Improving medical device connectivity

Brian
McAlpine

The application and use of auto-ID technology at the point of care in hospitals is not new. Auto-ID technologies can be implemented in various ways, and bar codes are by far the most common. Other ways include magnetic stripes, optical character recognition (OCR), smart cards, voice recognition, biometrics and various forms of radio frequency identification (RFID). Most auto-ID applications have inherent limitations, such as the need for line of sight (bar-code scanning), low data-storage capacity (bar codes) and the need for human intervention (voice recognition, biometrics).

RFID was developed to overcome these limitations and is gaining traction in hospitals. RFID is promising because it does not require line of sight, has a longer read range, can store large amounts of user data using integrated technology and can be implemented in many forms. But make no mistake, RFID is not about to replace the general use of bar codes in hospitals any time soon. Rather, RFID should be viewed as a complementary technology that can enhance and improve safety and clinical workflow.

From a historical perspective, medical device connectivity used to be much simpler and did not typically require the use of either bar coding or RFID. However, partly driven by the American Recovery and Reinvestment Act (ARRA) of 2009 and meaningful use, there is currently much more focus on ensuring medical devices are connected and able to send data to the electronic medical record (EMR).

Solutions for device connectivity are evolving to adapt to a new set of requirements, and workflow is becoming a key factor. We are now entering a stage where both bar coding and RFID technologies can be applied to improve workflow. Medical device connectivity and related device-setup workflows — whereby clinicians are required to set up devices at the bedside to enable integration — is becoming much more challenging because of changing requirements for connectivity. The following trends are contributing to the increasing complexity of device connectivity.

The scope of devices that require EMR integration is increasing, and the types of devices are changing at the same time. For example, in the past there may have been a requirement to integrate data from patient-monitoring devices in only the ICU. Now all devices at the bedside are candidates for integration, including ventilators, infusion pumps, pulse oximeters and wireless smart beds. The challenge here is mainly how to optimize the clinical workflow.

• The scope of clinical care areas that have devices requiring integration with EMRs is increasing. It used to be critical-care areas that were the main targets for device connectivity projects. Today, many projects are enterprise in scope and include specialty care areas and all medical surgical beds. Today's solutions must address requirements for both continuous and periodic data collection and clinician validation of data.

• The use of wireless and mobile devices is expanding rapidly, and lack of patient context limits the ability to integrate the data. The issue here for clinicians is how the patient-to-device association will get established to ensure the data gets to the right patient record.

• The industry is shifting to a patient-centric integration model that requires positive patient identification (PPID). Many hospitals are requiring device connectivity vendors to move away from location-based integration models because of concerns for potential wrong patient data mismatches and because of the Joint Commission National Patient Safety Guidelines that address proper patient identification.¹

This is where bar coding and RFID technologies can be applied in complementary ways to address these challenges, which are more related to the clinical workflow required to establish patient context than pure technology.

Clinicians are responsible for ensuring the devices are set up properly to enable data acquisition. And a component of the workflow requires PPID. The steps to scan the patient's bar-coded wristband and to confirm patient identification are very important. But equally important is the step where the right devices must be confirmed for a specific patient — especially when wireless devices, such as smart IV pumps, are used. This point-of-care workflow is referred to as positive patient association (PPA), which ensures the right devices are associated to the right patient. As a comparison to something more common, this is loosely analogous to the medication administration workflow (often referred to as “Five Rights”) that helps ensure that the right drug is administered to the right patient at the right time.

The optimal workflow is highly dependent on the type of clinical care area (ICU, OR, ED, etc.), the number and type of medical devices requiring connectivity to the EMR and the design of the device-connectivity application. There is no one-size-fits-all method of managing PPID and PPA. In some cases, such as in medical surgical care areas, there may be a requirement for a nurse assistant to collect data every four hours via a single spot-check monitor. In this use case, a single bar-code scan of the patient's wristband and a confirmation of the patient ID is all that would be required to enable the vital signs data to be sent to the EMR. In other use cases, it can be far more complex.

By examining the PPA workflow more closely, and considering the number of devices requiring integration on a per-patient basis is increasing, then it starts to become more obvious that a workflow designed exclusively around bar coding can be challenging. The more things a clinician is required to scan, and also remember to scan, the more the workflow becomes an issue. Breakdowns in clinical workflow can lead to workarounds being created on the spot ^2,3 — and this contributes to potential errors.

Technologies, such as ultra-high-frequency (UHF) passive RFID, have been proposed to complement the use of bar coding. When bar coding has reached its practical limits for enabling the best workflow, RFID can be used to automatically sense all of the medical devices and the patient, thereby reducing the manual bar-coding steps required. Instead of applying a bar code to everything, inexpensive passive RFID tags can be applied. By automatically identifying or sensing the devices in proximity to the patient, the clinician can be proactively prompted to confirm the patient-to-device association. This can reduce the number of steps required and simplify the overall workflow. Hospitals should think of auto-ID technologies as tools that can be applied to enable the right clinical workflow in each care setting.

It is recommended that when evaluating solutions for medical device connectivity, the following areas be assessed as a best practice:

• Determine the scope of your connectivity project, both short and long term. Recognize that eventually you will likely have to expand the scope to enterprise-wide connectivity. Evaluate vendors based on their ability to scale to very large implementations.

• Assess the range of devices that are candidates for connectivity. Determine if your vendor can provide connectivity “out of the box” or if they will have to develop compatible device drivers for some of the devices on your list. Also assess the method of connectivity for each device type, recognizing that there will be a variety of required connections, including serial/RS-232, wireless (typically Wi-Fi in devices such as IV pumps), and network-connected gateways (typically used for devices such as patient monitors and IV pumps).

• Based on the set of medical devices you intend to integrate in each care setting, assess the clinical-workflow impact when clinicians are required to set up devices to enable connectivity and determine the optimal workflow that can be achieved for managing how patients will be positively identified and for how (and where) patient context (PPA) will be established.

• Assess the role of auto-ID technologies, such as bar coding and RFID. Work with your connectivity vendor to determine where each technology can be used and how the best workflow can be achieved.

• Recognize that your care environment is dynamic in terms of the number and types of medical devices, as well as the skill and training levels of the clinicians who need to deal with device connectivity-related issues.

1. The Joint Commission. Critical Access Hospitals: 2011 National Patient Safety Goals, http://www.jointcommission.org/cah_2011_npsgs/.

2. Kobayashi, M., Fussell, S. R., Xiao, Y., & Seagull, J. (2005). Work coordination, workflow, and workarounds in a medical context. CHI Late Breaking Results. New York: ACM Press.
(Accessed via Internet at: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.71.6384&rep=rep1&type=pdf).

3. Halbesleben, Jonathon R. B.; Wakefield, Douglas S.; Wakefield, Bonnie J. (2008). Work-arounds in healthcare settings: Literature review and research agenda.