The Journey from Blackberry to iPhone Steve Miller, CTO Coordinated Care of Oklahoma

1. The Journey from Blackberry to iPhone Steve Miller, CTO Coordinated Care of Oklahoma

2. Presentation Overview • Healthcare Realities • Background (Solution History) • Lessons Learned • iPhone Pilot Results • Device Sourcing Options • Summary

3. Healthcare Realities A Few People Cost a Lot A relatively small number of patients – often older or chronically ill people – account for a large portion of all medical costs. These include frequent hospital readmissions and managing the consequences of obesity and uncontrolled diabetes. One in five Medicare patients discharged from the hospital will return within a month; half won’t have seen a doctor before their return. More than 50% of all discharged Medicare patients will be back within a year. SOURCE HENRY J. KAISER FAMILY FOUNDATION

4. Healthcare Reform Timeline Jan 1, 2016 All other HIPAA Transactions Jan 1, 2016 All other HIPAA Transactions Oct. 1, 2012 Unique Health Plan Identifier Jan 1, 2014 EFT and Payment/Remittance Dec 31, 2010 5010 Internal Testing Complete Dec 31, 2011 5010 External Testing Complete Feb 18, 2010 Breach Notification Rules Compliance Oct. 1, 2010 1st Qualification Date for MU Stage 1 ?? Oct. 14, 2014 / 15? ICD-10 Compliance Jan 1, 2012 5010 Compliance Jan 1, 2013 Claims Status & Eligibility Jan 1, 2016 Claims Attachments June 1, 2010 Red Flag Rule Compliance Jan 1, 2011 Accounting of Disclosures if EHR after 1/1/11 July 3, 2011 Last day to start 90 qualification for FY 2011 Jan 1, 2014 Accounting of Disclosures if EHR before 1/1//09 Oct. 1, 2012 1st Qualification Date for MU Stage 2 When Industries become digital Major Things Happen! Oct. 1, 2014 Qualification Date for MU Stage 3 Disruptive Innovation will occur!

5. Healthcare Reform Realities • Race to the Bottom (Payment Reform) – Those who can achieve high patient satisfaction and high clinical quality at the lowest cost will survive. • Radical Focus on Performance Management & Quality • Clinical / Business Discovery tools will dominate • Tableau, Qlikview, etc Enable Discovery from multiple data sets without complex normalization • Ubiquitous Access & Medical Device Integration Become Paramount to = High Quality w/Lower Cost • Improving Safety, Quality & Efficiency, Wireless a necessary component!

6. Interoperability The ability to integrate devices &systems such that they truly act as one. Literally to operate one from inside another. Graphic Courtesy of

7. Background / History

8. Background / History Requirements (2007) • Desire to Eliminate Central Monitoring Room • Need for Information at the Nurses Fingertips • Alerts based on specific requirements • Visual Indicator, Room and Wave Form (more than just a pager) • Automated Escalation Capabilities • Speed and Reliability • An Engine that would enable the connecting of people and devices.

9. Architectural Concepts Clinical / Business Needs Applications / Solutions Governance Security Infrastructure Usability and Adaptability

10. Solution • Connexall integrated with Draeger/RIM Monitoring Solution • Wifi only devices • (RIM Initially / Cincinnati Bell, Latest) • Policies on Device • Extensive WI/FI network • AM Shift Set / PM Shift Set • Allows one set to be charging at all times • Provides spares in case of failure • Alerts for all Critical Alarms & SPO2 Alarms • Escalation to House Resource / Charge Nurse

11. Lessons Learned from BB • Most issues were either ; • Education Issues (Alarm type/Escalation Rules) • Wi/Fi Turned Off • Failed Units (Zombie) • Drove Need to verify units in working order before each shift starts • Acknowledgment sent to all shift units at 7:00 a.m./7 p.m. (House Resource for each unit verifies all devices operational prior to placing them in Service). • Report Generated from Logs Daily • Reviewed daily w/ follow-up

12. Acknowledgements

13. Status report (a.m./p.m.) • Report Generated at 7 a.m. and 7 p.m. • Initially the report showed the entire week and every devices status

14. Status report (a.m./p.m.) • Later Redesigned / Revised Report to only show “Exceptions”

15. Fast Forward In-Place for 8+ Years • Near Real-time Alerts Delivered to Nurses carrying Blackberry SmartPhonesusing; • Connexall App integrated w/ Drager Patient Monitoring • Wifionly devices • (RIM/Blackberry 2007-2013) • Eliminated Need for Monitoring room! - $$$ • Fingertip Access w/ Alerts Configured to our requirements • Automated Escalation, Speed and Reliability • Allows Nurses More time with Patients • Decreased Noise and Alarm Atrophy Connexall Solution Drives Simplicity… Order out of Complexity

16. Journey to the iPhone

17. Drivers • Aging Condition of Blackberry’s • Issues / difficulty of procurement of Wi-Fi only version • Desire to Expand uses of Nurse Carried Device • Need / desire to continue to use a Wi-Fi only device • Usability!

18. What is Usability Engineering? A usable product… • Is easy to learn • Is hard to forget Columbia Obstruction Device User Doing a Job • Goals are to: • Maximize the reward • Minimize the pain Hungry rodent Shock Cheese size Cheese Electric grid Work Completed Pain of using the tools Intersection of Technology & Psychology • User-centered approach • Empirical wherever possible • Performance not Preference Go No go *Courtesy Human Factors International

19. Pilot • 2013 – Evaluation / Pilot (Blackberry Replacement) • Existing Cisco 8945 Wi-Fi Phone vs. IOS • (iTouch, iPhone, Ipad mini) • Nurse Managers felt need to separate phone from alerting device (may reconsider in future) – (Read and Talk) • Usability was best on Apple Devices • Nurses liked the ability to see previous messages on the iphone • Eliminated iTouch/iPad due to; • Voice capability. • Future Uses of TouchID (5s)

20. Solution • iPhone Selected • Best Usability and Platform for Future

21. Procurement Options • 5 Year Cost Analysis (U.S. Dollars) • ** Note OPEX Option Includes Overnight Exchange,Config, & 1 Upgrade to next device version in 5 Year Period

22. 5 Year Cost Comparison • Purchase 100 Devices From Carrier (AT&T, Verizon, Sprint, etc) • iPhone 5s 16gb without voice/data plan • Included the Cost of 1 Std Case and 3 belt clips per year per device • Included AppleCare and Cost of upgrading the device to latest model • 100 Phones with Accessories for 5 Years = $723,480 • Purchase 100 Devices From Cerner • iPhone 5s 16gb without voice/data plan • Included the Cost of 1 Std Case and 3 belt clips per year per device • Includes Overnight Exchange, Pre-config to MDM/Apps, and 1 upgrade • 100 Phones with Accessories & Service for 5 Years = $354,980 • Basically $55 per month per device

23. Accessories for Consideration • Basic Protective Case (with Hospital Logo) Third Party • Sled / Extended Battery & Scanner • Consider if Using Phones for more than receiving alerts. • We found if just using phone for Alerts Battery was fine for 12 hour shift (no texting, internet, voice, etc.) • Bluetooth Scanner • + Could be used for Meds Administration, Supplies, etc.

24. Next Steps • Complete Production Implementation / BB Replacement • Evaluate Options for Wider Alerting • Labs • Medications • IV’s • Bed Management • Assignments • Housekeeping • Evaluate use of iPhone as wi-fi voice device • Evaluate Possible Replacement of Other internal Systems with Connexall • Nurse Call, Server Monitoring, etc.

25. Mobile Device Management&Wi-Fi Lessons Learned

26. Wireless Lessons Learned • Have a “Wired Backup Strategy” • Ensure Switches on Emergency Power • POE Switch / AP’s • Deny Wireless “b” (a/g/n) • Support Voice First • Dedicated VLAN’s / SSID’s • Improves Power Consumption

27. Wireless Lessons Learned • AP Placement • Avoid Too Many or Not Enough • Cover all Patient Areas • Get Third Party Survey / Certification • “Outside-In” Layout for best results • Best For Location and Coverage • Redundant, Embedded / Distributed Controllers • Consider Future • (Wireless “ac”) • Don’t Forget Security!

28. Security • Devices must be registered • User must agree to Terms of Use: • Agree to report if lost or stolen • Agree to allow remote erase • Agree to use in accordance w/Policies • Requires device access password • Using Mobile Iron Device Management solution. • Balance End User Usability, & Preference vs. Security, Risk & Budgetary concerns

29. Summary / Closing

30. Summary The Economic Case for Wireless • Healthcare Reform Drives Organizations who can; • Achieve High Quality & Satisfaction at Lowest Cost • Wireless and Interoperability can be an Enabler for; • Improved Quality, Safety, Efficiency = $$ • The Hard and Soft Economics of Wireless are Real • You will be supporting Wi-Fi Regardless • Design it right with medical grade redundancy • OHH Saved saved nearly $2 million in Capital by implementing Wi-Fi Patient Monitoring over WMTS (2 Campuses) • The Flywheel Theory holds true for Wireless (Jim Collins) • Build a Solid and Secure Wi-Fi Infrastructure to support your future! • Wireless Capabilities drive Innovation

31. Mobile Evolution Applications versus Devices Embedded Apps & Wearable Wireless & Interoperable Wired & Interfaces Standalone Devices

32. Final Thoughts • Look For, Select, & Empower , Power Users at all levels (Physicians, Nurses, Pharmacists, Network Engineers and Architects etc..) • Partnership is Key (Physicians, Nursing, Lab, Pharmacy, Biomed, IT, Vendors) • Innovate for the best experience, improve processes & systems for patients…clinician…all team members • Usability Engineering & Service Focus can be major difference makers (Consider the Human Factors!) • Mobility & Wireless is here to stay – Plan & Design For it! • Get Advice / Ask for Help! Don’t be an IT/Clinical Engineering Department of NO, be one of KNOW-HOW!!!

33. Steve Miller Chief Technology Officer Coordinated Care of Oklahoma smiller@coordinatedcareok.com Thank you