Pulmonary Symposium Presentation on Critical Care

Critical Care in the 21st century
A survey of the information technology landscape required to
support intensivists and other clinicians in the ICU

Dr. John Zaleski
Product Manager, Soarian Critical Care
Siemens Medical Solutions USA

Overview
The Specialty Landscape
The State of Critical Care
Key Requirements
The Scope of the Integration Challenge
Communication & Connectivity
Device-level Interfaces
Device Gateways
Standards
Futures

© 2008 Siemens Medical Solutions USA, Inc.

Increasing Demand, Limited or Decreasing Supply
The Specialty Landscape:§
Billions of $ (US)‡
Allergists & Immunologists: shortage within next 20
years $5,000
Anesthesia: shortage projected through 2015 $4,000
Cardiology: 20% decrease by 2020 $3,000
Child Psych: HHS concluded US should have >30,000 $2,000
but currently <7,000 practicing $1,000
Critical Care: demand exceeds supply through 2020 $0
Dermatology: Nearly half of current community state 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
field can use more
% GDP‡
Emergency Medicine: overburdened, under-funded,
highly fragmented
Endocrinology: current demand exceeds supply by
15% 20%
Geriatrics: currently only meet 35% of estimated need 19%
Medical Genetics: 58% of current slots unfilled. 17 18%
states report shortages and 5-15 year projection
indicates continued trend. 17%
Neurosurgery: severe decline in number of active 16%
neurosurgeons and a static field of residents
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Oncology: demand expected to increase by 48%
through 2020
Pediatric Subspecialties: lack of adequately trained •Psychiatry: average age of practitioners is ~56 years and
pediatric providers force children to seek care from adult percentage < 40 declined from 24% in 1989 to 8% in 2002
specialists
•Rheumatology: average wait for a new appointment of 38
Primary Care: on verge of collapse days
‡Cinda Becker, “Slow: Budget Danger Ahead,” Modern Healthcare. March 3rd, 2008.
§”Recent Studies and Reports on Physician Shortages in the US,” Center for Workforce Studies, Association of American Medical Colleges, August 2007.
J. Zaleski 21 October 2009

State of Acute Care Space
American College of Physicians estimate 500,000 deaths annually in
ICUs (U.S.)
Key Drivers (Millenium Research Group)
Patient safety
Longitudinal EMR deployment
Increase efficiency
Staffing shortages
Increasing numbers of CC beds
Larger amounts of hemodynamic, respiratory, I&O information will be
automated
Motivates enterprise integration
Reduces charting workload
Improves completeness, accuracy


Key Requirements


Key Requirements
A complete record


Key Requirements
A complete record
All inbound hemodynamic, vitals data from monitors


Key Requirements
A complete record
All inbound hemodynamic data, vitals data from monitors
Support for fluids I&O (with automated intakes for IV drips, where possible)


Key Requirements
A complete record
Integrated respiratory mechanics & mechanical ventilation charting


Key Requirements
A complete record
Scoring


Key Requirements
A complete record
Scoring
Waveforms


Key Requirements
A complete record
Integrated respiratory mechanics
Scoring
Waveforms
Clinical decision support tools


Key Requirements
A complete record
Scoring
Waveforms
Effective, intuitive, displays


Key Requirements
A complete record
Scoring
Waveforms
Data in the eyespan


Key Requirements
A complete record
Scoring
Waveforms
Data in the eyespan
Trending, flowsheet all in one view


Key Requirements
A complete record
Scoring
Waveforms
Data in the eyespan
Tailored views


Key Requirements
A complete record
Scoring
Waveforms
Data in the eyespan
Tailored views
Accessibility


Key Requirements
A complete record
Scoring
Waveforms
Data in the eyespan
Tailored views
Accessibility
From anywhere (including home)


Key Requirements
A complete record
Scoring
Waveforms
Data in the eyespan
Tailored views
Accessibility
From anywhere (including home)
Ability to detect user, role and authenticate automatically

Key Requirements
Reliability & Availability, Performance


Key Requirements
The best system is the one which remains unnoticed


Key Requirements
Display updates < 3 seconds


Key Requirements
“Drop-down boxes are the work of the devil” (Don Rucker, MD)


Key Requirements
Fewer mouse clicks


Key Requirements
Fewer mouse clicks
Plug and play connectivity


Key Requirements
Fewer mouse clicks
Medical devices associate with critical care information system software
automatically


Key Requirements
Fewer mouse clicks
automatically
Patient association is automatic and does not require user intervention


Key Requirements
Fewer mouse clicks
automatically
Logging of device settings changes


Key Requirements
“Scrolling list boxes are the tool of the devil” (Don Rucker, MD)
Fewer mouse clicks
automatically
Logging of device settings changes
Automatic detection of new devices


Key Technology Enablers


Real-time location services


Radio frequency identification
using passive and active
technologies
Patient identification (passive)
Patient location (active)
Device identification (passive)
Device location (active)


technologies
Portable computing device
technology


technologies
technology
iPhone, BlackBerry


technologies
technology
iPhone, BlackBerry
Portable PCs


Medical Device Connectivity:
Essential to Future Vision


The Base


The Base
Patient survival is dependent upon the devices in the environment
Data are the manner of communication in technologically-dependent patients


The Base
The Catalyst


The Base
The Catalyst
Displays, flowsheets are the windows to the data
Complete and accurate records can only be achieved through data collection


The Base
The Catalyst
The Enabler


The Base
The Catalyst
The Enabler
Workflow, clinical decision support require data
Decision making and patient care management hinge upon the state of the
patient as determined through observations and findings


Understanding the Scope of
Medical Device Connectivity Challenges


Medical Device Connectivity
For the most part, seamless integration between devices and IT systems
is possible…as long as standard interfaces are employed
Tailoring of interfaces, even with standards, is almost always required
(e.g.: HL7 R01 components & segments)
Even standards have their limits and, in some circumstances, unique and
custom interfaces are required
Best practices can vary by customer enterprise, clinical workflow, user
preferences


Devices

Self-contained Workstations
(e.g.: Nursing station monitors, MRI & CT
Scan monitors)

Multiple measurement
(e.g.: Med/Surg & ICU Monitors, Ventilators) s)
tor
tila
)
O)
8% en
)
H2 ,v
=9 ce
ers
tra
O2 cm
=5 ak
Sp G )
C
P
, era m
.E
EE ce
7C E) e.g Pa
am
=3 ,P OL s ( .g. C g.
12
.T .
ST
g V rm l (e
(e.
Single measurement e
SI M efo dio (
SY tro
ts
.g. av
.A on
en
(e.g.: glucometers, thermometers, stethoscopes, u
e.g
e W A C
rem ngs ( s( P & eo & ote
su
probes) i
arm TC
ett em
ea id
Al R R
V
S
M
Data
Point-to-point serial

Point-to-point wireless (e.g.: blue tooth, IR)

Fixed IP Network enabled (e.g.: TCP/IP & Multicast over Ethernet)

DHCP IP Network enabled (e.g.: TCP/IP & Multicast over Ethernet)

Wireless Network enabled (e.g.: TCP/IP & Multicast over Ethernet)

Secure Wireless Network compliant (e.g.: WPA, WPA2)
lo ity
no tiv
gy
ch ec
Te onn
C


Devices

Self-contained Workstations
(e.g.: Nursing station monitors, MRI & CT
Scan monitors)

Multiple measurement
(e.g.: Med/Surg & ICU Monitors, Ventilators) s)
tor
tila
)
O)
8% en
)
H2 ,v
=9 ce
ers
tra
O2 cm
=5 ak
Sp G )
C
P
, era m
.E
EE ce
7C E) e.g Pa
am
=3 ,P OL s ( .g. C g.
12
.T .
ST
g V rm l (e
(e.
Single measurement e
SI M efo dio (
SY tro
ts
.g. av
.A on
en
(e.g.: glucometers, thermometers, stethoscopes, u
e.g
e W A C
rem ngs ( s( P & eo & ote
su
probes) i
arm TC
ett em
ea id
Al R R
V
S
M

rs
Data

ito
on
Point-to-point serial

M
U
IC
Point-to-point wireless (e.g.: blue tooth, IR)

Fixed IP Network enabled (e.g.: TCP/IP & Multicast over Ethernet)

DHCP IP Network enabled (e.g.: TCP/IP & Multicast over Ethernet)

Wireless Network enabled (e.g.: TCP/IP & Multicast over Ethernet)

Secure Wireless Network compliant (e.g.: WPA, WPA2)
lo ity
no tiv
gy
ch ec
Te onn
C

JR Zaleski © 2008


Communication & Connectivity


Devices → EMR
Respiratory Critical Care Vital Signs
Infusion

Ad Hoc Vital Signs

Scales

Results, Findings,
EMR
Notifications
(e.g.: to event queues)

Glucose


EMR → Devices
Respiratory Critical Care Vital Signs
Infusion

Ad Hoc Vital Signs

Scales

Admission, Discharge,
EMR
Transfer
(where applicable/possible)

Glucose


The essence of the challenge:
Communication
Many organizations, IEEE, IHE, AHIMA,
Individual Device communication, for
AAMI, HL7, ACCE, are actively
the most part, is non-standard.
engaged in promoting standards and
Many manufacturers provide proprietary
their development.
interfaces that follow the EIA232 (i.e.,
However, even with standards there is
RS232) interface requirements, but no
no consensus on the best methods for
informational formatting requirements
device integration.
Especially true of smaller, handheld devices
(glucometers, flow meters, home blood For example: IEEE 11073
pressure equipment, pulse oximeters, etc.)
Thus, claims seamless interfacing are
Larger manufacturers—especially those simply not the case: device-level
producing vital signs monitors, and interface standards are still not
some in the infusion pump market— universally adhered to by device
provide gateways. manufacturers.
Systems within systems that provide both
Yet, the HL7 standard (v2.x and
an internal proprietary mechanism for
beyond) does provide a framework for
communication and a gateway for
data communication among disparate
establishing a more ubiquitous interface via
systems (focused more on interfacing
an HL7 messaging approach.
of IT systems than medical devices)


Device-Level Interfaces


Device Level Interfaces
Can be developed using standard Example: Servo-i ventilator
Query
Sending: RB♦
programming languages
Received: 196224862094248920703066229021502317222521462048♦
E.g.: Java supports mature serial Sending: RT♦
communication libraries Received: 031204144241♦
nResults: 12 Response
Typically operate in Query-
sf = 5000.0
Response mode data = 1962
Asynchronous ::::: -0.0839876
OBX|1|NM|mib Flow^local^8462-4^^LAB||-0.0839876|l/s|||||C|||20031204144241
Proprietary command language
sf = 5000.0
Examples data = 2486
::::: 0.4277508
Mechanical ventilators
OBX|1|NM|mib Tvi^local^8462-4^^LAB||0.4277508|l|||||C|||20031204144241
Medical / Surgical Monitors sf = 50.0
Glucometers data = 2094
::::: 4.49236
Scales
OBX|1|NM|mib IAP^local^8462-4^^LAB||4.49236|cm H2O|||||C|||20031204144241
…


Device Level Interfaces (continued)
Not all devices of the same class
even produce the same data feeds
Different nomenclature
Uncertain parameter mappings
Example: Servo versus Puritan
Bennett Ventilators
Expiratory & Inspiratory Minute, Tidal
Volumes (Servo) versus Minute, Tidal
Volume (7200ae)
Example: Vital Sign definitions
require some mapping between ad
hoc monitors—a posteriori
calculation required to equate
parameter streams
Spot Vitals Signs Monitor temperature
data
Kelvin, Celsius, Fahrenheit
Dinamap temperature data
Celsius, Fahrenheit

Example: Servo-i ventilator
Sending: RB♦
Received: 196224862094248920703066229021502317222521462048♦
Sending: RT♦
Received: 031204144241♦
nResults: 12
sf = 5000.0
data = 1962
::::: -0.0839876
OBX|1|NM|mib Flow^local^8462-4^^LAB||-0.0839876|l/s|||||C|||20031204144241
sf = 5000.0
data = 2486
::::: 0.4277508
OBX|1|NM|mib Tvi^local^8462-4^^LAB||0.4277508|l|||||C|||20031204144241
sf = 50.0
data = 2094
::::: 4.49236
OBX|1|NM|mib IAP^local^8462-4^^LAB||4.49236|cm
H2O|||||C|||20031204144241
Inspiratory Tidal Volume vs Tidal Volume


Not all devices communicate in same base
Some Glucometers, scales, ad-hoc device monitors
But, manufacturer-published interfaces facilitate custom development (e.g.: Dinamap, Spot Vitals,
Critikon, etc.)

Transmit (ASCII)

Receive (HEXADECIMAL)


Some devices support synchronous communication
Transmit all the time
Either write to file or transmit over network

B.Braun infusion pump

Volume Delivered (ml)


Device Gateways


Networked Medical Devices
Many critical care monitors &
other devices communicate
via Ethernet to Gateways— Serial
Critical Care
Infusion Pump Ventilator
central points of Monitor

communication within a Proprietary communication
proprietary network.

VL

2
AN
A
N3

VL
Nursing
Gateway Server
Workstation
Access Point

Device Subnet
Hardwired Ethernet
Standards-based communication
Critical Care
Router
Monitor

HL7 Communication

Cisco 3524 swtich

Enterprise Network


Networked Medical Devices
Inbound ADT can be
communicated similarly
Serial
Scope of data content driven Critical Care
Infusion Pump Ventilator
Monitor
by device manufacturers
Wireless Ethernet
specifications
Proprietary communication

VL

2
AN
A

VL
N3
Nursing
Gateway Server
Workstation
Access Point

Serial-to-
Ethernet
Adapters (hard-
Device Subnet
wired)

Standards-based communication
Critical Care
Router Serial-to-
Monitor
Bluetooth
Adapters

Cisco 3524 swtich
Serial-to-Wi-fi
Adapters

Enterprise Network


Standards


Example:
HL7 Unsolicited Observation Result: the R01 Transaction
Message Header Segment
4D 53 48 7C 5E 7E 5C 26 7C 49 6E 66 69 6E 69 74 MSH|^~&|Infinit 00000
79 7C 7C 4E 55 52 7C 7C 32 30 30 33 30 33 32 38 y||NUR||20030328 00010
30 38 31 31 7C 7C 4F 52 55 5E 52 30 31 7C 7C 50 0811||ORU^R01||P 00020
7C 32 2E 33 0D 00 00 00 00 00 00 00 00 00 00 00 |2.3............ 00030
Patient Identifier Segment
50 49 44 7C 7C 7C 30 30 30 30 30 30 30 30 32 38 PID|||0000000028 00000
30 31 5E 5E 5E 5E 45 78 74 65 72 6E 61 6C 50 61 01^^^ÊxternalPa 00010
74 69 65 6E 74 49 44 7C 7C 6E 75 6C 6C 5E 6E 75 tientID||null^nu 00020
6C 6C 7C 7C 7C 55 0D 00 00 00 00 00 00 00 00 00 ll|||U.......... 00030

4F 42 52 7C 7C 7C 7C 30 30 30 30 30 30 30 30 32 OBR||||000000002 00000
38 30 31 7C 7C 7C 32 30 30 33 30 33 32 38 30 38 801|||2003032808 00010
31 31 7C 7C 7C 7C 7C 7C 7C 7C 7C 7C 7C 7C 7C 7C 11|||||||||||||| 00020
7C 7C 7C 7C 7C 7C 32 30 26 30 33 5E 30 33 5E 32 ||||||20&03^03^2 00030
38 5E 30 38 31 31 0D 00 00 00 00 00 00 00 00 00 8^0811.......... 00040 Observation: OBX Segment
(Patient Pulse)
4F 42 58 7C 7C 53 4E 7C 48 52 5E 5E 6C 6F 63 61 OBX||SN|HR^^loca 00000
6C 5E 38 38 36 37 2D 34 5E 5E 4C 4F 49 4E 43 7C l^8867-4^^LOINC| 00010
7C 36 37 7C 2F 6D 69 6E 5E 5E 49 53 4F 2B 7C 7C |67|/min^ÎSO+|| 00020
7C 7C 7C 52 7C 7C 7C 32 30 30 33 30 33 32 38 30 |||R|||200303280 00030
38 31 31 0D 00 00 00 00 00 00 00 00 00 00 00 00 811............. 00040
Observation: OBX Segment (Patient
Respiratory Rate)
4F 42 58 7C 7C 53 4E 7C 52 45 53 50 5E 5E 6C 6F OBX||SN|RESP^^lo 00000
63 61 6C 5E 39 32 37 39 2D 31 5E 5E 4C 4F 49 4E cal^9279-1^^LOIN 00010
43 7C 7C 7C 2F 6D 69 6E 5E 5E 49 53 4F 2B 7C 7C C|||/min^ÎSO+|| 00020
7C 7C 7C 52 7C 7C 7C 32 30 30 33 30 33 32 38 30 |||R|||200303280 00030
Observation: OBX Segment (Patient O2
38 31 31 0D 00 00 00 00 00 00 00 00 00 00 00 00 811............. 00040
Saturation)
4F 42 58 7C 7C 53 4E 7C 53 70 4F 32 5E 5E 6C 6F OBX||SN|SpO2^^lo 00000
63 61 6C 5E 32 37 31 30 2D 32 5E 5E 4C 4F 49 4E cal^2710-2^^LOIN 00010
43 7C 7C 39 37 7C 25 5E 5E 49 53 4F 2B 7C 7C 7C C||97|%^ÎSO+||| 00020
7C 7C 52 7C 7C 7C 32 30 30 33 30 33 32 38 30 38 ||R|||2003032808 00030
31 31 0D 00 00 00 00 00 00 00 00 00 00 00 00 00 11.............. 00040


Future


Remember the objective…
It’s about the data required to support patient care


Examples of Evolving Capabilities
Wireless connectivity to devices
Enterprise-wide communication (through existing hospital LANs)
Plug-and-play device connectivity
Medical device control (ventilation, infusion)
Device-patient association (e.g.: radio frequency identification)
Integrated infusion for automated intake calculations (I&O)
Early warning based on patient state (combination of clinical decision
support and expert systems / neural networks)
Extension of ICU telemetry across continuum of care (e.g.: ICU-
Med/Surg->Outpatient)
Telemetry-over-Internet


Available late Fall 2008…

John Zaleski, Integrating Device Data into the Electronic Medical Record
A Developer’s Guide to Design and a Practitioner’s Guide to Application

ISBN 978‐3‐89578‐323‐4
A19100‐L531‐ B977‐X‐7600
Approx. 300 pages
Approx. 100 illustrations

Contents:
The Medical Device Integration Landscape
Device networking and communication
Mechanisms for interfacing and integrating device data
Real‐time and non‐real‐time data management
Computer‐based patient record
Correctly associating device data with patients
Balancing data quantity with quality: techniques for data analysis and
reduction
How to display data in a flowsheet
Interface software as a medical device
The future of medical device integration, Including Device Command & Control
Example methods and software


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