminal
Cisco 7925 VoIP Phone
What’s inside Extension?
Communication interface Small database interfaced to
Cerner/Rauland Rules engine
What goes where? When? Escalation rules Filters (if – then)
(OpenTheRedBox.com)
Alert Routing
Can be routed based on role as well as location All based on patient assignment and location room/bed.
Can be routed to multiple people/groups at the same time.
Three layers of escalation so that no alert goes unmanaged
Reporting tools to review assignments and the amount of alert traffic.
Extensive ability to manipulate the Cisco handset
Handset alarm control: can have different ring tones If multiple Alerts come in at the same time the system will
prioritize based on our defined settings.
Physiological Monitoring
IHI Mortality 2x2 Matrix
ICU Admission ?Yes No
ComfortCareOnly?
Yes
No
Box #1 Box #2
Box #3 Box #4
Mortality Diagnostic: Aggregate Results for 64 US Hospitals
ICU Admission
No ICU Admission
Comfort Care 175/5535 3%
(0-44%)
773/5535 14%
(0- 65%)
Non Comfort Care 1936/5535 35%
(7-72%)
2661/5535 48%
(7-76%)
“Failure to Rescue”
Failure to prevent a clinically important deterioration from a complication of an underlying illness or a complication of medical care
PPH Vision / Industry Trends Technological Requirements
Continuous patient monitoring across the continuum of care: Ambulance , ER, Admitting Process, Transport within/to Facility, SNF, Clinic, Home, Anywhere.
Small form factor for extreme portability, Un-tethered / wireless devices, body area networks.
Distributed nursing model. Real time alerts sent to the right care-giver, at the right time.
Healing gardens and mobile patients. Sensors in the environment monitor movement. Automated tracking of patients, staff, and equipment.
Proactive measures to reduce hospital readmission rates.
Monitor patient vitals and other parameters, post discharge to enable the early detection of condition deterioration.
Bed exit, Patient fall detection. Monitor patient movement, change in position.
Emerging Requirements
• Continuous vital signs +– SpO2
– HR/PR– ECG (3/5 lead)– Respiration– Temp (skin)– NIBP – Continuous non-invasive blood
pressure (cNIBP)*
• Motion/Posture*
• Wireless communication (VoIP)
ViSi Mobile™ – Patient-Worn Monitor
* Not yet FDA cleared
Anticipated Outcomes
• Improved patient safety by detecting signs of patient deterioration or adverse events
• Reduced related costs by detecting / avoiding adverse events (e.g. cardiac arrest, falls, pressure ulcers)
• Improved staff efficiencies by reducing the need for repeat manual vital sign spot-checks, manual documentation
• Automated charting to Electronic Medical Record
• Improved patient engagement
ViSi Mobile – by Sotera
Sotera Solution
Allows mobility Can measure all of the key
physiologic determinants Integrates with our nurse call
system Can do all of this with or without
telemetry Can route all of these alerts to
the patient’s nurse as well as to central monitoring areas
Tomorrow’s standard of care on the general floor
(Automatic entry to EMR)
Patient Safety
ViSi Mobile™ and Cerner – System Architecture
ViSi MobileMonitor
iBus
PowerChart
PowerChart
AlertLinkTM Integration(Launching late Q42012)
Sotera Wireless
Cerner
PowerChart® Integration (Launching at CHC)
BYOD Environment
Cisco ISE : Identity Services EngineGuest NetworkSporadic tablet/Citrix useIndependent development
MIAA is a uniquely powerful user interface and user
experience which maximizes clinical efficacy and efficiency
for mobile clinicians
MIAA does not replace a host EHR. MIAA adds capabilities to a legacy
EHR, extending the functionality and reach to enable the mobile clinician
Scenario based interaction Who is the user? Why is the user doing what they're doing? What questions are they trying to answer? What actions are they likely to take? Provide information in a manner which improves comprehensionIntegrate actions without losing contextNIST Guide to the Processes Approach for Improving the Usability of
Electronic Health Records (Schumacher and Lowry, National Institute of Standards and Technology 2010. NISTIR 7741)
…real time access to…
Physiological Status Electronic Health Information
Complete the process
Thank you!Ben Kanter MD [email protected]
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