Heralded as the best example of 21st century healthcare design, San Diego county’s new Palomar Medical Center melds high technology and innovation within a healing environment of gardens, terraces, outdoor balconies and natural light. Palomar Health sought advice from the nation’s leading healthcare futurists to coalesce their ideas into a structure that has become the first in the nation to integrate the largest array of evidence-based features that will enhance healing and sustain functionality over time. Technology plays a critical role in the hospital of the future. Cisco communications and collaboration technology is used throughout connecting nurses, doctors, patients and their families together with tools like wireless IP phones, video and telepresence, integrated nurse call, and electronic tracking of medications and hospital assets. Join this session, led by Palomar’s chief medical information officer Dr. Ben Kanter, to learn how Palomar and Cisco have partnered together to build the hospital of the future.

1. Benjamin Kanter MD FCCP
CMIO, Palomar Health
Partner, Escondido Pulmonary Medical Group

2. Disclaimers:
Co-developer – MIAA mHealth Platform
Consultant – AirStrip Technologies
Chief Medical Officer – ConversePoint, Inc.

3. Special thank you:
Michael Haymaker, Director of Healthcare
Industry Marketing for the Americas, Cisco
Debra Levin
President and CEO, Center for Health Design
(www.healthdesign.org)

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

6. PPH by the Numbers
• 3600 Employees
• 750 Physicians (all private practice)
• 560 Volunteers
• 28,000 Discharges
• 19,000 Surgeries
• 90,000 Emergency Visits
• 850 Square Mile Health District
• 2,200 Square Mile Trauma District
• The Largest Public Health District in
California by area
• Primary service area of >500,000
individuals and growing
• A Magnet System (hospitals and
SNFs)

7. Palomar Medical Center
Escondido Research and Technology Center
• 1,200,000 sq. ft. hospital complex includes:
– Inpatient (Distributed Nursing Model)
• Acuity Assignable Rooms 168
• Medical/Surgical 192
– Women’s Center Beds (phase 2)
• Labor & Delivery 20
• Postpartum/GYN 44
• NICU 16
• Pediatric 16
Total Beds 456
– Diagnostic & Treatment
• Interventional Platforms 6
• Surgery 12
Opened August 19th 2012
• Emergency Dept. 56
• Imaging Rooms 18
– Women’s Outpatient Center

8. Prop BB
 Passed November 2nd, 2004 w 70% majority
 496M toward constructing the new campus
 Seismic retrofit requirements
 A general obligation bond measure
requiring a 2/3 majority for passage
 Hospital, Emergency Care, Trauma Center
Improvement

9. Evidenced Based Design
 “…the process of basing decisions about the built
environment on credible research to achieve the
best possible outcomes”
 Sadler BL, Berry LL, et al. Fable Hospital 2.0: The
Business Case for Building Better Health Care
Facilities. Hastings Center Report 2011;13-23.

10. Goals for Quality Improvement
» IOM goals : » Quality Improvement
 Increase safety Foci
 Efficiency  People
 Effectiveness  Process
 Person-centered care  Technology
 Quality of care  Physical
 Timeliness Environment!!
» IHI quality
improvement efforts: A Better Building facilitates the
 100K & 5M lives physical, mental, and social
campaigns well-being and productive
 Innovation communities
behavior of its occupants.

11. Credibility of Evidence
» Improve Safety » Improve other
dimensions of quality
EBD Research shows a well designed environment Improve overall healthcare quality and reduce cost
can improve safety and quality of care
Reduce nosocomial infection (airborne) Reduce length of patient stay
(contact) Reduce drugs (see patient safety)
Reduce medication errors Patient room transfers: number and costs
Reduce patient falls Re-hospitalization or readmission rates
Improve quality of communication (patient  staff) Staff work effectiveness; patient care time per shift
(staff  staff) Patient satisfaction with quality of care
(staff  patient) Patient satisfaction with staff quality
(patient  family)
Increase hand washing compliance by staff
Improve confidentiality of patient information

12. Credibility of Evidence
» Reduce Patient Stress » Reduce Staff Stress/
Fatigue
EBD research shows that the physical environments helps The physical environment impacts staff outcomes
to reduce patient stress
Reduce noise stress Reduce noise stress
Reduce spatial disorientation Improve medication processing and delivery times
Improve sleep Improve workplace, job satisfaction
Increase social support Reduce turnover
Reduce depression Reduce fatigue
Improve circadian rhythms Work effectiveness; patient care time per shift
Reduce pain (intake of pain drugs, and reported pain) Improve satisfaction
Reduce helplessness and empower patients & families
Provide positive distraction
Patient stress (emotional duress, anxiety, depression)

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

14. % of Responses

15. Flexibility
Develop facility infrastructure that can readily
accommodate long-term changes in medical
practice, equipment and technology
Develop a patient room and nursing unit design
that can flex between various acuity levels
Deploy a modular approach to planning where
appropriate (similar sized rooms that can change
over time)

16. Distributed Nursing Model

18. Operational Challenges
 Gardens/Mobility
 Monitoring
 Communication
 Location
 Distributed nursing
 Communication
 IHI 2x2 findings
 Nursing ratios
 BYOD environment
 Multiple new remote clinics
 Telepresence

19. Technology-Enabled
Rauland-Borg Responder 5
Nurse Call System
Patient Station Duty Station
Corridor Light
Staff Terminal Nurse Station PC Console
Console

20. Cisco 7925 VoIP Phone

22. What’s inside Extension?
(OpenTheRedBox.com)
 Communication interface
 Small database interfaced to Cerner/Rauland
 Rules engine
 What goes where? When?
 Escalation rules
 Filters (if – then)

23. Alert Routing
 Can be routed based on role as well as location
 All based on patient assignment and location room/bed.
 Can be routed to multiple people/groups at the same time.
 Three layers of escalation so that no alert goes unmanaged
 Reporting tools to review assignments and the amount of alert
traffic.
 Extensive ability to manipulate the Cisco handset
 Handset alarm control: can have different ring tones
 If multiple Alerts come in at the same time the system will
prioritize based on our defined settings.

24. Physiological Monitoring

25. IHI Mortality 2x2 Matrix
ICU Admission ?
Yes No
Yes Box #1 Box #2
Comfort
Care
Only?
No
Box #3 Box #4

26. Mortality Diagnostic: Aggregate
Results for 64 US Hospitals
No ICU
ICU Admission Admission
Comfort Care 175/5535 773/5535
3% 14%
(0-44%) (0- 65%)
Non Comfort Care 1936/5535 2661/5535
35% 48%
(7-72%) (7-76%)

27. “Failure to Rescue”
 Failure to prevent a clinically important
deterioration from a complication of an
underlying illness or a complication of
medical care

28. Emerging Requirements
PPH Vision / Industry Trends Technological Requirements
Continuous patient monitoring across the Small form factor for extreme portability, Un-
continuum of care: Ambulance , ER, tethered / wireless devices, body area
Admitting Process, Transport within/to networks.
Facility, SNF, Clinic, Home, Anywhere.
Distributed nursing model. Real time alerts sent to the right care-giver, at
the right time.
Healing gardens and mobile patients. Sensors in the environment monitor
movement. Automated tracking of patients,
staff, and equipment.
Proactive measures to reduce hospital Monitor patient vitals and other parameters,
readmission rates. post discharge to enable the early detection of
condition deterioration.
Bed exit, Patient fall detection. Monitor patient movement, change in
position.

30. ViSi Mobile™ – Patient-Worn Monitor
• Continuous vital signs +
– SpO2
– HR/PR
– ECG (3/5 lead)
– Respiration
– Temp (skin)
– NIBP
– Continuous non-invasive blood
pressure (cNIBP)*
• Motion/Posture*
• Wireless communication (VoIP)
* Not yet FDA cleared

31. ViSi Mobile – by Sotera
Anticipated Outcomes
• Improved patient safety by detecting
signs of patient deterioration or
adverse events
• Reduced related costs by detecting /
avoiding adverse events (e.g.
cardiac arrest, falls, pressure ulcers)
• Improved staff efficiencies by
reducing the need for repeat manual
vital sign spot-checks, manual
documentation
• Automated charting to Electronic
Medical Record
• Improved patient engagement

32. Sotera Solution
 Allows mobility
 Can measure all of the key physiologic
determinants
 Integrates with our nurse call system
 Can do all of this with or without telemetry
 Can route all of these alerts to the patient’s
nurse as well as to central monitoring areas

33. Tomorrow’s standard of care on the general floor
Patient
Safety
(Automatic entry to EMR)

34. ViSi Mobile™ and Cerner – System Architecture
Cerner
Sotera Wireless
PowerChart
ViSi Mobile
Monitor PowerChart® Integration
(Launching at CHC)
iBus
PowerChart
AlertLinkTM Integration
(Launching late Q42012)

35. BYOD Environment
Cisco ISE : Identity Services Engine
Guest Network
Sporadic tablet/Citrix use
Independent development

36. MIAA is a uniquely powerful
user interface and user
experience which maximizes
clinical efficacy and efficiency
for mobile clinicians

37. MIAA does not replace a host
EHR. MIAA adds capabilities
to a legacy EHR, extending the
functionality and reach to
enable the mobile clinician

39. Who is the user?
Why is the user doing what they're doing?
What questions are they trying to answer?
What actions are they likely to take?
Provide information in a manner which
improves comprehension
Integrate actions without losing context
NIST Guide to the Processes Approach for Improving the Usability of Electronic Health Records
(Schumacher and Lowry, National Institute of Standards and Technology 2010. NISTIR 7741)

40. …real time access to…
Physiological Status Electronic Health Information

41. Complete the process

47. Thank you!
Ben Kanter MD FCCP
Ben.Kanter@pph.org