00
Better Health, Better Care, Lower Cost :
How telehealth and real-time analytics can help critical care
achieve this tri...
11
Why monitor? :“Situation Awareness”
22
Mica Endsley’s Original Conception
Human Factors 37: 32-64 (1995)
33
SA involves more than “more data”
44
SA “on the road”
55
• Present all information in readily interpretable form, much as a
GPS receiver takes data from satellites and creates ...
66
Situation Awareness: Why does this “feel right”?
1. The perception of the data
2. The comprehension of its meaning
3. T...
77
This is NOT SA…
88
Because excess, uncorrelated data constitute
distractions…
99
ICUs, Present Day
Loss of situational awareness
is easy and common
1010
Staff cannot absorb more data. Really.
In today’s ICU,
there is too much opportunity for error
Do distractions matter in critical care?
An experimental study
Task: Alarm and vent checks Distraction:”I’m ready for hand...
1212
The Four V’s of Data
Challenge National Security Medicine Need
Volume
“We are... swimming in
sensors... and drowning
...
1313
“In the moment”—what is the current physiologic status of
my patient?
“Flowing data”—What is the trajectory of my pat...
1414
Challenge Medicine Need
Patterned Biology, and especially
pathobiology , is not random.
The state space is “lumpy”.
T...
1977
(single dimension)
1977
(multidimension)
1717
Does this matter?
Yes, it does. An example…
Duration of hypotension before initiation of effective
antimicrobial therapy = critical determin...
1986
1986 1969
2
Simulation Evaluation of an Enhanced Bedside
Monitor Display for Patients With Sepsis.
Giuliano, Karen; RN, PhD; Johanne...
Simulation Evaluation of an Enhanced Bedside
Monitor Display for Patients With Sepsis.
Giuliano, Karen; RN, PhD; Johanness...
2424
Does this matter?
One of our ICUs, 3 years ago
2626
“Patterned, Personalized, Predictive”
2727
●Physiologic time series
– Heart (EKG)
– Vasculature (Blood Pressure)
– Lungs (CO2)
– Brain (EEG)
– …
Detecting patte...
Goldberger AL, et al. Proc. Nat. Acad. Sci. USA (2002) 99 Supp1:2466
Which is the healthy pattern?
Heart Failure
Goldberger AL, et al. Proc. Nat. Acad. Sci. USA (2002) 99 Supp1:2466
Which is the healthy pattern?
Heart Failure Heart Failure
Goldberger AL, et al. Proc. Nat. Acad. Sci. USA (2002) 99 Supp1:2466
Which is the healthy patt...
Heart Failure Heart Failure
Atrial Fibrillation
Goldberger AL, et al. Proc. Nat. Acad. Sci. USA (2002) 99 Supp1:2466
Which...
Heart Failure Heart Failure
Normal Atrial Fibrillation
Goldberger AL, et al. Proc. Nat. Acad. Sci. USA (2002) 99 Supp1:246...
3333
● Nonstationarity
– Statistics change with time
● Nonlinearity
– Components interact in unexpected ways ( “cross-talk...
3434
What “not health” looks like
Goldberger, Peng,
Costa. Nature 1999;
399:461;
Phys Rev Lett 2002; 89 :
068102
Healthy d...
3535
“Not health” : infection (sepsis)
• Two similarly septic
patients
• First 24 hr of data
shown
• During the second 24
...
22% reduction in mortality!
If data-driven prediction was a drug in this setting, that 22% reduction in mortality
would ma...
3737
Reengineering Critical Care
Patients and
Conditions
Population Specification Populations
Care Path Development Fully ...
• Recognize physiologic decompensation as it occurs
• Classify decompensation by actionable mechanism
• Mitigate decompens...
• Harvest data in motion
• Real-time analytics
• Intuitive display
• Reliable interventions
Situation Awareness,
Response
Center for Critical Care
Data in Motion and
Real-Time ICU Analytics
Testing Novel Analytics
Synchrography
πRadians
•Situation Awareness:
Current State
Philips eICU
ECCC
Coarse data
Fine data
Quasi-real-time display and analysis of physiologic
data: architecture that we are currently using
Center for Critical Care
Architecture Example
Filter ECG data
RR Beat Detector
SampEn COSEn LDS
Database
BedMasterEx
Filte...
Center for Critical Care
ECG with beat detection
Analytics, etc.
MIT-BIH: 12 beats q30 min for 24 hours
400 600 800 1000 1200
0
100
200
300
AF
NSR
CHF III and IV
CHF I and...
Center for Critical Care
Coefficient of sample entropy (COSEn)
• An entropy metric
optimized to detect
atrial fibrillation...
Center for Critical Care
Real-time COSEn/AF Example
5151
Making the tools work: the eICU platform
Better
Health
(outcomes that matter to
patients and families)
Better
Care
(High-reliability and
evidence based)
Lower
Cost...
5353
●A lot of technology, rivers of data, lots of
expense → opportunities to create and deliver
value
●„In the moment des...
5454
Questions?
Gpt buchman
Gpt buchman
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  • The BodySystem View creates a focus on patient centered care that is informed by real insight into the situation of each patient. Physician review/documentation and multi-disciplinary workflows are enhanced through standard views of each body system that result in simpler interpretation, decision-making and ordering. 
  • Part of the solution is technology. No one would use this raw data safely. Yet each of us uses the processed data to best advantage. It creates situational awareness, so we understand the data and can project the data into the future.
  • Gpt buchman

    1. 1. 00 Better Health, Better Care, Lower Cost : How telehealth and real-time analytics can help critical care achieve this triple aim. Emory Critical Care Center Tim Buchman 22 March 2014 Disclosures: None Relevant to the Presentation
    2. 2. 11 Why monitor? :“Situation Awareness”
    3. 3. 22 Mica Endsley’s Original Conception Human Factors 37: 32-64 (1995)
    4. 4. 33 SA involves more than “more data”
    5. 5. 44 SA “on the road”
    6. 6. 55 • Present all information in readily interpretable form, much as a GPS receiver takes data from satellites and creates situational awareness to provide a map back to health Desiderata
    7. 7. 66 Situation Awareness: Why does this “feel right”? 1. The perception of the data 2. The comprehension of its meaning 3. The projection of that understanding into the future in order to anticipate what might happen
    8. 8. 77 This is NOT SA…
    9. 9. 88 Because excess, uncorrelated data constitute distractions…
    10. 10. 99 ICUs, Present Day Loss of situational awareness is easy and common
    11. 11. 1010 Staff cannot absorb more data. Really. In today’s ICU, there is too much opportunity for error
    12. 12. Do distractions matter in critical care? An experimental study Task: Alarm and vent checks Distraction:”I’m ready for handover!” Miss rate, 25%
    13. 13. 1212 The Four V’s of Data Challenge National Security Medicine Need Volume “We are... swimming in sensors... and drowning in data" • Medical literature doubling every 19 years • Torrent of patient data •Management of large data •Transform data to information Velocity Decision timelines range from days to seconds Decision timelines range from days to seconds Rapid extraction and presentation Variety Range of data types: imagery, video, signals, seismic data, field reports, informants, news reports Physiology, lab tests, physician notes, interventions, patient history • Data association • Information representation • Data provenance Veracity Military operations, targeting, collateral damage, rules of engagement Diagnosis & treatment of patients, life & death decisions, side effects, complications, malpractice concerns High-confidence decisions: Costs of mistakes are high
    14. 14. 1313 “In the moment”—what is the current physiologic status of my patient? “Flowing data”—What is the trajectory of my patient? Data (4Vs)-> Monitoring-> Situation Awareness
    15. 15. 1414 Challenge Medicine Need Patterned Biology, and especially pathobiology , is not random. The state space is “lumpy”. Treatments are aimed at lumps. Not all patterns are evident to clinicians. Management of large data requires meaningful pattern detection. Personalized There are three time scales that influence personalization: •Inherited aspects (“forever”); •chronic aspects (acquired, “allostasis”); •acute aspects (immediate threats, “homeostasis”) Data often convolve all three time scales. Knowing the patient‟s set-points and dynamics around the set points matters. Predictive Prediction horizons related to the time scales, e.g. •Lifetime risk for cancer •Obesity risk related to environmental stress •Arrhythmia risk due to electrolyte disturbance All three horizons require not only situation awareness but also a mechanism of alerting when the risks change. By extension, risk-management implies ongoing “what-if” scenarios. The 3 P’s that Matter to Health Care
    16. 16. 1977 (single dimension)
    17. 17. 1977 (multidimension)
    18. 18. 1717 Does this matter?
    19. 19. Yes, it does. An example… Duration of hypotension before initiation of effective antimicrobial therapy = critical determinant of survival, so knowing a single parameter contributing to the state affects decision-making Kumar A, et al. Crit Care Med 2006;34:1589 State= “sepsis”
    20. 20. 1986
    21. 21. 1986 1969
    22. 22. 2 Simulation Evaluation of an Enhanced Bedside Monitor Display for Patients With Sepsis. Giuliano, Karen; RN, PhD; Johannessen, Ann; RN, MSN; Hernandez, Cheri; RN, MSN; EdD, CCRN AACN Advanced Critical Care. 21(1):24- 33, January/March 2010. DOI: 10.1097/NCI.0b013e3181bc8683
    23. 23. Simulation Evaluation of an Enhanced Bedside Monitor Display for Patients With Sepsis. Giuliano, Karen; RN, PhD; Johannessen, Ann; RN, MSN; Hernandez, Cheri; RN, MSN; EdD, CCRN AACN Advanced Critical Care. 21(1):24-33, January/March 2010. DOI: 10.1097/NCI.0b013e3181bc8683
    24. 24. 2424 Does this matter?
    25. 25. One of our ICUs, 3 years ago
    26. 26. 2626 “Patterned, Personalized, Predictive”
    27. 27. 2727 ●Physiologic time series – Heart (EKG) – Vasculature (Blood Pressure) – Lungs (CO2) – Brain (EEG) – … Detecting patterns at the bedside Beat-to-beat heart rate heart n t heart n t 1 time, sec ECG II, mV
    28. 28. Goldberger AL, et al. Proc. Nat. Acad. Sci. USA (2002) 99 Supp1:2466 Which is the healthy pattern?
    29. 29. Heart Failure Goldberger AL, et al. Proc. Nat. Acad. Sci. USA (2002) 99 Supp1:2466 Which is the healthy pattern?
    30. 30. Heart Failure Heart Failure Goldberger AL, et al. Proc. Nat. Acad. Sci. USA (2002) 99 Supp1:2466 Which is the healthy pattern?
    31. 31. Heart Failure Heart Failure Atrial Fibrillation Goldberger AL, et al. Proc. Nat. Acad. Sci. USA (2002) 99 Supp1:2466 Which is the healthy pattern?
    32. 32. Heart Failure Heart Failure Normal Atrial Fibrillation Goldberger AL, et al. Proc. Nat. Acad. Sci. USA (2002) 99 Supp1:2466 Which is the healthy pattern?
    33. 33. 3333 ● Nonstationarity – Statistics change with time ● Nonlinearity – Components interact in unexpected ways ( “cross-talk” ) ● Multiscale Organization – Fluctuations/structures typically have fractal organization Patterns of health->Inferences about “not” health Healthy Dynamics
    34. 34. 3434 What “not health” looks like Goldberger, Peng, Costa. Nature 1999; 399:461; Phys Rev Lett 2002; 89 : 068102 Healthy dynamics are poised between too much order and total randomness The breakdown “data patterns” are similar in various organ systems
    35. 35. 3535 “Not health” : infection (sepsis) • Two similarly septic patients • First 24 hr of data shown • During the second 24 hr, the patient on the right developed multiple organ failure and died on day 12. Pontet J, et al, J. Critical Care (2003) 18:156
    36. 36. 22% reduction in mortality! If data-driven prediction was a drug in this setting, that 22% reduction in mortality would make it a BLOCKBUSTER
    37. 37. 3737 Reengineering Critical Care Patients and Conditions Population Specification Populations Care Path Development Fully Specified Care Processes and Protocols Current Care Workflow Modification Delegation, Algorithms Situation Awareness, Response Caregiver and Patient Activation Low Efficiency and Reliability High
    38. 38. • Recognize physiologic decompensation as it occurs • Classify decompensation by actionable mechanism • Mitigate decompensation by reversal of cause and supportive treatment Situation Awareness, Response
    39. 39. • Harvest data in motion • Real-time analytics • Intuitive display • Reliable interventions Situation Awareness, Response
    40. 40. Center for Critical Care Data in Motion and Real-Time ICU Analytics
    41. 41. Testing Novel Analytics
    42. 42. Synchrography πRadians
    43. 43. •Situation Awareness: Current State Philips eICU ECCC Coarse data Fine data
    44. 44. Quasi-real-time display and analysis of physiologic data: architecture that we are currently using
    45. 45. Center for Critical Care Architecture Example Filter ECG data RR Beat Detector SampEn COSEn LDS Database BedMasterEx Filter ICU Beds
    46. 46. Center for Critical Care ECG with beat detection
    47. 47. Analytics, etc. MIT-BIH: 12 beats q30 min for 24 hours 400 600 800 1000 1200 0 100 200 300 AF NSR CHF III and IV CHF I and II meanofthestandarddeviation mean RR interval
    48. 48. Center for Critical Care Coefficient of sample entropy (COSEn) • An entropy metric optimized to detect atrial fibrillation in very short records. • It has ROC area 0.98 for detecting AF in 12-beat records. 0 20 40 60 80 100 -4 -3 -2 -1 0 AF male AF female NSR male NSR female COSEn Age (years) Lake and Moorman, Am J Physiol, 2011 Demazumder et al, Circulation 2013
    49. 49. Center for Critical Care Real-time COSEn/AF Example
    50. 50. 5151 Making the tools work: the eICU platform
    51. 51. Better Health (outcomes that matter to patients and families) Better Care (High-reliability and evidence based) Lower Costs (Optimal configuration of people and materials) Right Care, Right Now, Every Time Execution Layer Strategy Workforce Operations Plan Ensuring that every test, drug, and procedure add value to care Event driven Intervention 1. Multiple event initiation triggers: such as requests from site (eLert button); admission/transfer event; detection of deterioration or collapse; advisory from another eICU staffer 1. Consistent (normative) behaviors 2. Verification that outcomes are achieved Processes Matter 1. Bundles are “DO-LISTS” 2. Standard list-driven responses to common care challenges in critical care 3. Responses are also “DO-LISTS” 4. eRN and eMD are PARTNERS in verifying adherence to standard bundles: DO-LISTS completed 5. eRN and eMD are PARTNERS supporting standard responses to common situations. DO-LISTS completed 6. eICU collaborates with ICU staff to verify desired results are driven by standard bundles and interventions 7. Scheduled e-rounding for initiation and adherence to “bundles” 8. Two-person e Staff confirmation of DO-LISTS completion 9. Remote support by eICU for bundle/response order sets. Value derives from what we do, making a difference 1. Debridement of drug lists 2. Elimination of unnecessary standing orders 3. Conversion to less expensive choice or route 4. Avoidance of complications (drug interactions) ECCC-eICU Driver Diagram Key Drivers Interventions
    52. 52. 5353 ●A lot of technology, rivers of data, lots of expense → opportunities to create and deliver value ●„In the moment descriptions‟ of „where the patient is‟ would be very helpful (“situation awareness”) ●Predictive analytics to drive towards treatment goals would be very helpful ●Predictive analytics that fail (patients off the predicted trajectory) even more important Takehomes
    53. 53. 5454 Questions?
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