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Neil A Halpern MD Chief Critical Care Medicine Memorial Sloan Kettering Cancer Center, NYC

Advanced informatics in critical care: The primary challenge inherent in future ICU design . Neil A Halpern MD Chief Critical Care Medicine Memorial Sloan Kettering Cancer Center, NYC. Disclosers. Medical advisor/consultant Cardio Pulmonary Corp Pronia Medical Instrumentation Labs.

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Neil A Halpern MD Chief Critical Care Medicine Memorial Sloan Kettering Cancer Center, NYC

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  1. Advanced informatics in critical care: The primary challenge inherent in future ICU design Neil A Halpern MD Chief Critical Care Medicine Memorial Sloan Kettering Cancer Center, NYC

  2. Disclosers • Medical advisor/consultant • Cardio Pulmonary Corp • Pronia Medical • Instrumentation Labs

  3. Informatic’sSecret Victoria’sSecret The seduction of informatics

  4. The seduction of advanced informatics • Looks great, seems cool & FDA approved, but new technologies are… • Manufactured by variety of vendors • Marketed as plug & play, but must be integrated with other systems • Challenging to integrate • Minimally tested in real “clinical” life • Certainly not tested with your middleware & hospital systems in your facility

  5. Three ICU-IT goals • RTLS: Track assets (devices or people) • Build a virtual device community • Transform reams of data to meaningful & actionable information

  6. Wireless Access Points and Sensors Bar Code Scanners Multi-Parameter/Port Device Integrator Wired Jacks Nurse Call Computer Wi-Fi IR RFID Ultrasonic Multimode Universal Labs Blood Meds POCT Mechanical Ventilator (Mobile) Supplies Environmental Sensors Bedside Physiological Monitor (Stationary) ADT Pharmacy Central Lab EMR Infusion Pumps (Mobile) RTLS Images Cardiology Alarms Medical Applications Blood Products Lab Specimen Meds Auto-ID Tag Bar Code Scanner ICU Bed Adaptor Mini-computer Wireless

  7. RTLSInventory & Asset Management

  8. Real Time Locating Systems/Solutions (RTLS) RTLS: wireless tracking of tagged items • Mobile Asset tracking • Improve workflow • Integrate with other systems

  9. Monitor Monitor Pumps Pumps Monitor Monitor Pumps Pumps Vent Vent Vent Vent RTLS Asset Management Where is it? Is it being used? Where is it? Is it being used? Is it leaving ICU? Where is it? Monitors Vents Pumps SERVERS

  10. Penguin in Atlanta Zoo

  11. ICU GPS system

  12. PATIENT TRAVELS WEDNESDAY, SEPTEMBER 19, 2012 - 9:15 a.m. Pt in ICU Pt in CT Scan Pt in IR Pt in ICU CT SCAN ICU ROOM IR Wireless Access Point Wireless Access Point Wireless Access Point

  13. Build a Virtual Device Community

  14. Devices, data & alarms are local Mechanical ventilators Problems: • Stand-alone • Bedside alarms only • No long-term data storage Ideal: • Join with other vents to form virtual community • Transmit selected alarms • Long term data storage PB 840

  15. Wireless Bridge Bernoulli Ventilator Management System, Cardiopulmonary Corp, Milford, CT

  16. Vent Vent Vent Vent Ventilator Ventilator Ventilator Ventilator Vent Vent Vent Vent Monitor Pumps Monitor Pumps Virtual Ventilator Community, Alarm delivery Data storage Monitor Pumps Monitor Pumps Monitors Vents Pumps SERVERS

  17. Bernoulli Ventilator Management System, Cardiopulmonary Corp, Milford, CT

  18. Transform data to meaningful & actionable information

  19. AlarmDeliverySystem Monitor Pumps Vent NC NC Nurse Call 1 2 Central Station Where is it? Is it being used? Where is it? Emergency Alert Marquee ALARM INFO NC Monitor Monitor Monitor Pumps Pumps Pumps Vent Vent Vent Monitors Bed 1 NC NC Vents Bed 2 Pumps Bed 3 3 4 Nurse Call Delivery Server Bed 4

  20. Alarm delivery & filter • Shift alarms to “delivery and filter” servers/APPs • Select “critical” device alarms only for transmission to avoid alarm overload • Monitor: 5 of 50 alarms • Vent: 4 of 40 alarms • Institute “novel” delivery models to get alarms where they need to go • Address Joint Alarm PSG 2014-2016

  21. Alarm DeliverySystem Monitor Pumps Vent NC NC NC NC 1 2 Filter Central Station Bed 1 BED 4 VFIB Bed 1 Where is it? Is it being used? Where is it?  Heart Rate  Heart Rate Emergency Alert Marquee ALARM INFO Bed 4 Bed 4 VFIB VFIB NC NC Monitor Monitor Monitor Pumps Pumps Pumps Vent Vent Vent Monitors Bed 1 NC NC NC NC Vents Bed 2 Pumps Bed 3 3 4 Alarm Delivery Server FILTER Bed 4

  22. The devil is in the details!

  23. Primary Informatics Challenges • Evaluate many technologies • Connectivity envelope • Association • Time synch, interoperability & data synch • Medical devices are informatics platforms • Roll out • Maintaining & upgrading

  24. Evaluating middleware Middleware: the systems that make everything work! Servers & APPs FDA certified? Yes, but still confusing! • MDDS: FDA Class 1 • Medical Device Data Systems • Data storage, mng, & transfer • Language conversion • Class 2 devices • Active pt monitoring & alarms

  25. Hi Tech Evaluation • Many similar products • Evaluate over a short time period • Discern subtle, but meaningful differences • Figure out the cost, initial & long-term

  26. Speed Dating for Technologies           You have 15 minutes,no slides, no sales pitch,just tell us what you got! NEXT! NEXT! BUZZZZZZZ

  27. Go to the Sim Lab • Set up BioMed-IT simulation lab with identical systems as ICU & hospital • Obtain & test all prioritized technologies in real-life settings • Perform gap analyses: current & proposed • Slow & deliberate phase-in

  28. Primary Informatics Challenges • Evaluate many technologies • Connectivity envelope • Association • Time synch, interoperability & data synch • Medical devices are informatics platforms • Roll out • Maintaining & upgrading

  29. Putting It All Together . . .

  30. or not . . .

  31. Five Steps to Creating the Smart ICU Step 1Install robust wired and wireless infrastructure ↓Step 2Attach Auto-Identification (Auto-ID) tags to all data sources ↓Step 3Attach adaptors and/or computersto medical device data output ports ↓ Step 4Install tracking and data acquisition hardware ↓Step 5Install middleware (gateways/servers/APPs)onhospital and ICU networks

  32. Connectivity Envelope Wireless Access Points and Sensors Bar Code Scanners Multi-Parameter/Port Device Integrator Wired Jacks Nurse Call Computer Wi-Fi IR RFID Ultrasonic Multimode Universal Labs Blood Meds POCT Mechanical Ventilator (Mobile) Supplies Environmental Sensors Bedside Physiological Monitor (Stationary) Infusion Pumps (Mobile) Medical Applications Meds Blood Products Lab Specimen Auto-ID Tag Bar Code Scanner ICU Bed Adaptor Mini-computer Wireless

  33. Hospital Network Hospital and ICU Systems,Servers and Applications ICU Network AlarmDistribution Administrative Bed 1 Bed 8 Bed 2 Bed 9 DeviceManagers Bed 10 Bed 3 Clinical RTLS Bed 11 Bed 4 ElectronicMedical Record SmartDisplays Bed 5 Bed 12 Bed 13 Bed 6 Telemedicine ICU Middleware Bed 7 Bed 14 Network Servers and Routers Network Servers and Routers Hospital Network

  34. Primary Informatics Challenges • Evaluate many technologies • Connectivity envelope • Association • Time synch, interoperability & data synch • Medical devices are informatics platforms • Roll out • Maintaining & upgrading

  35. Association Connecting pt to device & device to network is easy; linking data/device with pt is hard! • Location centric (bed #): data “sticks’ to location, not pt • Easy for venders to implement • However, data may be difficult to locate in dynamic datasets for insertion into EMR • Patient centric (name/MRN): data “sticks” to pt • Requires live ADT feed

  36. Association of Devices & Patient Location - ICU Room Number Medical device: Stationary (MONITOR) Medical device: MOBILE (VENT, PUMPS) Fixed location/ IP address No Location/ nEEDS Name ADT EMR vs. PT DEVICE MANAGER NameMRN ALARM MANAGER Location/ NAME Location/ ONLY Alarms

  37. Primary Informatics Challenges • Evaluate many technologies • Connectivity envelope • Association • Time synch, interoperability & data synch • Medical devices are informatics platforms • Roll out • Maintaining & upgrading

  38. 8:50 8:55 8:50 8:55 9:10 9:10 9:05 9:05 Monitors8:55 Pumps8:50 Vents9:10 Webcam9:05 8:55 8:50 8:50 8:55 9:10 9:10 9:05 9:05 Monitor Pumps Monitor Pumps Disparate ICU devices & systems not in sync! Vent Vent Webcam Webcam Monitor Pumps Monitor Pumps Time Vent Vent Monitors Vents Pumps Webcam Webcam Webcam SERVERS

  39. 9:00 9:00 9:00 9:00 9:00 9:00 9:00 9:00 Monitors8:55 Monitors9:00 Pumps9:00 Pumps8:50 Vents9:00 Vents9:10 Webcam9:05 Webcam9:00 9:00 9:00 9:00 9:00 9:00 9:00 9:00 9:00 Monitor Pumps Monitor Pumps Time Server Vent Vent Webcam Webcam 9:00 Monitor Pumps Monitor Pumps Time Vent Vent Monitors Vents Pumps Webcam Webcam Webcam SERVERS

  40. Device Data and Alarms: Interoperability Connectivity Envelope ICU Electronic Flowsheet NOW - I understand! what the … did that vent say to me? Servers φβηψτϵϴαρμωζγωζγβηψφβηφβφρμηψρμηψβηψτϵϴαρμωζγβηψφβηφβηψτϵαρμηψτϵαρμρμηψ ALARMS - 743203048 - ALARMS - 43038634663980 Conversion on Outbound or Inbound Alarm App Data Storage ALARMS - 7403048 - ALARMS - 463980 φβηψτϵϴαρμωζγβηψφβηφβηψτϵαρμ Electronic Flow Sheet Web EFS/Alarms Medical Device VENT ICU Bed Adaptor/ Wireless Mini- computer

  41. Interoperability • Enable seamless & secure access to health info • Provides specs, tools & svcs for interoperability • IHE Connectathon: Standards based interoperability for vendors & users of HIS

  42. Device Data and Alarms: Data Synch STOP Connectivity Envelope ICU Electronic Flowsheet “Respiratory Rate” ≠ “fR” “Respiratory Rate” = fR Crosswalk for data synch: Respiratory Rate = fR Alarm App 7906530437905432 Data/Alarms Alarms Data Storage 7906530437905432 Electronic Flow Sheet Servers Web EFS/Alarms VENT ICU Bed Auto-ID Tag Bar Code Scanner Adaptor/Wireless Mini-computer

  43. Primary Informatics Challenges • Evaluate many technologies • Connectivity envelope • Association • Time synch, interoperability & data synch • Medical devices are informatics platforms • Roll out • Maintaining & upgrading

  44. Infusion Pump: The Dark Ages One-time Purchase

  45. Infusion Platform: The Modern Era Infusion Pump: The Dark Ages SERVER MIDDLEWARE OFFSITE BACKUP PUMP SERVER PUMP ACCESS POINT PHARMACY EMR privacy

  46. Building the Infusion Pump System Medication Library Dosing Protection Medication Orders Wireless Communication Alerts Back-up Privacy Memory Handhelds

  47. Infusion Platform: The Modern Era MEMORY MIDDLEWARE Wireless Communication OFFSITE BACKUP PUMP SERVER PUMP ACCESS POINT Alerts PHARMACY Medication Library EMR Dosing Protection Medication Orders

  48. $$$ Infusion Platform Costs MEMORY $ $ $ $ MIDDLEWARE OFFSITE BACKUP PUMP SERVER PUMP ACCESS POINT $ PHARMACY $ $ EMR Ongoing Costs for Software Updates & Licenses

  49. Primary Informatics Challenges • Evaluate many technologies • Connectivity envelope • Association • Time synch, interoperability & data synch • Medical devices are informatics platforms • Roll out • Maintaining & upgrading

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