iHT² Health IT Summit in New York City 2012 - Case Study “The Hospital of the Future - Palomar Health”

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iHT² Health IT Summit in New York City 2012 - Case Study “The Hospital of the Future - Palomar Health”

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Heralded as the best example of 21st century healthcare design, San Diego county’s new Palomar Medical Center melds high technology and innovation within a healing environment of gardens, terraces,......

Heralded as the best example of 21st century healthcare design, San Diego county’s new Palomar Medical Center melds high technology and innovation within a healing environment of gardens, terraces, outdoor balconies and natural light. Palomar Health sought advice from the nation’s leading healthcare futurists to coalesce their ideas into a structure that has become the first in the nation to integrate the largest array of evidence-based features that will enhance healing and sustain functionality over time. Technology plays a critical role in the hospital of the future. Cisco communications and collaboration technology is used throughout connecting nurses, doctors, patients and their families together with tools like wireless IP phones, video and telepresence, integrated nurse call, and electronic tracking of medications and hospital assets.

Join this session, led by Palomar’s chief medical information officer Dr. Ben Kanter, to learn how Palomar and Cisco have partnered together to build the hospital of the future.

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  • This is the new Palomar medical center in north county San Diego. Built atop a plateau overlooking the cities of Escondido and San Marcos, the hospital is a publicly supported facility serving the north east quadrant of San Diego county. This new facility opened on August 19th – this is the story of the new facility and some of the novel technologies we’ve implemented to make it work.
  • Orientation to our facilities.Publicly elected BODTax payer supported
  • All private medical staff
  • New campus – new hospital – but not a like for like replacement.New paradigm for patient care as will be discussed.
  • The history: Once funded – expert advisory committee architects healthcare visionaries engineers communications more…
  • Fundamentally the hospital can be thought of not as a building but as an exceedingly complicated machine. The inputs are ill patients and the output are healing patients. Physicians and staff members distributed networked intelligences operating semi-autonomously within the structure. The structure therefore has an intimate relationship with the caregiver team. You want to provide a safe, comfortable place of healing. What data exists to guide the building of new healthcare facilities+ The first major innovative technology is the building itself. Evidence based design
  • We are all familiar with many of the QI goals – but the physical environment is often forgotten – not so when you have an opportunity to build a new structure.
  • I won’t go over this matrix in depth except to show that there are design strategies which have been used to improve the following healthcare outcomes…This matrix was used in the Center’s 2008 literature review to summarize the relationships between specific design factors and healthcare outcomes. The number of * in each cell shows the strength of evidence supporting the linkage. There is general acknowledgment that hospitals have become dangerous places because of the fact that approximately one in ten admitted patients will contract a healthcare associated infection (HAI). In addition to unacceptable patient mortality and morbidity outcomes and associated costs, the Centers for Medicare and Medicaid (CMS) and many states will now no longer reimburse hospitals for care costs associated with certain healthcare associated infections. Evidence-based design features such as single patient rooms with private toilets, alcohol-based hand-rub dispensers at the bedside, easy-to-clean floors, walls and furniture coverings that can readily and practically be maintained in a hygienic condition, and well-maintained water and ventilation systems are all supported by a fairly large amount of research. Additional research is needed to strengthen the evidence as well as demonstrating the business case to support these EBD investments. Ulrich, R.S., Zimring, C., Zhu, X., Dubose, J., Seo, J., Choi, Y., Quan, X., Joseph, A. (2008). A review of the research literature on evidence-based healthcare design. Health Environments Research and Design Journal, 1(3), 61-125.
  • The green blobs represent features specific to inpatient units – and this is what we’ve done in comparisonWhile not limited responses to evidence-based interventions, as a point of reference, the 2009 ASHE Survey results indicated the top five design features being incorporated into facilities to improve safety were: multiple locations for hand washing or hand sanitizing, added air treatment/ air movement capacity, decentralized nurse stations, use of noise-reducing construction materials, and multi-functional lighting systems. The top five features being incorporated into patient rooms included: wireless technologies for staff, individual room temperature control, in-room sink (separate from the bathroom), computerized provider order entry, and larger room size (200 SF or more). (Carpenter, 2009)
  • Supporting this design is a robust wireless infrastructure built on Cisco technology. We have a 10-gigabit backbone with 1 gig to each desktop – allowing us to move large data sets, images and the opportunity to do telepresence meetings everywhere.
  • Two towers:The East tower has 30 beds and west has 24. The west tower is built out to ICU standards. No traditional nursing stationsDistributed nursing with nurses working out by the patientsHealing gardens on every floor centrally and at the end of every unitHere’s where the design intersects with the caregiving team.
  • Healing gardens means increased mobiliityHow will we monitor patients on the moveHow do nurses communicate with patients? Nurses with physicians?Location of the patient on these very large units?Distribute nurses without unit secretariesHow does the care team communicate?Safety? We can’t monitor everyone and tele is a lagging indicator of deterioration.California mandatory nursing ratios – how do we support monitoring for mobile non-critically ill patients?Multiple new remote clinics – need for consultation and conferencingFinally – the BYOD environment
  • The nurses choice for the handheld device of choice.Once the staff had chosen to go with Rauland and Cisco we were set to figure out how to best enable communication/signals/alerts.Our goal wasn’t simply to place the nurse physically closer to each patient – but to also place them in closer communication. Change the path of communication for patient to RN, for MD to RN, for monitor to RN, for lab to MD, etc.
  • And after an RFP and looking at ~1/2 dozen potential middleware vendors we chose Extension – the agnostic router for signals.Some of the major decision points and the initial scope:Ability to manage and utilize all of the functionality offered by the cisco handsetNurses: only log in once at the beginning of the shift. Either through the middleware system or by using RB functionalityFlexibilityMessaging to physiciansProven ability to work with RB, PhillipsRoute phillips alarms, vent alarms, teletracking, Rauland- Borg, Cerner - routing stat orders
  • Phillips alarms going to BOTH our central monitoring room as well as to the RN.Different sounds and functions depending upon criticality Code blues called regionally within the facility and routed to the phones and pagers
  • An important, relatively new term used to measure quality of hospital careWhat happens to those patients during the critical 6-12 hours prior to arrest?What technologies are available that might impact box #4?
  • Straight forward
  • Improve safetyReduce costsImrove efficiency of staffImprove patient eperience
  • So here’s the future standard of care for patients on traditional med/surg wards:Everyone is monitoredInformation flows seemlessly into the medical record making the need to awaken the patient for VS mootData is analyzed real-time using algorithms to trigger additional attention or RRT when requiredThe patient can speak with the RN whether in the room or anywhere via the use of VoIP functionalityRTLS
  • Script:Cerner and Sotera Wireless’ collaboration will automate workflows and improve processes for charting vitals on patients remotely.  Each ViSi Mobile device will be connected to the CareAwareiBus to enable this functionality.  This will then enable the ability to chart vital signs in PowerChart regardless of the patients location.  The workflow we will be showing you follows the current BMDI workflow, however, ViSi Mobile will be used in units outside the critical care setting, thus enabling BMDI across your organization.   Upon attaching the Sotera ViSi Mobile device to the patient, the nurse will barcode scan the patient's wristband and the device to associate the device to the patient.  To chart the patient's vitals, the nurse will open the patient's chart and begin by reviewing the inpatient summary, which displays the past vitals and other important patient information.  The nurse will then go to the flowsheet, double-click the time column to chart the patient's vitals.  The vitals will then be pulled in based on data sent from the ViSi Mobile device through the CareAwareiBus.  The vitals initially come in as unverified (displayed as purple), upon reviewing the vitals, the nurse then verifies the vitals by clicking the green check to verify.  The vitals are then charted and complete. The instructions are:Open the demoThe Sotera demo will run when you click on the image of the device. On the keyboard, hold down control key and press enter key to start the animation. It will start after about a 2 second delay.After animation runs, you can click on the monitor (black portion) image to advance the screens. The first is the inpatient summary, the second is the flowsheet where you see the details, the next is the validation of the 2pm vitals.
  • Support virtual family visits via the Vgo mobile platform
  • Multiple campuses, multiple sites, frequent use of webex
  • With the outlying clinics under construction, the ability to telepresenceconsuts is likely to be important

Transcript

  • 1. Benjamin Kanter MD FCCP CMIO, Palomar HealthPartner, Escondido Pulmonary Medical Group
  • 2. Disclaimers:Co-developer – MIAA mHealth PlatformConsultant – AirStrip TechnologiesChief Medical Officer – ConversePoint, Inc.
  • 3. Special thank you:Michael Haymaker, Director of HealthcareIndustry Marketing for the Americas, CiscoDebra LevinPresident and CEO, Center for Health Design(www.healthdesign.org)
  • 4. Palomar Pomerado Health• 3 Hospitals• 2 Skilled Nursing Facilities• 5 Outpatient Health Centers• Ambulatory Surgery Center• 4 “ExpressCare” Retail Facilities
  • 5. 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)
  • 6. 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 Opened August 19th 2012 • Emergency Dept. 56 • Imaging Rooms 18 – Women’s Outpatient Center
  • 7. 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
  • 8. 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.
  • 9. Goals for Quality Improvement» IOM goals : » Quality Improvement  Increase safety Foci  Efficiency  People  Effectiveness  Process  Person-centered care  Technology  Quality of care  Physical  Timeliness Environment!!» IHI quality improvement efforts: A Better Building facilitates the  100K & 5M lives physical, mental, and social campaigns well-being and productive  Innovation communities behavior of its occupants.
  • 10. Credibility of Evidence » Improve Safety » Improve other dimensions of qualityEBD Research shows a well designed environment Improve overall healthcare quality and reduce costcan improve safety and quality of care Reduce nosocomial infection (airborne) Reduce length of patient stay (contact) Reduce drugs (see patient safety) Reduce medication errors Patient room transfers: number and costs Reduce patient falls Re-hospitalization or readmission ratesImprove quality of communication (patient  staff) Staff work effectiveness; patient care time per shift (staff  staff) Patient satisfaction with quality of care (staff  patient) Patient satisfaction with staff quality (patient  family) Increase hand washing compliance by staff Improve confidentiality of patient information
  • 11. Credibility of Evidence » Reduce Patient Stress » Reduce Staff Stress/ FatigueEBD research shows that the physical environments helps The physical environment impacts staff outcomesto reduce patient stress Reduce noise stress Reduce noise stress Reduce spatial disorientation Improve medication processing and delivery times Improve sleep Improve workplace, job satisfaction Increase social support Reduce turnover Reduce depression Reduce fatigue Improve circadian rhythms Work effectiveness; patient care time per shift Reduce pain (intake of pain drugs, and reported pain) Improve satisfaction Reduce helplessness and empower patients & families Provide positive distraction Patient stress (emotional duress, anxiety, depression)
  • 12. Ulrich, Zimring, et. al; “A Review of the Research Literature onEvidence Based Design”, HERD Journal, Spring 2008
  • 13. % of Responses
  • 14. 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)
  • 15. Distributed Nursing Model
  • 16. Operational Challenges Gardens/Mobility  Monitoring  Communication  Location Distributed nursing  Communication IHI 2x2 findings  Nursing ratios BYOD environment Multiple new remote clinics  Telepresence
  • 17. Technology-EnabledRauland-Borg Responder 5 Nurse Call System Patient Station Duty Station Corridor LightStaff Terminal Nurse Station PC Console Console
  • 18. Cisco 7925 VoIP Phone
  • 19. What’s inside Extension? (OpenTheRedBox.com) Communication interface Small database interfaced to Cerner/Rauland Rules engine  What goes where? When?  Escalation rules  Filters (if – then)
  • 20. 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.
  • 21. Physiological Monitoring
  • 22. IHI Mortality 2x2 Matrix ICU Admission ? Yes No Yes Box #1 Box #2ComfortCareOnly? No Box #3 Box #4
  • 23. Mortality Diagnostic: Aggregate Results for 64 US Hospitals No ICU ICU Admission AdmissionComfort Care 175/5535 773/5535 3% 14% (0-44%) (0- 65%)Non Comfort Care 1936/5535 2661/5535 35% 48% (7-72%) (7-76%)
  • 24. “Failure to Rescue” Failure to prevent a clinically important deterioration from a complication of an underlying illness or a complication of medical care
  • 25. Emerging RequirementsPPH Vision / Industry Trends Technological RequirementsContinuous patient monitoring across the Small form factor for extreme portability, Un-continuum of care: Ambulance , ER, tethered / wireless devices, body areaAdmitting Process, Transport within/to networks.Facility, SNF, Clinic, Home, Anywhere.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 Monitor patient vitals and other parameters,readmission rates. post discharge to enable the early detection of condition deterioration.Bed exit, Patient fall detection. Monitor patient movement, change in position.
  • 26. ViSi Mobile™ – Patient-Worn Monitor • 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) * Not yet FDA cleared
  • 27. ViSi Mobile – by Sotera 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
  • 28. 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
  • 29. Tomorrow’s standard of care on the general floor Patient Safety (Automatic entry to EMR)
  • 30. ViSi Mobile™ and Cerner – System Architecture CernerSotera Wireless PowerChart ViSi Mobile Monitor PowerChart® Integration (Launching at CHC) iBus PowerChart AlertLinkTM Integration (Launching late Q42012)
  • 31. BYOD EnvironmentCisco ISE : Identity Services EngineGuest NetworkSporadic tablet/Citrix useIndependent development
  • 32. MIAA is a uniquely powerful user interface and user experience which maximizesclinical efficacy and efficiency for mobile clinicians
  • 33. MIAA does not replace a host EHR. MIAA adds capabilitiesto a legacy EHR, extending the functionality and reach to enable the mobile clinician
  • 34. Who is the user? Why is the user doing what theyre doing? What questions are they trying to answer? What actions are they likely to take? Provide information in a manner which improves comprehension Integrate 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)
  • 35. …real time access to…Physiological Status Electronic Health Information
  • 36. Complete the process
  • 37. Thank you!Ben Kanter MD FCCPBen.Kanter@pph.org