Benjamin Kanter MD FCCPCMIO, Palomar Health

Partner, Escondido Pulmonary Medical Group

Disclaimers:Co-developer – MIAA mHealth PlatformConsultant – AirStrip TechnologiesChief Medical Officer – ConversePoint, Inc.

Special thank you:Michael Haymaker, Director of Healthcare Industry Marketing for the Americas, Cisco

Debra LevinPresident and CEO, Center for Health Design (www.healthdesign.org)

Palomar Pomerado Health• 3 Hospitals • 2 Skilled Nursing Facilities• 5 Outpatient Health Centers• Ambulatory Surgery Center• 4 “ExpressCare” Retail Facilities

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)

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• Emergency Dept. 56• Imaging Rooms 18

– Women’s Outpatient Center

Opened August 19th 2012

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

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.

Goals for Quality Improvement» IOM goals :

Increase safety Efficiency Effectiveness Person-centered care Quality of care Timeliness

» IHI quality improvement efforts: 100K & 5M lives

campaigns Innovation

communities

» Quality Improvement Foci People Process Technology Physical

Environment!!

A Better Building facilitates the physical, mental, and social well-being and productive behavior of its occupants.

Credibility of Evidence

» Improve Safety » Improve other dimensions of qualityEBD Research shows a well designed environment

can improve safety and quality of care

Reduce nosocomial infection (airborne)

(contact)

Reduce medication errors Reduce patient falls

Improve quality of communication (patient staff)

(staff staff)

(staff patient)

(patient family)

Increase hand washing compliance by staff Improve confidentiality of patient information

Improve overall healthcare quality and reduce cost

Reduce length of patient stayReduce drugs (see patient safety)

Patient room transfers: number and costsRe-hospitalization or readmission rates

Staff work effectiveness; patient care time per shiftPatient satisfaction with quality of care

Patient satisfaction with staff quality

Credibility of Evidence

» Reduce Patient Stress

» Reduce Staff Stress/ Fatigue

EBD research shows that the physical environments helps to reduce patient stress

Reduce noise stressReduce spatial disorientation

Improve sleep Increase social support

Reduce depressionImprove circadian rhythms

Reduce pain (intake of pain drugs, and reported pain) Reduce helplessness and empower patients & families

Provide positive distractionPatient stress (emotional duress, anxiety, depression)

The physical environment impacts staff outcomes

Reduce noise stress Improve medication processing and delivery times

Improve workplace, job satisfaction Reduce turnover

Reduce fatigue Work effectiveness; patient care time per shift

Improve satisfaction

Ulrich, Zimring, et. al; “A Review of the Research Literature on Evidence Based Design”, HERD Journal, Spring 2008

% o

f Res

pons

es

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)

Distributed Nursing Model

Operational Challenges

Gardens/Mobility Monitoring Communication Location

Distributed nursing Communication

IHI 2x2 findings Nursing ratios

BYOD environment Multiple new remote clinics

Telepresence

Technology-Enabled Rauland-Borg Responder 5

Nurse Call System

Patient StationCorridor Light

Nurse Station Console

Duty Station

PC ConsoleStaff Terminal

Cisco 7925 VoIP Phone

What’s inside Extension?

Communication interface Small database interfaced to

Cerner/Rauland Rules engine

What goes where? When? Escalation rules Filters (if – then)

(OpenTheRedBox.com)

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.

Physiological Monitoring

IHI Mortality 2x2 Matrix

ICU Admission ?Yes No

ComfortCareOnly?

Yes

No

Box #1 Box #2

Box #3 Box #4

Mortality Diagnostic: Aggregate Results for 64 US Hospitals

ICU Admission

No ICU Admission

Comfort Care 175/5535 3%

(0-44%)

773/5535 14%

(0- 65%)

Non Comfort Care 1936/5535 35%

(7-72%)

2661/5535 48%

(7-76%)

“Failure to Rescue”

Failure to prevent a clinically important deterioration from a complication of an underlying illness or a complication of medical care

PPH Vision / Industry Trends Technological Requirements

Continuous patient monitoring across the continuum of care: Ambulance , ER, Admitting Process, Transport within/to Facility, SNF, Clinic, Home, Anywhere.

Small form factor for extreme portability, Un-tethered / wireless devices, body area networks.

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 readmission rates.

Monitor patient vitals and other parameters, post discharge to enable the early detection of condition deterioration.

Bed exit, Patient fall detection. Monitor patient movement, change in position.

Emerging Requirements

• 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)

ViSi Mobile™ – Patient-Worn Monitor

* Not yet FDA cleared

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

ViSi Mobile – by Sotera

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

Tomorrow’s standard of care on the general floor

(Automatic entry to EMR)

Patient Safety

ViSi Mobile™ and Cerner – System Architecture

ViSi MobileMonitor

iBus

PowerChart

PowerChart

AlertLinkTM Integration(Launching late Q42012)

Sotera Wireless

Cerner

PowerChart® Integration (Launching at CHC)

BYOD Environment

Cisco ISE : Identity Services EngineGuest NetworkSporadic tablet/Citrix useIndependent development

MIAA is a uniquely powerful user interface and user

experience which maximizes clinical efficacy and efficiency

for mobile clinicians

MIAA does not replace a host EHR. MIAA adds capabilities to a legacy

EHR, extending the functionality and reach to enable the mobile clinician

Scenario based interaction Who is the user? Why is the user doing what they're doing? What questions are they trying to answer? What actions are they likely to take? Provide information in a manner which improves comprehensionIntegrate 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)

…real time access to…

Physiological Status Electronic Health Information

Complete the process

Thank you!Ben Kanter MD FCCPBen.Kanter@pph.org