Advanced informatics in critical care:
The primary challenge inherent
in future ICU design
Neil A Halpern MD
Chief Critical Care Medicine
Memorial Sloan Kettering Cancer Center, NYC
Disclosers
• Medical advisor/consultant
– Cardio Pulmonary Corp
– Pronia Medical
– Instrumentation Labs
I NFORMATIC
V ICTORIA’S’SS S
ECRET
ECRET
The seduction of informatics
The seduction of advanced
informatics
• Looks great, seems cool & FDA approved,
but new technologies are…
– Manufactured by variety of vendors
– Marketed as plug & play, but must be
integrated with other systems
– Challenging to integrate
– Minimally tested in real “clinical” life
– Certainly not tested with your middleware &
hospital systems in your facility
Three ICU-IT goals
• RTLS: Track assets (devices or
people)
• Build a virtual device community
• Transform reams of data to
meaningful & actionable information
Computer Wired
Jacks
Wireless Access Points and Sensors
Bar Code Scanners
Wi-Fi
IR
RFID Ultrasonic Multimode Universal Labs Blood Meds
Bedside
Physiological
Monitor
(Stationary)
Mechanical
Ventilator
(Mobile)
Multi-Parameter/Port
Device Integrator
Nurse
Call
Infusion
Pumps
(Mobile)
Medical
Applications
Lab
Specimen
POCT
Blood
Products
Meds
Auto-ID Tag
Environmental
Sensors
ICU Bed
Supplies
Adaptor
Mini-computer
Wireless
Bar Code
Scanner
RTLS
Inventory & Asset Management
Real Time Locating
Systems/Solutions (RTLS)
RTLS: wireless tracking of tagged items
• Mobile Asset tracking
• Improve workflow
• Integrate with other systems
Monitor
Pumps
Monitor
RTLS
Asset
Management
Vent
Pumps
Vent
Where is it?
Is it being
used?
Is it leaving
ICU?
Monitor
Pumps
Monitor
Vent
Pumps
Vent
Monitors
Vents
Pumps
SERVERS
Penguin in Atlanta Zoo
ICU GPS system
PATIENT TRAVELS
WEDNESDAY, SEPTEMBER 19, 2012 - 9:15 a.m.
Pt in ICU
Pt in CT Scan
Pt in IR
Pt in ICU
CT SCAN
Wireless
Access
Point
ICU ROOM
Wireless
Access
Point
IR
Wireless
Access
Point
Build a Virtual Device
Community
Devices, data & alarms are local
Mechanical ventilators
Problems:
• Stand-alone
• Bedside alarms only
• No long-term data storage
Ideal:
• Join with other vents to form
virtual community
• Transmit selected alarms
• Long term data storage
PB 840
Wireless Bridge
Bernoulli Ventilator Management System, Cardiopulmonary Corp, Milford, CT
Monitor
Pumps
Vent
Virtual
Ventilator
Community,
Alarm delivery
Data storage
Monitor
Pumps
Vent
Ventilator
Ventilator
Ventilator
Ventilator
Monitor
Pumps
Monitor
Vent
Pumps
Vent
Monitors
Vents
Pumps
SERVERS
Bernoulli Ventilator Management System, Cardiopulmonary Corp, Milford, CT
Transform data to meaningful &
actionable information
Monitor
Pumps
Vent
NC
1
Alarm
Delivery
System
Nurse Call
Monitor
Pumps
Vent
NC
2
CENTRAL STATION
EMERGENCY ALERT MARQUEE
Where is it?
Is it being
used?
NC
Monitor
Pumps
Monitor
Vent
NC
Monitors
NC
Vents
3
Pumps
Nurse Call Delivery Server
4
Pumps
Vent
Alarm delivery & filter
• Shift alarms to “delivery and filter”
servers/APPs
• Select “critical” device alarms only for
transmission to avoid alarm overload
– Monitor: 5 of 50 alarms
– Vent: 4 of 40 alarms
• Institute “novel” delivery models to get
alarms where they need to go
• Address Joint Alarm PSG 2014-2016
Monitor
Pumps
Alarm
Delivery
System
Vent
NC
1
Filter
Monitor
Pumps
Vent
NC
2
CENTRAL STATION
BED 4 VFIB
EMERGENCY ALERT MARQUEE
Where is it?
Is it being
used?
NC
Monitor
Pumps
Monitor
Vent
NC
Monitors
NC
Vents
3
Pumps
Alarm Delivery Server
FILTER
4
Pumps
Vent
The
devil is
in the
details!
Primary Informatics Challenges
•
•
•
•
•
•
•
Evaluate many technologies
Connectivity envelope
Association
Time synch, interoperability & data synch
Medical devices are informatics platforms
Roll out
Maintaining & upgrading
Evaluating middleware
Middleware: the systems that make
everything work! Servers & APPs
FDA certified? Yes, but still confusing!
• MDDS: FDA Class 1
– Medical Device Data Systems
• Data storage, mng, & transfer
• Language conversion
• Class 2 devices
• Active pt monitoring & alarms
Hi Tech Evaluation
•
•
•
•
Many similar products
Evaluate over a short time period
Discern subtle, but meaningful differences
Figure out the cost, initial & long-term
Speed Dating for Technologies
  
  
 

You have 15 minutes,
no slides, no sales pitch,
just tell us what you got!
NEXT!
Go to the Sim Lab
• Set up BioMed-IT simulation lab with
identical systems as ICU & hospital
• Obtain & test all prioritized technologies in
real-life settings
• Perform gap analyses: current & proposed
• Slow & deliberate phase-in
Primary Informatics Challenges
•
•
•
•
•
•
•
Evaluate many technologies
Connectivity envelope
Association
Time synch, interoperability & data synch
Medical devices are informatics platforms
Roll out
Maintaining & upgrading
Putting It All Together . . .
or not . . .
Five Steps to Creating the Smart ICU
Step 1
Install robust wired and wireless infrastructure
↓
Step 2
Attach Auto-Identification (Auto-ID) tags to all data sources
↓
Step 3
Attach adaptors and/or computers
to medical device data output ports
↓
Step 4
Install tracking and data acquisition hardware
↓
Step 5
Install middleware (gateways/servers/APPs)
on hospital and ICU networks
Connectivity Envelope
Computer Wired
Jacks
Wireless Access Points and Sensors
Bar Code Scanners
Wi-Fi
IR
RFID Ultrasonic Multimode Universal Labs Blood Meds
Bedside
Physiological
Monitor
(Stationary)
Mechanical
Ventilator
(Mobile)
Multi-Parameter/Port
Device Integrator
Nurse
Call
Infusion
Pumps
(Mobile)
Medical
Applications
Lab
Specimen
POCT
Blood
Products
Meds
Auto-ID Tag
Environmental
Sensors
ICU Bed
Supplies
Adaptor
Mini-computer
Wireless
Bar Code
Scanner
Hospital Network
Hospital and ICU Systems,
Servers and Applications
ICU Network
Bed 1
Alarm
Distribution
Bed 2
Bed 3
Device
Managers
Bed 10
Clinical
Bed 11
RTLS
Smart
Displays
Bed 6
Bed 7
Administrative
Bed 9
Bed 4
Bed 5
Bed 8
Bed 12
Electronic
Medical Record
Bed 13
Telemedicine
Network
Bed 14
Servers
and Routers
ICU Middleware
Network
Servers
and Routers
Hospital Network
Primary Informatics Challenges
•
•
•
•
•
•
•
Evaluate many technologies
Connectivity envelope
Association
Time synch, interoperability & data synch
Medical devices are informatics platforms
Roll out
Maintaining & upgrading
Association
Connecting pt to device & device to network
is easy; linking data/device with pt is hard!
• Location centric (bed #): data “sticks’ to
location, not pt
– Easy for venders to implement
– However, data may be difficult to locate in
dynamic datasets for insertion into EMR
• Patient centric (name/MRN): data “sticks”
to pt
– Requires live ADT feed
Association of Devices & Patient
Location - ICU Room Number
ADT
MEDICAL DEVICE:
STATIONARY (MONITOR)
FIXED LOCATION/
IP ADDRESS
MEDICAL DEVICE:
MOBILE (VENT, PUMPS)
NO LOCATION/
NEEDS NAME
EMR
DEVICE
MANAGER
ALARM
MANAGER
vs.
PT
Name
MRN
Primary Informatics Challenges
•
•
•
•
•
•
•
Evaluate many technologies
Connectivity envelope
Association
Time synch, interoperability & data synch
Medical devices are informatics platforms
Roll out
Maintaining & upgrading
Monitor
8:55
Pumps
8:50
Disparate
ICU devices
& systems
not in sync!
Vent
9:10
Webcam
9:05
Monitor
8:55
Vent
9:10
Pumps
8:50
Monitor
8:55
Vent
9:10
Webcam
9:05
Monitors
Pumps
8:55
8:50
Vents
Webcam
9:10
9:05
Time
Monitors
Pumps
8:50
Monitor
8:55
Pumps
8:50
Vent
9:10
Vents
Pumps
Webcam
9:05
Webcam
SERVERS
Webcam
9:05
Monitor
9:00
Pumps
9:00
Monitor
9:00
Time
Server
Vent
9:00
Vent
9:00
Webcam
9:00
Webcam
9:00
Monitors
Pumps
8:55
9:00
8:50
9:00
Vents
9:00
9:10
9:00
Monitor
9:00
Vent
9:00
Pumps
9:00
Pumps
9:00
Webcam
9:05
9:00
Time
Monitors
Monitor
9:00
Pumps
9:00
Vent
9:00
Vents
Pumps
Webcam
9:00
Webcam
SERVERS
Webcam
9:00
Device Data and Alarms: Interoperability
Connectivity Envelope
ICU
Electronic
Servers
Flowsheet
φβηψτϵϴαρμωζγβ
ALARMS
- 7403048
-ηψφβηφβηψτϵαρμ
ALARMS - 463980
NOW
- I that
understand!
what the
… did
vent say to me?
φβηψτϵϴαρμωζγωζγβηψφβηφβφρμηψρμηψβηψτ
ALARMS - 743203048 - ALARMS - 43038634663980
ϵϴαρμωζγβηψφβηφβηψτϵαρμηψτϵαρμρμηψ
Conversion on Outbound
or Inbound
Data Storage
Electronic
Flow Sheet
Web
EFS/Alarms
Medical
VENT
Device
Adaptor/
Wireless
Minicomputer
Alarm App
ICU Bed
Interoperability
• Enable seamless & secure access to
health info
• Provides specs, tools & svcs for
interoperability
• IHE Connectathon: Standards based
interoperability for vendors & users of HIS
Device Data and Alarms: Data Synch
Connectivity Envelope
Crosswalk for
data synch:
Respiratory
Rate = fR
ICU
Electronic
Servers
Flowsheet
“Respiratory
“Respiratory Rate”
Rate”≠ =
“fR”
fR
Alarm App
Data/Alarms
Alarms
Data Storage
Electronic
Flow Sheet
Web
EFS/Alarms
VENT
ICU Bed
Auto-ID Tag
Bar Code Scanner
Adaptor/Wireless
Mini-computer
Primary Informatics Challenges
•
•
•
•
•
•
•
Evaluate many technologies
Connectivity envelope
Association
Time synch, interoperability & data synch
Medical devices are informatics platforms
Roll out
Maintaining & upgrading
Infusion Pump: The Dark Ages
One-time Purchase
Infusion
Infusion
Platform:
Pump: The
TheDark
Modern
Ages
Era
MIDDLEWARE
ACCESS
POINT
PUMP
SERVER
PHARMACY
EMR
OFFSITE
BACKUP
PUMP
SERVER
PRIVACY
Building the Infusion Pump System
Medication
Library
Memory
Dosing
Protection
Medication
Orders
Back-up
Privacy
Alerts
Wireless
Communication
Handhelds
Infusion Platform: The Modern Era
MIDDLEWARE
ACCESS
POINT
PUMP
MEMORY
PHARMACY
EMR
Medication Library
Dosing Protection
Medication Orders
OFFSITE
BACKUP
PUMP
SERVER
$$$
Infusion Platform Costs
MIDDLEWARE
PUMP
MEMORY
PHARMACY
$
EMR
OFFSITE
BACKUP
PUMP
SERVER
ACCESS
POINT
$$$$
$
Ongoing Costs for
Software Updates
& Licenses
$
Primary Informatics Challenges
•
•
•
•
•
•
•
Evaluate many technologies
Connectivity envelope
Association
Time synch, interoperability & data synch
Medical devices are informatics platforms
Roll out
Maintaining & upgrading
Roll out
WORK IN
PROGRESS
Obamacare: Lessons learned
•
•
•
•
•
•
•
•
Good management to oversee project
Coordinate technical teams
Extreme testing to duplicate real-life use
Anticipate problems
Don’t minimize depth of the problems
Don’t keep problems secret
Roll out is critical
Launch dates are not holy
Primary Informatics Challenges
•
•
•
•
•
•
•
Evaluate many technologies
Connectivity envelope
Association
Time synch, interoperability & data synch
Medical devices are informatics platforms
Roll out
Maintaining & upgrading
Hospital Network
Hospital and ICU Systems,
Servers and Applications
ICU Network
Bed 1
Alarm
Distribution
Bed 2
Bed 3
Device
Managers
Bed 10
Clinical
Bed 11
RTLS
Smart
Displays
Bed 6
Bed 7
Administrative
Bed 9
Bed 4
Bed 5
Bed 8
Bed 12
Electronic
Medical Record
Bed 13
Telemedicine
Network
Bed 14
Servers
and Routers
ICU Middleware
Servers
HEAVY Network
and Routers
TRAFFIC
Hospital Network
Who broke it?
We didn’t do nothin’
except upgrade
the system!
BioMed Engineering
IT
We had to
fix this!
No one
communicates with
each other!
ICU Team
Hospital Admin
Closing thoughts
•
•
•
•
•
•
Data analytics
Security
Dark data
Future proof
The box: In or out
The “Bottom line”
Data Analytic Center
WOW! Too much data!
What data do we
want to analyze?
What about
PHI?
Data from devices,
applications & calculations?
What message do
we want to show?
Security: Real or a Joke?
NSA,
Washington DC
Hawaii
Dark Data
Dark Data
• Dark data - decentralized data that
resides outside the IT environment in
unprotected non-compliant locations
– Segregated or hidden data
– USB keys & mobile apps
• No one knows its there!
• Data cannot be analyzed or tracked
• No central insight into content
Avoid future chaos
“Future-proof”
“Future-proof”
• Technology that will not become
outdated in future (Webopedia)
• ICU should also not become obsolete in
the future
• Build to last vs build to grow
• Try to anticipate future developments
• Avoid chaos of unknown IT future
– Power, data, network cables & large network
closets
Thinking
Outside
the Box
Thinking
theBox.
Box.
ThinkingOutside
Inside the
C
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From Tech Intro to
Advanced Informatics
• Technology Introduction in Critical Care:
Just Knowing the Price Is Not Enough!
Halpern NA and Pastores SM. CHEST 1999; 116:1092–1099
• Innovative Designs for the Smart ICU
Part 3: Advanced ICU Informatics
Halpern NA. CHEST 2014; APRIL
Conclusions
• Advanced informatics systems are complex
• Successful implementation requires
– Don’t fall for hi-tech seduction
– Visualize solutions that meet your needs
– Understand underlying IT concepts
– Sophisticated planning & testing
– Thoughtful & phased introduction of new
technologies
– Long-term care
Thank You!