Falls and HIT Polic Committee Measure Concepts

Yes, the title gives it away this is a serious one. I read recently on a blog that the HIT Policy Committee is creating “measure concepts” that will be applied into meaningful use standards. At the very bottom – in fact the last one listed – is "Measures of fall events and screening". While we each are passionate about one item or another on that list, I believe there is some low hanging fruit that could easily be picked off and taken care of quickly AND provide the hospital with real “meaningful” savings.

The tricky thing about falls is that you are dealing with a patient. Patient’s actions, movements, attitudes, and even behaviors are a challenge to categorize into the neat and tidy little boxes that EMR vendors need to have strong governance in documentation standards. That’s a mouthful that says patients don’t follow the rules. The key is to look at the patterns of patient behaviors, staff behaviors, and other key dynamic factors then balance them with some static information. That is where you will find the answer to identifying Key Performance Indicators that link to predictive modeling for falls.

I know, I know you have never heard me use so many $20 words in one sentence. The answer is all ready there in the data. Think of it like seeing a Picasso – some people look at a Picasso and see random shapes, meaningless strange pictures and some people look at it and can interpret a story. I see the story in regards to the data surrounding falls. I had a great experience the other day with a hospital that “got it”. While I presented the data and our assumptions on the patient behaviors and indicators the staff filled in their specifics surrounding the staff’s behaviors. We see the same thing in the data – over and over again. We see the story.

This data should be in the Medical Record, it should be part of meaningful use standards, and it is part of the patient experience in the hospital. This is low hanging fruit – as my dad would say “easy pickins” – a real problem that is solvable.

I believe the key to reducing falls in a hospital lies in the ability to categorize, capture, and document the behaviors and actions. Believe me there are consistencies that we can currently identify. You just have to know where to look.

Symphony of Information

Have you ever heard a 9th grade band on their first few days of rehearsal? I lived it – well a much heavier, awkward, glasses wearing, hair out of control, version of myself. The interesting thing about 9th grade band is everyone has had their instruments for a while so most can make a noise that resembles music, but “musicality” is really lacking. What they teach you in that critical year is how to be “Symphonic” which means taking something that is very complex and diverse and pull it together harmoniously. For a percussionist (like myself) that means - just because you can play the loudest doesn’t mean you should and that following the conductor is not an optional activity.

As I was reviewing data this week (reams and reams of data) I began to notice a series of new patterns. Patterns, within themselves, are fascinating but they get interesting when variations occur. So in musical terms if you have 4 measures of quarter notes and then a measure of 8th notes and then a measure of 16th notes the original pattern varied to a pattern that builds intensity. Intensity builds excitement and excitement builds to the climax of the song. As geeky as this may sound the workflow data we review is often like a musical score to me – sometimes just out of sync.

I don’t know about you but when my mind gets stuck on patterns I have a hard time breaking free. My solution has always been to get in my car and turn the radio up to blaring sound to let my mind focus on the patterns in the music. After a few minutes identifying them, and figuring out the layering it is easier to refocus on something new.  This week was especially overwhelming as we discovered patterns outside of alarms that affect our data points AND that the information is readily available.

That’s when it hit me – the problem with the patterns that I was seeing for this particular hospitals report were that they are simply out of sync with the other dimensions of the unit. (Clear as Mud?) Think of it like a musical score – if the woodwinds are playing 3 measures behind the brass who is playing two measures ahead of the percussion it sounds like noise. However, if the conductor is able to see how the patterns line up and is able to pull everyone into sync then it’s an amazing symphony.

Music at it's base is a complex math equation - music at it's core is art and soul.  The key to making beautiful music is to be able to define where the math ends and the soul begins.  The same is true in clinical workflow design the numbers may speak the "truth" but the answer may lie in the "soul" of the work.  That's what we do - we help the hospital define the math so that the clinicians can better create the soul.

I know this is two months in a row of shameless plugs but we are creating a new dashboard that is unlike anything in the market today.  We have welcomed several new team members in to help us mold the product into something that can quickly help a hospital reduce falls, increase patient satisfaction, and increase safety. 

Defining What "Matters"

Creating focus can be challenging. I am a firm believer in goals (lots of Zig Ziglar growing up) but sometimes defining those goals is just as hard as achieving them. We may create a visionary goal, but not understand the detail to make it achievable. Many times our inability to identify what “matters” leads to failure, and our lack of understanding of the information produced creates a foggy understanding of success. That’s why it’s critical to be able to break things down into digestible chunks so we can quantify the achievement (or failure) towards our goals.

My six-year old struggles with spelling – if you have read my blog long, you know it’s genetic. In September his third spelling test score was a D. As soon as I saw that paper, I emailed the teacher to request a conference. The teacher explained that they had 20 words and 10 phonics per week, and the importance of good penmanship. (All I heard was 20+10= 30 items per week to learn!)

That information in hand, I devised a plan of action for home study. The plan was simple break down the materials into daily digestible goals. The next week we hit the ground running. We practiced daily, and he got a D+. To me, this indicated failure of the plan, not the child. We reviewed the goals, made an adjustment to the plan, and the following week he got a C+ then a B. Last week, I am pleased to announce, he had his first A, missing only 1 word!

The reason I am reviewing 1st grade spelling tests is because had I waited for the grade card, my baby would have had a D or F on his grade card. (The C he got broke my heart.) Using indicators, in this case the spelling test, to shine light on a potential problem we were able to thwart a hard to recover disaster of a bad grade card.

Hospitals are faced with a number of challenges – one of which is alarm fatigue. Alarm fatigue is a multi-faceted problem that encompasses everything from noise, to acuity mix, staffing and so much more. If you try to tackle the problem by saying "REDUCE ALARM FATIGUE" that solution is foggy at best.  However, if you look at the issue pragmatically then you can identify the multiple layers each with a “spelling test" indicator. Just like the spelling test above the solution lies in breaking down the problem into digestible chunks and refining those goals based on the outcome of the result.

Shamelss Plug - Our Scorecard is a tool – something that can be used like a spelling test – that along with daily goals and observation could solve the problem. The quarterly trend is much like a grade card. If you wait for the grade card to correct course – then you may be too late.
My advice for today – look at everything as a solvable problem. When the problem is too big – break it down as many times as it takes to become understandable and digestible.

Changing Lanes

I was driving to work yesterday in the Tahoe (aka Mommy Mobile) since my car (aka Princess) has a flat. As I sped down the road with Cruise Control set – I couldn’t figure out why the Tahoe wasn’t slowing down as I approached a much slower moving vehicle. All of the sudden, I remembered that the Tahoe does not have the cruise control distance feature that Princess has built in to ebb and flow with traffic.  I slammed on the break as to not hit the vehicle in front of me. You see, the Princess car can practically drive itself. You set cruise control and it slows down as it approaches a vehicle and once that vehicle moves out of your lane it resumes its constant speed.

This change in vehicles has caused a number of issues for me this week. I have no hands free calling if I push a button on my steering wheel and say “Call Dad on Cell” it only changes the radio. When I go to change lanes there is no light telling me there is someone in my blind spot. When I go to back up, I actually have to look over my shoulder because the radio does not change into a back up camera picture. All fun and joking aside - This experience really relates to what we are seeing with devices and workflow design in healthcare. (Bet you didn’t see that coming.)

There are really two paradigm shifts. First, there is an expectation that a technology will provide more and require us to “do” less. This does not discount the fact that we still need human interaction. Princess really can’t drive herself, but Ford has developed ways to reduce the amount of action I need to take while driving. They looked at the driving requirements and removed steps out of the process that could be replaced with technology. They also provided technology that could enhance the driver’s ability to make decision. Isn’t that what all technology is supposed to do?

There is a warning that should be going off in your head at this point.  All of this high tech stuff is great but what do you do if the technology is different from unit to unit? What if Med-Surge is driving a Tahoe and Med-Oncology is driving a Princess? Caregivers float between units. They are asked to shift from one process to another without missing a beat. This is the second paradigm shift, technology must be flexible but the flexibility must be tempered by continuity. We ask a caregiver to go from driving a full featured princess car to driving a low featured school bus then we wonder why there are mistakes.

Workflow design should be based in finding commonalities and working to drive similarities between the units. Every car is different but every car has a turn signal, break lights, head lights, and there are requirements to use them within the standard confines of the law. Then that has to be monitored to drive the similarities to be consistencies.

Please heed my warning to all of you in Kansas City – especially those at Cerner because I pass your facility daily - If you are driving home and see a large Tahoe barreling up behind you – I recommend you just change lanes. I am not an aggressive driver but sometimes I forget what technology I have (or don’t have) at my finger tips.

Alarm Fatigue

I was cooking a BIG meal – one with several burners going, the oven on, and even the microwave.  It was one of those “Martha Stewart has nothing on me moments.” (Ok, I was really more like a I'm a tall version of Rachel Ray) There were 4 boys running in and out asking questions and trying to “help” - other kitchen noises like the garbage disposal, can opener, food processor plus of course the TV was on in the other room. It was loud - like the Chiefs Stadium when we beat the Chargers on Monday night – LOUD! The point is I had a lot going on and neglected to set the egg timer for one of my pans and ignored the beeping on the oven……all of this to say we ended up eating at Culvers that night.

My kitchen scenario is much LESS intense than a nursing floor. No one was critically ill, there were no emotionally distraught family members, there was no Code Blue – it was a kitchen. (Well, the food was critically ill by the end of it – I digress) The point is think about your most intense - loud - busy moments and then think of how much more intense - loud - and busy the nurse is and you will begin to understand  “Alarm Fatigue”.

On a floor with 30 patients with IV pumps, nurse call, telemetry, other physiological alarms, etc there is bound to be some noise. The current methodology of listening for an alarm can really hinder productivity – but leave productivity out of it – it is a major safety concern.

Let’s take an easy one - Do you know the most common way we document a response to an IV pump alarm? The patient has pressed their call button and the nurse is notified that the IV Pump was dinging in their room. Think about how scary that is for a patient and their family – who has no idea what the dining means. Do you know the most inexpensive way to fix that problem? Automate an IV pump alarm to the caregivers wireless and explain to the patient and their family what will happen if the alarm goes off. (BTW – repeat that information every time you enter the room for rounding.)

Here’s a freebie - Depending on your nurse call system there is generally a quarter inch jack that can take a contact closure alarm – old school – this is the way my Dad did it when he sold nurse call in the early 1980’s. Order the cord you can use it tomorrow in your hospital. IF you have a question (hospital) – call or email me I will walk you through it. There are much more expensive ways to automate these as well.

The challenge is at some point in alarm automation and “management” you simply begin to displace the problem. If a clinical alarm device is trigger happy then your wireless device will be as well. Too many alarms is still TOO MANY ALARMS – just because it’s quieter on the unit does not mean its better. At some point it’s time to really review the technology that is making the alarm happen, AND review the process of who is getting what alarm when and why. The event in Boston was not due to the alarm noise, really it wasn’t even due to accountability because no one “heard” the alarm. The Critical alarm was turned off and the Warning alarms were ignored. Some automation would’ve helped the issue but it may not have solved.

Patient safety officials across the country have said the heart patient’s death at Mass. General shines a spotlight on a national problem with heart sensors and other ubiquitous patient monitoring devices. Numerous deaths have been reported because of alarm fatigue, as beeps are ignored or go unheard, or because monitors are accidentally turned off or purposely disabled by staff who find the noise aggravating.  ()http://www.boston.com/news/local/massachusetts/articles/2010/04/03/alarm_fatigue_linked_to_heart_patients_death_at_mass_general/?page=1

It’s tragic that a death occurred due to an alarm issue, and no family should have to go through that.  That death should be a rally point for all of us in the device industry.  

See - Hear - Paint by Numbers

Those of us who work in automation of process often are asked to take a “look” and “see” what could be done better. Which is really the basics of what we do – visually obtain information and document it so that it can be assessed. However, you may not want to judge a book by its cover.

Several years ago my Dad went to buy a Cadillac. He showed up to the dealership on a Saturday in his old blue jeans, flannel shirt, and his post card which said if he test drove a Cadillac he could get a free pull over. The dealership was empty – not a customer in sight. He entered – found a sales person – and was promptly told that he would need to make an appointment to test drive a Cadillac. Dad persisted showing the card he had received in the mail for a free pull over with a test drive but the sales person made an assumption that he was not someone who would buy a Cadillac and turned him away. Ironically, two weeks later Dad found the model he wanted online with every feature available at a dealership in Minnesota, went there, purchased the car, and drove it home. Based on what the sales person saw he made an assumption and lost the sale. In the same way we may be looking at a process and seeing each interaction but not make the connection on what is occurring.

In the story above the sales person was focused on how Dad was dressed. Sometimes consultants are focused on what they see and don’t balance it out with what they hear. The verbal interaction with staff – explaining why an observed process had a specific method is critical. The trick is asking the right questions – in the right sequence – to elicit the honest response. Questioning people on how and why they do specific workflows is really an art blended with a science. (Anyone who tells you different is selling you something) The science is the sequence and the information needed to be gathered that provides patterns. The art is the phrasing and interaction. It’s the way you respect their environment and their specific personality.

The final point in workflow modeling is being able to develop a picture of what is occurring without looking or hearing anything. I heard a story on the radio of a woman who had lost her sight. She described how she could see objects with her hands. The form, the texture, the edges all became data points in her mind and she was able to create a picture of what she was holding. In the same way that you can look at the data that comes out of devices, integration software, systems, etc and begin to build a pretty extensive picture of what is occurring on the unit. It’s basically paint by numbers for geeks – a series of “If and Then” statements that when you put them together in the right order create a very in depth picture.  Just like when a doctor looks at a patients chart – the data creates a picture.

We have had a pretty busy month at Sphere3 - which means the blog has taken last place.  Topics are always welcome please send them through to kgovro@sphere3consulting.com

When Our Use becomes "Meaningless"

I recently read a blog post by Regina Holiday that was both incredibly moving and really thought provoking. Regina lost her husband to cancer and has recounted the experience throguh art and speaking. She has gained national attention because of her patient’s rights movement her voice emphasized through murals. Sometimes words are not enough.
She along with other noted leaders like E-patient Dave are paving the way for more information - better information- to let patients make informed decisions. The point that stuck out to me was the concept that the medical information could be presented to the family in a format as easy to read as the Nutrition Facts label. While I don't want to discount the difficulties to do this nationwide with consistent standards - it just makes sense. People didn't understand what everything on the nutrition label meant initially, but now most of us know sodium # high = bad. (I could soap box for days on the unhealthiness of the US and our unwillingness to read the label and make good choices but that's a different post for a different blog)
All of the “bring it to basics” mentality brought me to reflect on the creation of Sphere3. It came out of frusteration that all the creatvivity in the world associated with integration was thwarted due to the difficulties associated with trying to communicate the functional process. (that was a mouthful) In other words most geeks want to tell people "how" it's done instead of "what" will occur.

The "what" to me is like writing a book or a movie - there are characters, there are scenes, ther are props, and if all is done correctly there are great reviews. It makes what we do in integration design look really simple, which is good. My theory (which is shared by many) is a Nurse needs to be concerned with the patient and things that cannot be replaced by technology. There is nothing more frustrating then being handed additional technology to “make life better” which just complicates life more. Nurses should spend a majority of their time helping people – not fiddling with unnecessary technology.
This is a scene from my own life – and I encourage you to remember a scene from yours that will help you focus on the clinician and the patient. Remembering that the technology should be complimentary – the people should be the main focus.

One night, when BFB (Big Fat Baby - see our story) was in the hospital, he was having difficulty breathing. The Oxygen reader (aka 02 Sat) began it ring. I was "sleeping" in the chair next to his bed, my head propped against the side of the crib my hand holding the fat fingers. I turned my head to see the machine (which I had learned to read a few days prior) and the numbers where dropping. At first, I thought his toe thing is loose, so I unwrapped him to find it firmly attached. I began to follow the cable to the machine to make sure it wasn't unattached. As I did the door opened and in came the RN, followed by the Respiratory Therapist. "Please step back Kourtney" she said stepping between me and my bundle.


In my head all I could hear was a warning announcement saying "Warning! This is not a drill...".My heart stopped and everything around me seemed to be in slow-motion as the night nurse and Respiratory Therapist (among others) began poking ,prodding , and suctioning (to this day I can hardly look at that suction when I walk into a patient room for work). His skin looked gray, his fat arms barely fought the team as they suctioned, and worst of all - he wasn't crying. So, I took on the role for him. Crying dosen't really describe what I was doing - sobbing unconctrollably - the kind of experience where you know at the end of it you will look like a prize fighter. David had emerged from the bed in the back of the room and tried to comfort me. We didn’t want to watch but it was like a train wreck that we couldn't help but watch. As it ended and it seemed as though someone gave the "all clear" signal - the nurse turned to me and I said "is he going to make it through this?” She was experienced, had as many gray hairs as my mom, and had kept her cool the entire time. The kind of person you want in a foxhole with you - bullets wouldn't faze her. "The worst is almost over" she said as she touched my arm and smiled. Though she didn't say it I knew she was saying "he's going to be fine". After the group left the room - I returned to my watch post at the side of the bed, reached in, and my fingers were met by the firm grip of BFB.

A Nurse’s primary role is to care for the patient - do things that we can't do ourselves. Her secondary role is to assure you - in a way that few can - that all will be ok. Neither of those things can be replaced by technology.

Our job as "technologists" - "integrators" - "geeks" is to enable these people to do what they do best - help with people. If what we do gets in the way of those roles our use is meaningless.

Intuitive Caller ID

During many of my phone interviews with CEO’s “Please excuse the noise” is often referring to airport pages, bustling people, or highway traffic. This particular late Friday afternoon, Todd Plesko, CEO of Extension, was referring to his family – namely a gaggle of children preparing to head to the lake. Making family a priority is a challenging thing to do when you are running a start up (from the voice of experience) but he has chosen to set priorities according to his values. He sneaked in an hour of time to talk with me about his company's rise from concept to actual.

As we chatted about industry changes and his appliance style “Red Box” (which makes me think of movie rentals.....) I kept thinking how is this software different from any other Integration Software on the market – or is it just another “Me Too” application to ride the wave of Cisco’s movement (did I say movment - oh I meant potential Tsunami) into the market. Then almost in passing he said something about “Caller ID” and I thought "Did he really just call Integration Software Caller ID?" To reduce the solution to that seems is to reduce value and make it appear like something that a call manager could do.

However, as I listened the story became really clear.   What Todd and the team are claiming is not "Caller ID" like you would get from a simple SIP interface, it's multiple pieces of data compiled into one. Think about it - here is a team that started as a ReSeller of GE Centricity, created a hosted solution, and has a strong foundational knowledge of HL-7 and medical records. This is not a integration software company focused on alerts - this is a healthcare company focusednon information - or to use Todd's words Aggregate Data.

I think that better terminology is "Intuitive Caller ID." Intuitive because of the ability to garner information from the medical record and build a messaging structure that includes not only an alert but decision enhancing data. Their strength appears to be more data rich message need such as Lab. The challenge will be communicating that to the marketplace and delivering on the workflow design.  The product has a lot of flexibility to the "what" it can become challenging to determine how much is needed when and how.  

I think it sounds interesting, but I haven't seen it in action therefore it wouldn't be fair for me to note it as a solid solition. However, Todd claims 25 installs in the United States and he claims all as raving fans so if you are looking at the product ask for the list and call. (A little word to the wise make sure you talk to a Clinician and an IT person and if possible BioMed)

All of these incredible points about the platform weaves a great outlook for their product, however it has two very notable weaknesses. Integration software companies are easily assessed by their ability to integrate to telemetry and the quantity of available output points. Extension is really limited in both areas - they have no current telemetry integrations. A strong Telemetry relationship is important as that information point can be critical to a hospital’s mobility plan. Though there are many work around design models, at some point it needs to become a cog in the workflow communications plan.  Second, current state they only integrate to Cisco VOIP wireless phones. Though Ciscos presence in the marketplace can't be ignored - they are the Golliath of every industry.  Nor can you think little of any company hitching their wagon to them - it is Cisco. The handset has a lot of challenges with durability and the integrations I have seen the user interface for alarm messaging can take several button pushes to get to the information. The biggest benefit Cisco VOIP phones have - brand and recognition by everyone as a leader in every aspect of IT.

Todd and the team at Extension do have a strategy to begin to expand their output device capability as they plan to launch an intuitive message platform for the Iphone, Droid, and Blackberry in September. They are targeting Doctors with the ability to use their personal phones to obtain data about their patients and interact with it in a meaningful way. While I see it as a response to the Voalte, Amcom, and Connexall solutions their plan is to raise the bar by offering a FDA Class 3 certified solution. I look forward to seeing it.

Thanks again to Todd for the great conversation.

Workflow and Growth

I have found with a start up there are several rules – I think of them like the If / Then statements we use in developing our software.


The three that I have found to be critical are:

1. IF you don’t have enough Capital THEN you are hosed.

2. IF you don’t make the right relationships THEN you are hosed.

3. IF you don’t create replicatable processes where every move isn’t hinged on you THEN you are hosed.

The third item I noted is one of my favorites – hence the reason for writing the Sphere3 Workflow Tool aka our software program. I don’t like to do the same thing twice, and it kind of drives me nuts to watch someone else do repetitive processes. (Once I have figured out the puzzle you might as well garage sale it because it’s not like revisiting an old friend for me, it’s just dull.)   I think that’s why I like to look at workflow – while there are patterns there are also variables around those patterns keep things interesting.

I recently found a kindred spirit in this vein, Tony Marsico, CEO of PCTS. Tony stopped by our office on a recent trip to Kansas City to get the “Grand” tour. Tony has a graduate degree in documentation of complex processes and corporate training. (No, I didn’t make that up, and yes I did laugh when he told me.) Which makes him perfectly suited to run PCTS, a analytic software firm that provides business intelligence for hospitals via an RTLS system.   He is an investors dream with his ability to clearly document and communicate process back out to his team.

PCTS provides real time business intelligence for Operating Rooms and Emergency Departments with “air traffic control” like screens, mobile buttons, and integration to systems and medical records. The really interesting thing about their product is its ability to run workflow rules and associate them with other rules. (That’s an over simplified way of describing that) Breaking down processes to physical movements, allowing for interaction levels and not only the “time association stand point” such as “IF the RN is in the room for X period of Time THEN do XYZ” obtaining information from other systems to validate the entry and interaction with patient specific information. All of which I have seen in “Demo” mode.

As I have said before I usually don’t believe it until I see it and PCTS was gracious enough to take me on a site visit and let me watch their team in action at Cook’s Children’s Hospital. This was an asset tracking project, so not nearly as complex as the workflow in an Emergency Department or OR, but interesting and exciting. The team was incredible, and the processes appeared to provide real time value to staff.  Including the ability to better locate, identify, and collect recalled pumps and modules.

It’s important to note – while PCTS is dependent on RTLS they are NOT an RTLS company. However, they do provide RTLS products. Tony’s explanation made a lot of sense.   Analytics based on workflow using RTLS is not simple and the validity of the information is a direct correlation to the installation of the RTLS product.    His challenges, similar to many companies I have talked to, is who to hitch his wagon to. He is in need of companies who understand analytics, understand workflow, and understand the relationship to hardware. (That last point may sound “easy” but take it from the voice of experience it’s not)

My assessment – Tony Marsico is an Investors dream - he could "McDonalize" processes within a company.  He has also surrounded himself with good people - which I have found to be the key to building a successful people.  (Yes, that's my secret - I hire people smarter than me.)  He is driven, intelligent, and has an eye for creating better workflow inside his firm and outside.

Tony’s Most Recent Read: Inside the Tornado – which I read the following week and it was a really interesting read. (Note to audience: Just read the first couple of chapters and you will get the gist of the entire book)

Sphere3 celebrated our first birthday in May. Though there was no noted celebration there was a strange, we have arrived moment – meaning that the phone has been ringing a lot and business is definitely starting to move. That momentum has really increased my travel - which has noteably decreased the blog posts. Stay tuned there are good posts to come later this month: Chad West, CEO of Ascom Wireless and Todd Plesko, CEO of Extension

Who put the "I" in Innovation....

It seems anytime you put an "I" in front of a product it can represent a number of different things.  In healthcare it means innovation, interaction, intelligence, and integral.  The goal however is to make sure that it does not become irrelevant, inferior, or illogical. 

The I-phone has spurned a number of discussions because of it's innovative nature.  The product has been built on a platform that allows everyone to create their own "Aps" - in my world that means design their workflow in a way that works for their unit not generically designed to work in all applications. (just a quick warning that can be bad also)

The flexibility of the platform that is open to large and small organizations (and individuals) is the best way to drive new ways to solve problems.  Let's face it - it's not always the big guys with all the ideas.  It's also not always those of us who break out and build a business - more times than not it's the people who live in the situations everyday. Therefore, the intelligence in the product is built by the users, and the flexibility allows it to become an integral part of the workflow and daily life.  So integral often times we overlook product "issues" such as durability and compatibility with infrastructure.

The challenge will be how do we make sure a strong "I" shaped platform does not become irrelevant and illogical.   The best way to approach this is to make sure that it's the workflow that drives the innovation and not the innovation.  Cool - for Cool sake - is not so Cool.  This is not meaning you need to run out and hire a Sphere3esque firm to document and help design your wireless device workflow - it just means if you are not currently doing it - why not? What innovative value are you missing?

The I-Phone is driving people to design applications that can be used in the healthcare space - in my world that's for automation of alerts to a wireless device.   Amcom releasing software that will automate information to the Iphone is interesting, but as you saw in my previous post about Voalte that application for clinical alarms to the Iphone is still hard for me to accept.  Durability has to be in the decision process for a clinical device not just innovation.  Also as we drive more information to a single device are we really making the best decision?  It sounds logical - don't get me wrong - one device that can get alerts, call the on-call doc, use decision making software, access facebook, see information on a med record, etc sounds great but is it really the best choice?  (I am throwing that out there for interaction sake because honestly I am not sure - I see benefits but I also see a lot of limitations due to the critical nature of alarm automation)

The device has more application to those who work outside the hospital, like a doctor but then the question becomes what information does he need that requires integration to the hospital.....this I know, but I will let  you ask me to find out.

From a market perspective - it's only good news to have multiple competitors in the on coming tornado that will occur with smart phones. 

Command Centers

In a strange turn my blog has lead me to interviewing – ok so not really interviewing more having conversations with really interesting leaders in the healthcare medical device community. I want to be transparent – probably don’t need to say this because it’s apparent – I am not a journalist and 100% of what you read is my opinion.


Since the blog started last May, I have encountered all sorts of people. Some I like- Some I didn’t like so much. One that I have really enjoyed getting to know, during my contracted work with his organization which is now complete, has been Chris Heim, CEO of AmCom Software.

Chris is a genuine nice guy which permeates the corporate culture of his organization. He is genuine because he has never forgotten his roots.   He started in a garage - not in a band but building a shipping software platform that grew and grew and was eventually sold for multi-million dollars.   A lot of people would be pretentious after achieving that, not him.  He is down to earth and even willing to talk shop and understand the journey of little start up software company like mine.  Just because he’s a nice guy doesn’t mean he isn’t competitive – think of the way that Magic Johnson and Larry Bird competed – tactically, well practiced, engaged, and with a team spirit. That’s the competitive attitude of Amcom.

In 2007, Am Com Software, an operator/ call center company, saw an opportunity to enter a market space purchased a middleware company called Com-Tech. From the view of most middleware players Com-Tech was a simple “point to point” solution, one that wouldn’t rival the depth of Emergin, the flexibility of Connexall, and the integration to wireless power of Ascom. While the perception of the product is a challenge, the team behind it is building a well researched powerful offering.

Even at a high level view AmCom has a unique market opportunity. Their core product is operator or call center software, with a unique application that provides doctor on-call contact information. Since I have only seen in it a lab – the view is appears well organized and easily attainable. If you were to create a central call command center, then the operator software and middleware for alarms this could be a valuable pairing.

Communication from a patient perspective is any interaction dealing with their care, whether it is a with a licensed care provider, a volunteer bringing an extra pillow for their spouse, or even with the dietary group to order lunch. Communication from a caregivers perspective is any interaction from a patient, other caregivers, doctors or services provided that enable them to provide better care or services within the hospital. The faster triaged information can be provided the faster care can be administered.

Notice that I said triaged information. Information overload can hinder the effectiveness of the hospital’s performance. Sometimes I hear caregivers say, “we had pagers and/ or phones but we quit using them because they didn’t help”. Most of the time they “didn’t help” because the information was not provided in a usable fashion – in a central command center portions of the communications can be triaged and managed more efficiently than by pure automation. I’m a geek – I would like to say let the computer make all the decisions, but I have also been a patient, a patient advocate, and a parent –human interaction is more than just obtaining and triaging information.  It's about connecting - not just systems, people.

If you look at a central call command center from the view point of one communication point, it is really just a fancy phone booth. (not discounting it's importance, but couldn't we do more?)  The value of that command center is exponentially increased by leveraging it for additional abilities.   Even non-clinical - Think about the value of this application from a Mass Notification Emergency Communication standpoint! (see previous post on Seattle Grace)

It appears to me that the AmCom suite coupled with the Com-Tech software could be the “Killer App” in a command center design. Granted, I have only seen this application and their middleware piece in a lab environment. You all know my stance, I have to see it live to believe it would really work. (I do live in the Show Me State)

AmCom has a lot of "futures" planned and they have an impressive team of individuals who are working to build a really powerful very well integrated platform.  I look forward to watching them grow. 

To Wash or Not to Wash....

Recently, I enjoyed a spirited conversation with Hill-Rom’s GM and Vice President, Mike Gallup. Mike is a former IBM consultant who has been tasked with creating an unstoppable force in the Hill-Rom HITS (Healthcare Information Technology Systems) Group. His goal is to systematically coordinate the design of applications, creation of partnerships, and integration of collaborative initiatives that will strategically confront the marketplace status quo.  He was gracious to share his thoughts and a new project that they are going to be launching soon.

Hill-Rom as written and developed a patent on hand washing that should cause the industry to sit up and take notice. Hospital infections are costly and many are preventable. Those two items are ear perking to people who focus on providing value to a hospital. Not to mention the pain and discomfort that they cause a patient, and potential additional infections throughout the hospital. The ability to decrease infection by a simple hand washing or sanitization is crucial. To put dollars to the thought, according to Hill-Rom MRSA infections can cost in excess of $200,000.

Hill-Rom approached the marketplace trying to identify a strategic partnership with an RTLS provider that could meet the system and software requirements developed in the patent. After much research they decided on Centrak. Centrak’s ability to get granular in the patient room allows for the proximity of the caregiver to the dispenser to be identified. It also detects the actual motion and interaction with the cleaner.

Sound a little like Star Trek? It’s not.

The concept is actually quite simple, but software and application is really brilliant. The motion sensor within the Centrak tag notices movement of the dispenser when it is touhed and the badges correlate the proximity of the caregiver. To “fool” it you would actually have to have a caregiver bump the dispenser on purpose and not clean their hands. This would seem to be a farfetched idea. I am not an expert on hand washing, by any means, but I would assume that a majority of the time that a caregiver didn’t wash their hands prior to interacting with a patient would be more out of forgetting, and not intentionally avoiding.

I see this as a brilliant tool. Since it’s a standalone system it could be tied into a number of different integration points to track the effectiveness, but also offer some proactive notifications to the caregiver or manager. While the application is not prime time at a facility today the system has made it through all of the Hill-Rom and Centrak’s internal testing. Mike’s projection is to have it live within the next three month.

Thanks again to Mike Gallup – www.hillrom.com I look forward to more spirited interactions about healthcare in the future.

The Trauma at Seattle Grace

Normally, I would not blog about a television show, especially Grey’s Anatomy. Personal views aside, I was drawn in to the finale this year.  A disturbed man entered the hospital with a gun and the facility went on lockdown. Doctors, Nurses, Visitors, and Patients were held in terror for 2 hours as he made his way throughout Seattle Grace. No one permitted in or out as the local police department determined the proper course of action. No one inside knew where the shootings were occurring, or what to do to protect themselves. The shooter made his way through the building killing and terrorizing all.

Hospitals will be receiving increasing pressure from AHJ (Authorities Having Jurisdiction) to be prepared for these types of events. Seattle Grace (as depicted in the show) was horribly ill prepared and it resulted in a number of dramatic losses and over dramatic saves. It was as if the building had no internal security system. (They should partner up with the hospital on the tv show 24 – they were able to view cameras in the hospitals on a tablet PC - by the way that's not as difficult as it may sound)

Here are just a few thoughts on “acts of terror” on a hospital. The security office should have access to view both internally and remotely all security cameras.  They should have a cooperative program with the local police department.  Providing access to the local police is not as challenging or space age as it may sound. Digital and IP based cameras can be network based or the Video Server can be leveraged. The security plan and threat assessment should determine how to notify staff of the location of the shooter. The Mass Notification should identify the following: What is occurring and what should the people do to be safe? Imagine if there were a series of cameras in the hospital that could identify where the shooter was and begin to strategically lock down areas within the hospital to keep him out. You can’t necessarily evacuate a hospital but you could minimize casualties by limiting the shooters movements within the building.

Additionally, there was no internal communications occurring. The doctors had pagers, but there were no internal wireless phones. The saddest scene in the show was when Dr. Bailey dragged the dying young doctor to the elevators only to find they had been shut down. She has no ability to call for help - she had to sit and hold him as he died. She had a pager. If she has wireless phones in this situation she could have called a central command post. To take it a step further, if there was a central command post they could have been able to see the entire situation unfold on a camera and have dispatched a help team.

This TV show depicted what Mass Notification Emergency Communication (MNEC) is all about. It’s sad that we live in an age where people find release in killing others, but casualty counts can be reduced if proper security people, process and technology are applied.

MNEC is really about choreographing movement based on the threat that is occurring. It’s about knowing who needs to get what information and how are we going to get it to them.

Power to the Pager....

Buzz Buzz the PCT’s pager sounded as he was taking my mother's vitals. He stopped – looked at the pager – then smiled and said “I never seem to be in the right place at the right time.” He silenced the pager and went back to checking her vitals. Before he could finish the pager sounded again – frustrated this time he smiled wearily at my groggy mother and said “I am popular today”.

The trouble with pagers when used in a decentralized methodology is their limitations on actively interacting with patients and the call while mobile. The message is received and its plain simple information about the patient such as the room number, the call type, and whether or not this is the initial notification. In a straight nurse call to pager design – even though they are cost effective they are not very effective. That’s not to say this is a useless piece of technology, because if applied correctly it can be very effective.

The reason that pagers are purchased in mass quantities for hospitals is primarily the price. They offer low initial cost and low total cost of ownership. While I am all for creating low cost options for alert designs and see pagers as very applicable in specific situations there are limitations to these power packed little boxes. For those of you who talk with the CFO – “if designed correctly – pagers used in a workflow application can see a payback potential”

Designing workflow in a way that properly leverages the power of the pager is critical. The power of the pager is it can be non-intrusive if used correctly. The Caregiver needs to know that there is information attached to the page that is specifically for them. They need to know that the patient need has all ready been triaged and that they can quickly and efficiently answer that need. For example, a pager should be used on Normal Calls only if triaged through a central point (whether through the PBX or Unit Secretary or Others) However, pagers can be leveraged with other emergency call types – such as Code Blue.

One final tip on pagers – this is a freebie – NEVER use an external pager system to automate a Code Blue. A Code Blue should only be automated to an internal paging system such as WaveWare. The latency and delays are a patient safety issue and should be seen and addressed that way. If your hospital is currently using an external paging system your delays can be in excess of 10 minutes during peak times. If your hospital is using an external paging system then the CFO will be pleased to know that by replacing 90% of the pagers with an internal system there are HUGE potential savings.

So the moral of the story – use a pager if you would like but design it properly.

A Personal Note: Spending time with my mother in the hospital brought back a lot of the initial reasons I started Sphere3. Ironically, it was 1 year ago this month that we launched. Designing alarm automation often times we get caught up in the geek side. It’s cool that through the air we can make something ring or buzz – it’s interesting to examine process maps and charts, apply lean principles that help us assess the efficiency of the process.

However, when you sit with your mother in a patient room – watching her recover - helplessly knowing that the red button is the only methodology we have to engage the outside world – your eyes are opened to the other side of the map – the human side. The human side is where lean and process don’t always compute. As much as we would like to make the processes as straightforward as building a cheeseburger at McDonalds the fact is my mom wasn’t a cheese burger.

I want to thank the team at Columbia Regional Hospital in Columbia, Missouri. My mother received excellent care. It wasn’t just the care that she received – it was the non-clinical emotional care that we all received while in that hospital. It was the true demonstration of team work that I saw between team RN and her Care Assistant. The friendly and helpful volunteers, and overly helpful support staff. Thank you from the bottom of my heart.

There's an Ap for that....

Some of you that know me well – know that growing up some people had pictures of Rock Stars on their walls – not me I had a file cabinet and books by Jack Welch. (I am serious, I asked for a file cabinet when I was 12 so I would have some place to store my budgets and letters). In other words – my rock stars were CEOs, movie producers, innovative genius, and other leaders. So, being able to talk with a great CEO is always high on my list.


I had a great conversation with Rob Campbell the CEO of Voalte. Rob, as you might know, has worked with the likes of Steve Jobs and Bill Gates on a little program – not well known at all – PowerPoint among others. Just talking to him was incredible. He has an amazing business mind and a keen understanding of the healthcare marketplace – which is surprising since he didn’t come from the file and ranks of an EMR vendor, medical device manufacture, etc. He is really an outsider who has stepped in to help launch the first Healthcare iPhone “App” for medical device connectivity.

What do you really think about that – an iPhone in the healthcare environment? Since I have been through 4 (yes, really) in the last two years I am a bit skeptical. The device, while loaded with features, is fragile. Dropping at the right angle can shatter a screen (been there) – not to mention that scratching a screen can render the device useless (done that). In addition the battery life can be – let’s say challenging (got the t-shirt). I have worked with wireless internal communication devices in hospitals for more than 10 years. They are as abused as a rental car in a third world country. That’s why Cisco rushed to replace earlier models that weren’t suited for being crushed by a Stryker bed, Ascom has made their phone survive the swim that often occurs when a Caregiver helps a patient off the toilet, and Spectralink’s case can be dropped and kicked down the hall.

Now, before you throw your hands up and run screaming from the device think about the flexibilities of what they have just developed. The Apple iPhone is one of the most user friendly devices on the market. If you are using the wireless device to receive patient calls and the average patient call per hour is 1.5 then making the “answer” function easy is essential. I challenge you to try answering a Cisco phone. (Hint: there are more than 3 button pushes to answer and speak with a patient) I don't claim to have experienced the Volate Answer process, but from what I have seen it appears very straightfoward.

Stop for a moment and think about the flexibility of this concept. How many Nurses currently have a “Smart Phone”? How many are using the facebook, twitter, yelp, urban spoon, or other crazy ap? The device is like a piece of clay that can be molded to it’s environment.  Aside from that it's fun and easy use.  The smart phone can display pictures, it can use decision assistance medical programs, and that little thing – enter information into the EMR.

If I didn’t say I was enamored with the concept – I would not be truthful. We are talking about Apple here – Steve Jobs is the Walt Disney of cool gadgets.   If I didn’t love my iPhone why would I have spent the money to replace and repair it 4 times...or maybe 5.   The device is great – it offers a lot flexibility to the hospital workflow. Some may argue that it also provides a lot of challenges for a hospital when it comes to policy of what is appropriate use, but no more so than a PC.

I recommend checking out their new website http://www.voalte.com/

BTW - anyone who wants to indulge me the one CEO who has been on my list for years is Meg Whitman, former CEO of Ebay.

Translation Fascination Part 2

The brilliance behind the early device integration software pioneers was the building of the library. There is significant VALUE  in the library of integrations. Anyone can build a little black box with a rules engine. (Please don’t throw things at me Integration Software folks - it's only slightly sarcastic)

Many different models have been taken to gain the library. Some “skim” the information off without building a relationship. This is a dangerous model that – while it works – updates can be missed. Some charge a fee to device manufactures which may seem like a poor model and not “open” but actually is smart. It makes people put skin in the game to ensure that development completes fully. Some work hard in the industry to build mutually beneficial relationships seeing a Co-development relationship that has more value long term and being less focused on the short term capital needs.
So why are these relationships so crucial? Think about it the changes in the language that might affect the way things are processed. Imagine if someone from 1776 tried to translate for someone in 2010.  "OMG that is so wrong - lol."  It wouldn’t work so well. That’s why building relationships between Integration Software and Device Manufactures is really important.

Sounds logical – almost easy right? Wrong. There are many device producers that are closed nations – they don’t share enough about their language to allow for high level translation. 

So is "Interoperability" a dream?

Translation Fascination

I have blessed to travel to several countries. I am always excited to see the sites, experience the culture, and of course – eat the food. One thing I have learned is in the countries where I don’t speak the language (so anywhere that they don’t speak English or Spanish) I can do very little without a translator. Believe me hand signals and acting out the need can only get you so far and does not work well in restaurants….and I do love to eat.

If you think about interoperability engines – each is a translator that allows for multiple items to speak with each other. The more “integrated” a engine provider is to the device the higher the level of communication you can provide. For example, I studied Spanish in a Classroom for 6+ years but I didn’t learn Spanish until I immersed myself in the culture and language when I lived in Seville, Spain. The culture and the language enhance your ability to communicate. The same is true for device integration – the more immersed you are in the product, the stronger the relationship - the more ability it will have.

Stay Tuned for Part 2

Top 5 Nurse Call: 2& 3

2) Which has the best equipment warranty and lowest cost of ownership?

Nurse call no matter how you slice it is equipment. Equipment needs maintenance – physical maintenance. An electronic component breaks down.

As equipment, once it is in the wall it is challenging to replace due to back boxes, cable and other “installation” issues. The house we talked about previously if you decide you would like new Kitchen Cabinets and countertops once you change what is there it is really cost prohibitive (if not prohibitive, it’s a really bad investment choice) to change it 6 months later.

Therefore, the long term cost of ownership is important.

3) It’s broken – now what?

As Nurse Call Systems enter the realm of VOIP it is amazing that the support structure Du jour is “off site” or “call center” similar to the change from full service to self service at the gas station. As described above, a Nurse Call System is hardware that is controlled by software that interacts with other software and systems.

The item I do think is valuable is using the hospital help desk to assess the issue, but they need to be aware that diagnosing the issue is more than just dialing into a software platform and making an assessment. If a clinician calls in on a fully integrated system and says “my phone doesn’t work” then the person answering the call needs to know it’s probably not the “phone” that’s broken. That’s why we developed a “Help Desk” training program that assists a call center in diagnosing the problem in an integration.

It is necessary to have an available group to be on-site within a period of time. If your disaster plan or maintenance plan categorizes a Nurse Call System to only be down for a set period of time then you need to make sure a response on-site can be within that time.

Top 5 for Nurse Call: 1) Can it do the workflow we have designed for our hospital?

Pre-Determining how the system will function is the only way you can determine which system will fully meet your needs. This can be done internally but utilizing a 3rd part workflow designer. If you are a do it yourself kind of place figure out what you are doing currently and how it would need to change to be better. One of the biggest mistakes made is allowing an equipment vendor to design the vision for a patient call system. Yes, they have experience but they are also partial to the system they are providing.

To put it in perspective, one of the largest personal purchase decisions you will make is buying a house. When evaluating houses inevitably you will begin to picture yourself in that house – what you will be doing? If you visit the house and the listing agent (seller's rep) is there – they are going to direct your eye to all of the “great” features and downplay any of the features their house is lacking. For example, if the house is a split entry the selling agent is not going to point out to you that you will be climbing stairs every week with multiple trips to carry in groceries. They will be directing your attention to beautiful view of the Cul-De-Sac and how your kids will love playing there.

The same is true for Nurse Call (stay with me techy geeks) If you have all of the Nurse Call Vendors present and you do not know what is important to you – then they will tell you what is important to you based on their systems capabilities. This is called features based selling. It’s not wrong or deceptive. It’s them presenting their product in the best way possible. It’s only deceptive if you ask them if their system can do something and they tell you it can when it can’t. Or they sell you a “road-mapped” item as current.

Entering the house with your top 10 criteria is the best way to approach purchasing houses. Understanding why you are purchasing is crucial. Has your family expanded, therefore you need more room? Are you getting older (or plan to grow old in the house) and need fewer steps?  Carry this thought process into purchasing a nurse call system.

The best tactic for reviewing vendors is to provide them with pre-determined workflow prior to their presentation then let them explain how they would provide you with that workflow.  Verify they can meet the expectation.   At that point they can show you additional items you may find of interest based on their products specific capabilities. This IS valuable information because your core need is being met. Their additional “features” then become the icing on the cake.

Stay Tuned for #2 Evaluating equipment warranty and lowest cost of ownership?

Patient Communication & Technology Part One

People ask me all the time why Sphere3 addresses Nurse Call first when we look at Alarm Automation. Quite Simply - it is the hub of all patient interaction at a hospital. If you want to see immediate change then address the way caregivers are interacting with patients. Nurse Call is the only Patient controlled device in the room that is related to their care. (Yes, interactive TV people may disagree) It is a life line for patients to interact with people who know how to help no matter what the request.

This is a medical device that is required to be in every hospital for notification of patient need. However, if you are just using it for that type of interaction then you are not fully leveraging the investment. For example, if you can purchase a button that can be used for bed management as opposed to a bed management system then isn’t it leveraging that base platform more efficiently? The key word above is “required” but the key idea is how do you leverage a required piece of equipment for innovative workflow processes that are outside the basic scope. Nurse Call purist will disagree with this point by saying that adding extra workflow processes decreases safety. By not using the system for its intended use you actually increase risk that a peripheral function would disrupt a critical one. However, most platforms are designed so that you can’t disrupt a critical process unless it’s not implemented correctly.

Further, when evaluating the system it’s important to define how it will be used. I have found that a majority of the time the system is being evaluated on a few key features – not necessarily on how the system will be used. Don’t follow the Shiny Ball folks!

To put it in other words – a hospital knows they need a nurse call system for communication but rarely has its uses or additional workflows been pre-defined. Many rely on vendors to provide outlines and designs on how the system set up, but that’s how it is looked at as “system setup” not workflow. There may be some base anecdotal type information about wanting to “send it to a phone” but not a true plan.   Having a plan of how each aspect of the nurse call is to be used prior to making a purchase decision is crucial.

Important: System design is how the components and cabling are put into the hospital. Workflow design is how the caregivers use the system. Workflow design overlaps system design because there are specific component needs that enable the workflow.

Stay Tuned for the next post: Top 5 things a hospital should look at when evaluating a Nurse Call System

Keep it Simple Sweetie.....

I was recently asked why I related healthcare IT to a car in a previous post, and did I think that it made me sound less “techy” or intelligent?    Forgive me while I soap box a bit - One of the things that bothers me about healthcare IT is we use overly fancy words, acronyms, and phrases to describe something really simple. While I understand this is similar in many industries – for example, the dentist yesterday he used 15 different words to describe my sore tooth. It’s the second tooth from the back on the right side people! Bicuspus chomper regularus painfulugus!

It would be easier if we could all just translate a little. That’s why I try to use a lot of non-healthcare and non-IT analogies. Not because I don’t understand – because I do. I understand that to most people we work with the concept is more powerful then a detailed description of the program or Code. The result is more critical then the how.

To those of you who program – don’t get me wrong I understand that the details must be covered and if not then the concept can never occur.  To those of you who live in the concept – the details drive you nuts but without them your vision is just words.  Words accomplish very little.

With everything occuring in Healthcare IT - communicating between technical and non-technical people is critical to making things work right.

What do I know?  I am just a little gal from Missouri…..with a company that takes “Anything that rings, dings, or buzzes and we design the workflow to get it to a wireless gadget that a caregiver carries.”

Grady Health Systems Surgical Service Workflow

At HIMSS I had the opportunity to tour the Surgical Services area of Grady Health System in Atlanta. The visit was facilitated by Centrak and hosted by Hakan Iliken the Director of Anesthesia and Director of Process Improvement. Iliken was an exciting individual who shared his vast knowledge of process design which is rooted in his Industrial Engineering, Software Development, and CEO background. Iliken is in charge of making sure the technology applies and assists the caregivers, patients, and doctors throughout the day. What I found unique about Iliken was his ability to not only look at things through clinical glasses, but also examine it with a business mindset - balancing clinical and business.  The technology implemented was a Centrak RTLS System tied into a Perioptimum tracking board.


According to Iliken - The Goal of the Implementation is to “Improve Surgical Services throughput and productivity by utilizing a system with Real Time Accuracy.” A secondary goal was to "Increase Transparency."

The Primary Goal is “easily” definable – increase utilization, and ultimately increase revenues. Iliken has seen a 10% increase in Utilization during Prime Time. They are mobilizing staff and moving patients more efficiently and effectively, and they are able to identify bottlenecks readily.

One of the key ways that they accomplished documenting efficiency was to utilize the three flexible buttons on the In-touch badge. The way Iliken designed the processes ,which were enabled by the technology, is each button represented the next step in the process – the wow factor in the design is as the badge physically moved into a different area (Pre-OP, OR, PACU, etc) the buttons would change meaning.  Thus, offering extreme flexibility.  For example button 1 (represented by a *) means “Anes ready” in PreOp, in OR it means “Induction Begins”, and in PACU the same button means “Phase 1 Complete”.  To aide in the ease of use color coding was used on the tracking boards in the staff area recording and identifying the patient’s location and specific steps in the process.  Each staff member is provided with a "cheat sheet" that is card sized and fits into the ID badge holder.  In addition, since the button pushes were not tied to a physical item such as a wall it provides for additional future flexibility.

The ability to dissect a process is a powerful tool. Think of it like an assembly line at Ford. Each person in the process touches the product, and with extreme accuracy they can identify where the issue occured. They can also identify if it was a people or process issue.  Can all of this be achieved with RTLS and process design in a hospital? While I am on board with lean and six sigma design and the ability to reduce errors by using strict process – I believe that healthcare at its core is about people helping people. People who are sick and people who are taking care of them – no matter how we try there will always be a people element. Technology is a tool – it’s not always total the answer.  
Stay Tuned for Part Two - The secondary goal, I found most fascinating, probably because of my groupie like appreciation for Paul Levy’s blog. Transparency means no holds bar real data – the truth that bypasses the finger pointing and assumptions.

The Patient Within the Code

HIMSS made me have one of those “Wow” moments where the world was once flat and now is in full Spherical shape. I was amazed at the bright colorful booths, the well dressed executives, and the hustle and bustle of it all. As I had a complete geek out moment – playing with widgets, talking tech with providers and hospitals – I began to get lost in the forest of tech and saw how it would be easy to lose the patient amongst the code.


Technology is enabling – Technology is empowering – Technology can become overwhelming and overused.

I had the luxury at HIMSS to tour Grady Hospital with Hakan Ilikan, Director of Process Improvement. Ilikan’s passion is to see technology make life better for the caregivers, patients, and families.  I will tell you the full story in a later post, but one moment stood out.  As I walked through the waiting room of the OR my gaze carried past the screen of information about the patients progression through surgery and I made eye contact with a woman – for a brief moment I was reminded why we are all doing this – for her and her loved one.

How many times a day does the patient enter your conversation?
How about their family?
How many times a day do you visualize how your technology helps them?
Does your technology really help them at all?

Maybe I am the only techy geek that sometimes forgets what it’s all about – maybe I am not. I keep a picture on our website which serves as a reminder for myself and my team of why we do this – why we focus on making life better. 

Technologists – Manufactures – Service Providers is it possible that we are so consumed with the competition, development, deployments, that the patient becomes de-emphasized in our equation?


Don’t misplace the patient among the code – Don’t forget why we are all in this game.


We as a company have not shared our Vision but I think it is important – it’s not long – we didn’t hire a large consulting firm to help us –it’s pretty simple “To Make Life Better” followed by our Mission “To Empower Organizations with integration of people, process, and technology.”

Disruption is NOT Always in the Initial Splash

Disruptive Technology – at first glance it almost sounds negative. Disruption as a term means to throw into confusion or disorder. Disruptive Technology is disruptive to a process, disruptive to an industry, but most importantly disruptive to a mindset.

I sat in two conferences. One a group of well intentioned manufactures wanting to disrupt the space surrounding falls in hospitals and the other with a group who wants to disrupt current processes in healthcare by reducing workloads. Phrases like “Change is inevitable” and “If we don’t change then we will be left behind” resonated with me as I tried to collect my thoughts over the weekend. How does this add value to the hospital? How does a hospital make sure it’s not just one more PO on a piece of technology that could end up never being used because of its inability to fit into the life of the caregiver?

As we drove back to the office, my Analyst had a stroke of genius (which happens often) she said “You know that vital device we saw – that could save at least 30 minutes.” To which I replied “30 minutes a day doesn’t change much.” “Not a day! Every time they do that! Kourtney, that would allow us to decentralize at .…..” as she rattled on through several scenarios. (As a former caregiver, she is always excited to find ways to save time.) Then it really hit me – The disruption does not always lie in the immediate process sometimes it’s in the ripple effect.

Have you ever watched a pebble thrown in a pond or puddle? The initial splash is sometimes impressive but what’s truly impressive is to watch the rings as they multiply and span out over the water. Think through the ripples – there is an assumption that the time being gained is used for productive activities and that the productive activities free up another area.

As the ripple gets larger there are more related items that could fill that 30 minutes of time saved, and possibly more time can be gained in other areas. The direct connection back to “that” 30-minutes becomes looser as you move farther from the initial “splash”. In theory and on paper assumptions become strong cases to justify the actions/purchases of administration. I think we will see a lot of that in the coming year, and while skeptics might balk at simple associations – without the creativity of process design – no one would’ve found “that” 30 minutes and we would still be wasting it today.

Have you ever thought about that – let your mind wander through all of the things that one item changes? You have heard of 6 degrees of Kevin Bacon – what’s the 6 degrees of one innovation? How many rings does it make? That’s the true value.

My instruction “Blow it Up”! We work in an industry that is so ripe for innovation. There is a new era of change – not just change for the sake of change. We are not talking about technology that ends up in a recycle bin because its value was linked to “fancy” and not linked to improving the day of the caregiver. We are in an era where healthcare providers are demanding follow through on a promise and PROOF in the pudding.

Workflow Ability - The Final in the Series!

Workflow Ability takes into account the product life (base ability) combined with the technology life (things we can’t live without) and balances it against the Optimal Workflow. It is determined by examining specific parameters such as staffing, unit layout, and technical acumen. Optimal workflow is not wholly determined by the technology that is in place, but does take that into account as a limiting or enabling item. Onceit is determined then the limitations of old technology can be balanced and married with the enhancements of the new utilizing a unifying technology.

So, for example, a cell phone allows a person to call while mobile. In its raw basic form – it’s clunky – you have to learn to dial one handed, hold a phone to your ear and drive. (Plus drink your latte, manage the kids, and change the radio station - not that I have ever done that.)

The iPhone is equipped with a unifying technology called Blue Tooth. If a person wants hands-free calling utilizing their iPhone then they need to upgrade their car to a 2010 model with Microsoft SYNC technology. SYNC provides voice command dialing and open voice communications over the cars speakers. (Like a Vocera Badge) However, to get SYNC you have to purchase a brand new 2010 Ford. OR you can utilize a different unifying technology which leverages the abilities of the iPhone in hands-free mode over the car speakers. Until you purchase the new car, you will still have to do the one hand dial, but at least you can set the phone in the cup holder and drive with your both hands on the wheel at 10 and 2.

Now apply this principle into the world of nurse call or other healthcare technology. Upgrading an entire nurse call system can be in excess of $5,000 per room. I will be the first to tell every caregiver – the new system will make your life easier and offers a number of flexibilities. However, it is better to decide workflow prior to purchase, decide if you can utilize existing systems with a unifying technology – then make the upgrade decisions.

While the capabilities of the new system will become a necessity ( I almost didn’t drive the other day because my front end collision warning was not working due to the snow even though I have driven without it for 15 years) leveraging existing platforms is a real possibility.

Stay Tuned for Our Next Blog post – Disruptive Technology and its Influence on Workflow - insights gained from our recent trip to Cerner.

Product Life, Technology Life, Workflow Ability - Part 3

Technology Life Decisions are more readily linked to the exciting features that differentiate the products one from another. Some might call them frivolities, some might see them as necessities. Either way they are items that enhance the base goal of the product.

Technology Life Decisions are difficult to make due to the ever changing nature of technology. The “lifespan” for many technology decisions for medical devices is shortened to 5-6 years (sometimes more or less depending on the flexibility of the platform that is being purchased). Hospitals may delay purchase to wait for the next model to be released. Road Mapped items become decision points and actual realities become less critical. Not to say that a product, software, or service that has a vision for the future is unimportant but reality is more critical than vaporware.

Interestingly, the technology life decision points – things that a manufacture or developer creates to differentiate their product - often become base product decisions. Think of power windows. 20 or fewer years ago wasn’t it suitable to have a crank and before that wasn’t it a luxury to have a crank? Power Windows are an enhancement, but because of the end users interest they have become the standard. The point is often the technological enhancements won’t be enhancements for long .

Early Nurse Call Light Systems consisted of one light and one tone. Now we have systems that have unlimited light and sequence capability through LED and unlimited tones by allowing for wave files to be uploaded. Eventually, this will not be a technological enhancement – it too will become the standard.

So how do we bridge the gap between the technological enhancements of the new products and the apparent short comings of previous products. We believe the answer lies in Unifying Technologies coupled with proper workflow design.

For example, in a car, Micosoft SYNC integration allows the information from your mobile phone to download into the car and allows for voice command and hands-free calling through voice command. While all base capability of making a phone call while mobile is available using just your mobile phone, SYNC increases the value of the vehicle by enhancing your experience with the phone.

SYNC’s value is enhanced because of a unifying technology called BlueTooth.
Similarly, all nurse call systems can notify a caregiver of a patient’s need with a light and a tone. However, some can integrate to wireless phones allowing the caregiver to be mobile while speaking to the patient. There is intrinsic value to the time savings that a hospital will find by integrating their nurse call system to the nurses wireless phones. According to our research, over 30 minutes per day per RN or more depending on the style in which the integration is made. However, prior to today all of that is only possible with a unifying technology called Middleware. Interestingly, this "feature" and ability developed by a vendor outside of nurse call is becoming part of nurse call systems. Eliminating the need for a "unifying technology" all together.

Stay Tuned for
Workflow Ability and how you can transition from one platform to the next more easily and over a longer term investment.

Product Life, Technology Life, and Workflow Ability Part 2

The first step is to define the base purpose for the purchase. Every product has a basic underlying goal. For example, I purchase a car to get me from point A to point B. Yes, I am glad it’s red but red is not my reason for purchase – color does not necessitate a change.

A hospital purchases a nurse call system to notify a caregiver of a patient need. This can be fulfilled with ANY nurse call. The basic ability to light a light and tone a tone are the requirements for the nurse call system to meet code. The same is true for every medical device. They each have a basic function that has to be fulfilled. Features are provided to reduce the ability for the product to become commoditized.

The reason we need to appreciate basic functionality is to start to build on the decision points/ timelines. The first is Product Life. Just like your car, a piece of medical equipment cannot live forever, as the product ages the cost of ownership increases. Generally, the product life of a medical device is 10-12 years. This doesn’t mean it will suddenly stop working (though on occasion this may occur) quite simply put the older it is the more costly it is. Eventually, replacement parts will become more and more scarce, and ware and tare will take its toll. This is why for product life decisions items like Mean Time before Failure, Maintenance Costs, and availability of service providers becomes the basis.

Making a matrix of decision points on Product Life is a good way to assess competition. All products within a category should meet the base goal, but utilizing a scoring method to assess mean time before failure, maintenance cost, serviceability, and availability of support can solve half of the equation.

However, if driving from point A to point B were the only criteria that mattered then everyone would drive the least expensive highest miles per gallon car. The fact is that billions of dollars are made each year in the auto industry by creating vehicles to meet the specific goals and desires of drivers. Taking otherwise frivolous items such as navigation systems, built in DVD players, and (dare I say it as a frivolity) power windows and pairing them against the competition as necessities. Driving up costs and changing the spectrum of competition.

Leading to the next Decision Point: Technology Life

Stay Tuned!
Technology Life
Workflow Ability
Unifying Technology

Technology Life, Economic Life, and Workflow Life

“What color do you want?” This is the first question I am asked when I go car shopping. (Yes, it does irritate me.) While I see that is an important decision for most people, do people really buy a car for it’s color?

Wouldn’t it be more effective to ask – “Why are you shopping for a car?” This should be the question of every vendor pushing a medical device to a hospital. "Why are you purchasing this product? Why now? What initatives are you trying to solve with this purchase?"

If you look at purchase decisions. Most will fall into one of two timelines or life-spans: Product Life and Technology Life. Product Life is the underlying practical reason for the purchase, and Technology life is the technological enhancements we "can't live without". We believe there is a third area for medical devices that can leverage existing platforms, blend their usage with new product platforms making transitions easier – we call it Workflow Ability.

Technology Life = 5-6 years vs Product Life = 10-12 years

Workflow Ability can extend the Technology Life 3-5 years balancing out the difference between Technology and Product Life. It allows for proper transition between platforms.

So how do we bridge the gap between the technological enhancements of new products and the apparent short comings of a previous investment?

Many hospitals will simply make a Capital Investment and change to the new platform, but is that really necessary? In these economic times is that really a practical decision?

We believe that the first two decision points (product and technology), while important in making a transitional question are lacking in their ability to allow the hospital to make a long-term transitional change. We believe that Workflow coupled with unifying technology can really increase the lifespan of existing platforms thus leverage the hospitals original investment.

This is a LONG post so I am breaking it up into sections.

Stay tuned for more on:

Product Life

Technology Life

Workflow Ability with Unifying Technology

Patient Satisfaction and Value

Patient Safety initiatives can readily be linked directly to value for the hospital. If a hospital reduces one fall there are savings of litigation, and non-reimbursable care. Patient Satisfaction can be a little more abstract when measuring results – not that you can’t get a score very readily from a Press Ganey Survey. What does that mean for dollars? How can we measure our effectiveness in these initiative? Adding new dimension to this is the HCAPS Surveys and how they will affect reimbursement for care.

Every business uses some sort of performance metrics. Often quantity of incoming requests (similar to incoming patients) and quantity of “credits” given for mistaken work (similar to non-reimbursable care) – not that these are exactly the same in all instances but they are similar and make the point that tracking specific information can be helpful when improving business practices.

Sphere3 believes that a stand-alone metric, while valuable information, is less effective as one that is cross-referenced with another. For example, if a hospital were to look at average response time balanced with the staff to patient ratio and correlated with total average call volume – you could use the information together and create a multi-faceted metric. Then take that metric and see if there is safety improvement and if there is also an improvement in patient satisfaction score.

Most importantly, what is the link it to dollars? Will the hospitals elective surgeries increase? Will the hospital have a consistently higher census? I understand there are some large assumptions when loosely linking these two data points but the point is if you had the power to easily look at information such as (1) your response times, (2) quantity of direct interactions with patients, (3) average wait time before exit, and (4) total call volume, would you be able to make specific linkages to improvement in patient satisfaction? Would you be able to take that information and link it to increase in electives and increase in revenues based on increase of paying heads in beds?

Our new Sphere3 Scorecard™ will make it easier for hospitals to get specific information on clinician response and interaction which can be compared to patient satisfaction.

Call us for a full presentation.

Location, Utilization, and Movement

I had an interesting call with Will Lukens, Vice President of CENTRAK, a Real Time Locating System (RTLS) company. There are a number of debates swirling around RTLS such as what’s the best technology to use? (Wi-Fi, RF, Hybrid - Check out JHIM from Fall 2008 for further reading on the technology.) No matter what technology you use in the background, RTLS is a great mechanism to track the effectiveness of workflow for staff and “stuff”.

Step One is always to decide “what” you want to accomplish prior to deciding “how” or with which technology you want to use. The "what" or goal froma workflow perspective can be evaluated in three areas Location, Utilization, and Movement. Using these areas you can evaluate numerous abilities to track implemented technologies and initiatives.

LOCATION: It’s been reported that caregivers currently spend less than 30% of their time at the patient bedside, but that’s an average which is not applicable for every facility. Using RTLS a hospital could track the actual time frames that a caregiver spends with a patient and set a baseline for their specific facility.

Location is the portion of the puzzle that has the most value and the most apprehension. The ability to track caregiver’s locations with detailed reports of who, when is sometimes labeled “Big Brother” and “Micro-Management” and honestly, would you be pleased to wear a tag that tracked your movement the entire time you are at the office? “Bob, you spent way too much time at the coffee pot.” Using this as a coporate means of improvement as opposed to individual tool for punishment is really key.

UTILIZATION: “Work Around Artists” is a term that Karen Cox, Executive Vice President of Children’s Mercy Hospital in Kansas City coined in the last issue of Ingrams. That name captures the innovative spirit of the caregiver. They are the modern day MacGyvers using available resources to find more efficient paths.

Often hospitals will implement initiatives, or provide technologies with the desire to see an improvement in something that is lacking. For example, if there are high infection rates they may implement a hand washing initiative and provide a new sink in every patient room. What if the utilization of the sink could be documented automatically – even more so what if that information could be correlated back to the reduction of infection rate.

MOVEMENT: Frank Lloyd Wright would watch people’s movement habit’s to design walk ways. Once he didn’t put in a single side walk at a University until after the students had worn paths to show where he should be putting those walk-ways. RTLS is the modern day observation and automated documentation of movement habits. A caregiver walks 1 to 4 miles per day (depending on size of facility and quantity of patients) often a technology is provided to reduce that foot traffic. Hospitals can have humans track the movement with clipboards and pens or pedometers, but if they have an RTLS system that information is being collected.

Before you begin your journey - A great resource when planning RTLS purchase and implementation Robert Konishi’s RFID-RTLS Strategy and Planning Guide. Robert is the former CTO of UCLA Medical Center, and Current CEO of T2 Technology Group. According Konishi, there are four main areas that can be assessed to link to value when evaluating the RTLS system for equipment tracking:

• Cost savings associated with rental or duplicate purchases
• Lost Revenue and Opportunity Cost due to utilization
• Lost Time for Staff
• Quality of Patient Care, Throughput, and Regulatory

Konishi provides very helpful insights in the article from RFID News (http://www.rfidproductnews.com/pages/searchview.php?key=konishi&p=issues/2008.03/medical2.php) and a subsequent RFID-RTLS Strategy and Planning Guide.

The power of RTLS is the ability to track specific information. That information can become a metric which can be used to help the hospital better assess their workflow choices. A metric on it’s own is important – every business needs to track it’s ability to improve – however correlating those metrics with other data is the most powerful way to look at the data. That's why Sphere3 has developed our automated web based Sphere3 Scorecard™.

We look forward to sharing it with you.