“The Intelligent Hospital” Adaptive Information Management

1. “The Intelligent Hospital” Adaptive Information Management mHealth Summit Dec 8-11, 2013 , Washington DC Paul, H. Frisch, PhD. FHIMSS Attending Department of Medical Physics Chief, Biomedical Physics & Engineering Memorial Sloan-Kettering Cancer Center. New York, NY

2. Toilet Emergency Room HUB Patient Station Code Blue Hub Router Hospital Backbone Ventilator Management Application Pump Medication Management RTLS Physiological Monitoring Hospital Gateway Nurse Call Application Server Intelligent Hospital Room Level Devices Outside of Room Dome Indicator CISCO Access Point Nurse Hands Free Wireless Devices (Vocera) Directed Communications (Emergin) Alarm & Physiologic Data Manager Physiologic Data Manager (Connectivity) RFID Medication Administration Sample Collection RTLS EMR Archiving

3. Objective: Design of an Integrated Intelligent Hospital • Increased Data Accuracy & Availability • Electronic Medical Records • Shared Medical Device Interconnectivity and Integration • Global View of the Patient / Unit • Rapid Information Dissemination & Response • Physiological Data • Alarm Event Management • Advanced Communication Platforms (PDA, iPhone, etc.) • Location Content • Enhanced Error Checking & Validation • Identification & Association • Location Content • Correct Information • Optimization of Workflow & Resource Management

4. Patient Treatment & Care Supporting Operations Hospital Environment • OR • Acute Care (ICU) • Emergency Department • General Patient Care Areas • Outpatient • Specialty Areas • Radiology • Radiation Oncology • Cardiology Suite • Pharmacy • Central Supply • War Room • Data Center • Biomedical Engineering • Information Technology

5. GPS Real Time Information Delivery Treatment Planning Staffing / Assessment Rapid Routing OR , Cath Lab Necessary Supplies Demographics Status , ETA Field Assessment Allergies Physiological Data

6. RFIR Virtual Wall Emergency Room (ER) Time Sync. Clocks Medical Devices & Connectivity (Barcode & RFID) RFID Hand Hygiene Compliance RFID Coupled Patient / Staff Tracking Patient Identification generate wristband @ bedside (Barcode, Passive & Active RFID) Label Scanners & Printers: Wristband, Sample Collection RFID Coupled Bed / Patient Management System

7. Integrated Hybrid OR Wall of Knowledge Drager Anesthesia System Video Camera RFID Surgical Table • Wall of Knowledge - Routable Images • Minimally Invasive Surgery Boom • Device Control • RFID Coupled Surgical Instruments • RFID Coupled Sponges • OR RFID Couple Status Board • RFID Coupled Supplies • Interactive Consultation / Education Robot • Boom Mounted Video Integrated Philips C-Arm 2012 HIMSS Expo. RHCC Intelligent Hospital Pavilion

8. ICU 2012 HIMSS Expo. RHCC Intelligent Hospital Pavilion

9. Intelligent Pharmacy

10. Environmental Metrics & Safety

11. War Room Telemedicine Ambulance Data ER / OR Dashboards Bedside PC Tactical Strategic (Business Intelligence) Education / Consultation Ventilator Management & Analytics Alarm Management Physiological Data Bed Management

12. Big Data Real Time Information • Clinical Data • Physiological Parameters • Physician Orders • Laboratory Information • Radiological Information • Alarm Management  Alarms & Alerts • Real Time Location Content • Workflow • Resource Availability • Equipment & Supplies • Staff • Environment of Care • Temperature • Humidity • Fire Protection • Administrative / Management Information • Business Intelligence Reports

13. Alarm Volume Filtering Thresholding Escalation Intelligent Alarm Processing • ICU (12 Bed Unit) • Physiological Monitoring Only • 72 Hour Full Disclosure Results • 36,000 Alarms • 42 Alarms / Bed / Hour • Telemetry (90 beds) • 72,397 Alarms over 20 days • 3620 Alarms / Unit / Day

14. Selective Filtering Alarm # 1 Alarm # 2 Telemetry Ratio 4:1 24 Alarms 2 / hr 6:1 36 Alarms 1.5 /hr Alarm on Limit Adjustment Filtering SpO2 < 85 278 1.15 Alarms / Hr / Nurse SpO2 < 80 198 .8 Alarms / Hr / Nurse SpO2 <70 24 1.0 Alarm / Hr / Unit t1 Thresholding t2

15. Average Alarms Per Bed Per Shift Average Alarms Per Bed Per Shift Patient Staff Ratio 4:1 64 Critical Alarms / Hour Critical Event Every 11 minutes

16. Connentivity & Point of Care Information Delivery Handheld IP Phone Alarms Delivery Staff to Staff Communications Handheld PC Can access all Hospital Applications Pagers

17. Dynamic Identification and Association • Medical Devices & Systems • Physiological Monitoring • Bernoulli Ventilator Management • Infusion Pump Systems • Nurse Call • Alarm Management & Data Distribution • Critical Alarms to the Point of Care • Staff to Staff Communications • Medication Administration • Sample Collection • Electronic Medical Record Pharmaceutical Equipment to Patient • Frisch, P.H., Miodownik, S., Booth, P., Carragee, P., Dowling, M., Patient Centric Identification and Association. • IEEE Engineering in Medicine and Biology Society, Proceedings of the 31th International Conference. 2009: 1722-5

18. RTLS, Network Clients, ADT, etc. ActiveRFID Passive RFID Bar Codes User Interface Processor Identification Association Data Applications Institutional RTLS Solution

19. 2012 HIMSS Expo. RHCC Intelligent Hospital Pavilion Supply Chain • Item Level Identification • Shelf level Tracking • Validation of Supplies • Check Expiration • Serial #, Lot # • Update Inventory Bar Code RFID Antenna

20. Surgical Applications - Retained Objects: • 1 in 5,000 open cavity surgeries result in a retained object • 40% of surgical cases are open cavity • 70% of retained objects are sponges • 764 Medicare incidents in 2006 • Tray Development • Validate Surgical Tray Content • Before & After Procedure • Validate Sponge Counts • Confirm Cleaning & Sterilization Processes Ascension Health, Scott Lambert, Lead Partner, Engagements & Prototypes Transformational Development, 2008 Midwest Chapter HIMSS

21. Medication Administration RFID Coupled Dispenser Application Workstation: Integrates to Physician Order Entry Validate 5 Rights (Bar Code) Hand Held Bar Code Reader 2012 HIMSS Expo. RHCC Intelligent Hospital Pavilion

22. Process Validation Station #1 #2 #3 #4 ………. Antenna Network If #1 and #2 and # 3 and #4  Good to Go ID#1 Scope Sterilization Hand Hygiene Cleaning Processes Laboratory Processes Document Transfer

23. RFID Coupled Device Status & Utilization Infusion Pump Server Device Location Status Formulary Version Channels in Use Operation Parameters Alarms Programmable Events Gateway RFID System MSKCC – Carefusion- Aeroscout Collaboration

24. Is Location Sufficient ?

26. EXCITER EXCITER EXCITER EXCITER EXCITER EXCITER EXCITER EXCITER EXCITER Synchronized RF-ID Tracking & Event Streaming “ Dynamic Workflow “

27. Workflow Metrics & Analytics • Patient Wait Times • Treatment Time • Staff Presence • By Specialty • Time Sequence of • Alarms & Events • Utilization & Availability • of Devices & Supplies

28. Tag #12 Patient Alice Smith June 18, 2012 The Patient Experience Workflow Metrics Room RN MD Check out Registration Fellow

29. Cautions & Considerations • Lack of Strategic Vision & Planning • ROI Based on Institutional Plan • Not Application Specific • Network Impact • Interference (EMI) • Regulatory Issues • Business Intelligence • Management • Application Development • Simulation / Test Environment

30. Simulation Laboratory Duplicates Environment of Care Infrastructure Devices Applications Enables Test & Evaluation Upgrades to Infrastructure Wireless Network / AP’s Device Upgrades Application Changes New Technologies Dynamic Training & Facilities Modeling

31. Toilet Emergency Room HUB Patient Station Code Blue Hub Router Hospital Backbone Ventilator Management Application Pump Medication Management RFID Physiological Monitoring Hospital Gateway Nurse Call Application Server Biomedical Device Information System Automatic Patient Centric Identification Outside of Room Dome Indicator Bed Embedded RF Transmitter Receiver Embedded Bed / Nurse Call Staff Workstation CISCO Access Point Nurse Hands Free Wireless Devices Pharmaceutical Equipment to Patient (Vocera) Directed Communications Middleware Alarm & Physiologic Data Manager Patient Centric Identification Physiologic Data Manager Bed Centric Identification Envelope Devices (Emergin) RFID EMR Questions ?