New wireless systems speed up access to clinical information and boost patient care

By Andy Shaw

Bullfrogs and Mount Royal (in the heart of Montreal) probably aren’t the first things that spring to mind when someone mentions the phrase “wireless medical technology.” But for Dr. Bernard Segal, there’s a definite connection.

Now the country’s leading expert on the effects of electro-magnetic interference (EMI) on medical equipment, the McGill University professor began work on a PhD in neurophysiology by studying balance and dizziness in bullfrogs. Graduating to cats and then humans, he became expert in shielding his equilibrium measuring instruments from ground waves and other electronic distortions. As he also held a master’s degree in biomedical engineering, it wasn’t long before he was getting calls seeking advice on similar interference problems from local Montreal hospitals.

“A city with a central mountain is a good place to put up an aerial, and it’s also a good place to put a hospital, so that patients have a nice view,” says Dr. Segal. Both factors help explain why the cluster of medical institutions around Mount Royal were among wireless medical technology’s earliest adopters.

Since his student days, Dr. Segal has gone on to form the McGill Biomedical Engineering Group on Electro-magnetic Compatibility. Members include, among others, the heads of biomedical engineering in five Montreal teaching hospitals, several engineering professors, a lawyer, and even, Dr. Segal admits, a physician. Recognized by the Canadian Wireless Technology Association for its expertise, the group researches EMI, educates, and sets guidelines for bringing wireless technology into the healthcare world safely.

“Because hospitals work in a mobile fashion, there is no question that hospitals NEED wireless technology – and you can write the word NEED in bold flashing letters,” says Dr. Segal. “The business community recognized some time ago that if it didn’t adopt information technology it would go bankrupt. The medical community needs to do the same thing, or our healthcare may well go bankrupt.”

And no form of technology is better suited to the hurly-burly of hospital life than cord-free devices. “It’s not just a matter of efficiency but there are medical errors that can only be prevented by wireless technology, and I don’t think most people realize that.”

Dr. Segal cites the prescription of drugs as an example.

“It’s a very long chain of events and those events take place not just at the nursing stations, but by the patient’s bedside, in the halls, in the pharmacy, and all over the place. If those events are not monitored every step of the way, there is a very real chance for medical errors. And that applies to just about every other system in the hospital.”

Yet Dr. Segal is first to admit there are good reasons why wireless solutions have not yet taken acute-care problems by storm.

“First of all, the EMI risks of wireless are not theoretical, they are real. People have been injured, and worse, as a result of the radio waves wireless devices emit. There are also other reasons why technology generally hasn’t reached its full potential in the medical world yet, including security, reliability, and perhaps most of all, user interface issues.”

That’s not to mention the precarious state of healthcare and hospital budgets, nor the tearing down of walls to replace old network infrastructures. Nor the non-electronic interference such physical changes bring to patients’ lives.

Nonetheless, Dr. Segal remains a firm believer in the potential of wireless systems to address acute care needs, provided they are implemented with special care. As they have been in two notable instances recently, at Cancer Care Manitoba and at the Mount Sinai Hospital in Toronto.

The government-sponsored Cancer Care Manitoba is responsible for cancer detection, treatment, and research in the province. But like so many other institutions, it was jammed for space, especially at its main facility in Winnipeg.

So much so that its IT staff were moved up to “temporary” trailers on the rooftop. More than three years later, all Cancer Care staff are looking forward to the relief a new building under construction next door will bring when it opens next year. But this year they are already benefiting from a state-of-the-art, wireless patient information system that has been retrofitted into the old building and will also come with the new space. As they move about, users can now stay in touch with Cancer Care databases via an AirConnect Wireless LAN from 3Com.

Meanwhile, at Mount Sinai Hospital in Toronto, average response times to patient calls have dropped dramatically, thanks to wireless wizardry that links a nurse call system from manufacturer Rauland Borg to micro-cellular phones from Lucent Technologies. The four-year project was made possible by the donation of a single, anonymous donor.

In both locations, the challenge was: how to implement new systems in old surroundings without closing shop.

“Our problem was also lack of space, so there was no room to put in wires or a complicated infrastructure. And to have shut down for any amount of time to install it would mean disruption to patient care,” says Mark Kuchnicki, Cancer Care Manitoba’s director of information services. “So a wireless system was the answer. We already had wireless installed in our old building, but the problem was, it did not have enough coverage. Yet we didn’t have the room to put up any more (repeating) nodes than we had in place.”

But Kuchnicki found the new nodes from 3Com had a lot more range than the old ones. So now wireless coverage extends over an entire chemo-treatment floor using just nine nodes instead of the 12 that had served only half the floor previously.

Not only was the old system’s coverage inadequate, so was its speed. “Nursing staff looking for data, or entering data, were constantly having to wait for long stretches while their screens refreshed,” says Kuchnicki.

Now AirConnect delivers high speed networking to wireless laptops and hard-wired desktops alike. Nurses can do charting and reporting instantly and unobtrusively from the patient’s beside, sharing records and information with other care-givers in real time, regardless of their location within the coverage area.

Kuchnicki says the performance of the new system is fives time that of the old and is remarkably flexible. He cites the example of what happened last year during a flood.

“A contractor cut through a water pipe by accident and water began pouring over eight patients undergoing day-long chemo-therapy in a special treatment room we have for them in the basement,” re-calls Kuchnicki. “So our staff just closed up their laptops, rolled the patients up to our regular room, opened up their laptops and were right back in business.”

At the 480-bed Mount Sinai Hospital, the speed and range of its wireless patient call system are equally impressive.

“Before we put in the system, our studies showed that it took the mean average to respond to a patient call of about seven minutes,” says project manager Dana Ormston. “Now the average time is 1.14 minutes.”

Ormston, a former nurse with 30 years experience, made herself into medical informatics specialist by taking a master’s degree in the subject at the University of Toronto. There, she was taught by Dr. Lynn Nagle, now her colleague and Mount Sinai’s CIO.

Ormston and Nagle agree that the anonymous donation and the system it financed have been a godsend to patient and practitioner alike.

“Our patients told us that long delays in getting responses to their calls was causing a great deal of anxiety and discomfort,” says Ormston, “and our nurses told us the existing intercom system had poor audio quality. Not only that, it was being used as a paging system to find providers and equipment. So the general noise level was just not acceptable.”

But before accepting any system Ormston says thorough consultations went on with close to 200 individuals representing patients, care givers, and staff in the hospital, including building engineers. That resulted in a task force given three responsibilities. The first was to manage the risk of replacing the old system. This it accomplished by recommending the hiring of extra nurses, making more frequent rounds during the two weeks patients went without a buzzer by their beds.

The task force’s second responsibility was to figure out criteria for the mechanics of a “wireless telephony solution”. Top of the list (Dr. Segal would be pleased to know) was to ensure that whatever new gear was picked would not interfere with cardiac monitors, infusion pumps, and other gear sensitive to EMI emissions. Also, the communication devices the nurses and others would be carrying had to be full function telephones, with a minimum of four hours of talk time in their batteries, and have the ability to make conference calls and receive text. The phones also had to integrate with Mount Sinai’s digital phone system and thus enable users inside the hospital to make outside calls.

The third responsibility was to “ensure user buy-in and provide comprehensive training packages (see columnist Richard Irving’s article in our September 2000 issue) for the new communications and emergency response system. This was done largely through “lunch and learn” training sessions conducted by the Rauland Borg Responder IV systems local supplier AATEL Communications and by Lucent supplier AVAYA Communications.

As a result, the sight of a nurse running to her station to pick up a phone call at Mount Sinai is a thing of the past. Now, when a patient pushes a bedside call bell it rings the Lucent wireless phone the nurse is toting. The nurse, regardless of where he or she is in the hospital, can re-act immediately to the patient’s needs. The nurse, in turn, can page a physician, or ring up service assistants to bring supplies or perform tasks. Also, if nurses encounter patients in cardiac arrest, for example, a push on a Code Blue button above the patient’s bed rings all the phones of the nurses on the unit as well as all the Code Blue team’s pagers simultaneously.

“The system is revolutionizing how care providers communicate with their patients and with each other,” concludes Dr. Nagle.

With vendor help, Mount Sinai was able to complete the four-year project using in-house staff to complete almost all of its aspects.

“The one aspect we needed outside consulting help with was enabling us to link our 300 or so Lucent Definity wireless phones to our existing PBX telephone switch. That was our biggest technical challenge by far,” she says.

Cancer Care Manitoba had its own technological challenges.

“Getting 11 megabits (of data transmission a second) over our new system is a huge improvement over the 1 megabit speed of the old one,” says CancerCare’s Kuchnicki, but there are just some tasks that are handled better by a 100 megabit desktop.”

3Com’s Rhys Davies agrees. He’s the company’s director of business development and health, and is keenly aware of both the technical potential and psychological limitations of wireless.

“Hospital people all want to move their information faster and know that wireless can do that, but they are also all concerned about how it will affect their other equipment,” says Davies. “So in the CancerCare Manitoba case for example, we took it down to the level of serial number and date of manufacture to confirm that each piece of equipment would not be interfered with.”

Once that EMI concern is allayed, says Davies, the trick is for each potential user to figure out which piece of their puzzle they want wireless to solve and then pick the most suitable kind of wireless. “We’re looking at expanding the system at Cancer Care Manitoba, for example, so that we can wirelessly connect up the offices of about 30 physicians. Now Bluetooth (infrared) wireless is arriving on the scene and it would be ideal. It is inexpensive and the offices are all within Bluetooth’s 30-metre range. Most of the work the physicians will do in those offices is reading, documenting, and reviewing text materials. They are not trying to look at images. They do that at the crash carts (using high-bandwidth radio frequency wireless) on the floor. So Bluetooth’s small bandwidth would be quite adequate.”

In the end, whatever approach potential users take to wireless, Dr. Segal recommends, they should start with the wireless research findings and consequent recommendations perhaps best articulated on the Web site of the American Medical Association (www.ama-assn.org/ama/pub/article/2036-2918.html).

But clearly there’s more missionary work to be done.

“I’m amazed to be told, as I was recently by a local biomedical engineer, that his hospital won’t pay the $60 for the handbook,” says Dr. Segal. “And I still get calls asking if it is OK for a surgeon to use his cell phone in the operating room.”

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Computerized patient records system pulls data from medical devices

TORONTO – Toronto East General Hospital has installed bedside computers in its Intensive Care Units that automatically collect information from medical devices hooked up to patients. These devices include cardiac monitoring devices, ventilators and dialysis machines.

The information is available at the bedside, but is also fed to a central server, allowing the data be accessed by medical professionals throughout the facility.

The technology, called INet, was supplied by Cerner Corp. “As we move towards an Electronic Health Record, this is a key step in electronic documentation that is both progressive and new,” said Pegi Rappaport, director, special projects, at Toronto East General. The INet implementation was built on the foundation of other modules already used at the hospital, such as Cerner’s central data repository and the Powerchart viewing tool.

Close surveillance of ICU patients is especially important, and an application that can alert doctors and nurses throughout the facility about their status of patients is extremely useful. “Patients in the ICU require constant monitoring and care,” said Rappaport. “Complete and extensive charting of the patient’s condition and treatment is an integral component of the care received.”

How does INet work? The cardiac monitoring devices, ventilators and dialysis machines all have an RS-232 port interface that automatically downloads information into a local Microsoft Access database on the bedside computer. Information is collected every minute and is held in an acquired data table on the hard drive of the bedside PC.

The information is reviewed by the nurse, usually every hour, to ensure that the data represents the patient’s current clinical condition. It’s also charted to the central patient data repository on the hospital’s main server.

The charted information is available throughout the hospital. With automatic data capture, a large portion of the manual typing for documentation is eliminated.

However, to complete the documentation of the patient’s clinical condition, staff input other data such as I.V. medications using a combination of drop-down boxes and manual input.

The system also allows for interdisciplinary charting. For example, Respiratory Therapists document their respiratory assessments into the same system, eliminating the practice of separate charting. As a result, charting is complete without duplication.

Every ICU nurse participated in an extensive four-hour training and education program, which was an integral component to the implementation. Other healthcare providers, such as respiratory therapists, pharmacists and physicians, were also trained on how to use the system for their needs.

The technology also exists to make ICU patient information available to physicians in their offices and at home. Toronto East General plans to implement this capability as security policies are completed.

The only true manual documentation of ICU patient care that is left is nursing interventions and medication administration. The Cerner system has the capability of capturing this data electronically as well, and it will be addressed in future system enhancements.

Overall, the INet system supplies the following benefits to the ICUs at Toronto East General:

• automated documentation
• consistent documentation and charting, mainly with structured data
• elimination of duplication in charting between RNs and RTs
• interdisciplinary charting

“The INet technology at the bedside is a key example of a clinical information system that is directly related to patient-focused care,” said Jim Shave, regional vice president, Canada, Cerner Corp. “Toronto East General Hospital was visionary in identifying the potential of electronic documentation, and is now well-prepared to move forward towards the complete electronic health record.”

Toronto East General selected Compaq as the back-end server supplier. Compaq’s Alpha server technology supports large, mission-critical applications – such as the electronic health record project. “This is another example of Compaq’s commitment to advancing the electronic patient record,” said Anne Lawrence, Canadian Health and Education manager. “Compaq is proud to be part of a leading-edge project that takes data directly from medical devices and makes it part of the patient chart.”

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Ontario resurrects its Smart System for Health

By Jerry Zeidenberg

TORONTO – The Ontario government has revived its Smart Systems for Health project, which aims to electronically connect healthcare providers and patients throughout the province.

It’s widely believed that such a network could vastly improve the delivery of healthcare services by speeding up the delivery of patient records, reports, tests, images, and other information among care-givers.

Ambitious plans were in the works three years ago to produce a province-wide system of the same name, but the project never got beyond the cabinet approval stage.

Queen’s Park has now given the green light to the plan, but in a different form. While the original Smart Systems for Health proposed the development of many clinical projects – including the creation of comprehensive electronic health records and telehealth services – the current effort focuses on infrastructure.

“It’s not about HIS (hospital information systems) or clinical information systems,” said Michael Connolly, chief information officer, I & IT cluster, Ministry of Health. “It’s more about wires, lines, messaging and data centres.”

Still, there are some exceptions. The government-funded plan does call for some clinical development in the form of an emergency health record. The voluntary record would enable emergency physicians to obtain information – about allergies and medications, for example – for patients who are brought to ER departments and are unable to recount their own medical histories.

And ultimately, the secure network may spur the use of a wider range of clinical systems, like electronic patient records, lab and pharmaceutical software. Once the infrastructure is in place, medical facilities and independent practitioners may find that it pays to invest in the clinical systems to obtain faster results and quicker access to information.

Queen’s Park has already started to issue competitive tenders – or will do so in the next few months – for the following Smart Systems for Health components:

• Secure messaging
• Practitioner Registration and Security
• Data centre
• Call centre
• Emergency health record
• Health knowledge and education.

The announcement of the revived system was held at a Toronto hotel, under the auspices of the Information Technology Association of Canada’s Ontario wing, which has been a longstanding partner in the efforts to produce the Smart System for Health.

The meeting attracted an overflow crowd of computer, software and telecommunications vendors, along with representatives from hospitals, long term care centres and medical associations.

In his introductory remarks, Connolly quipped that he was “surprised that after all these years, people are still interested in Smart Systems for Health.”

At the event, stakeholders such as the Ontario Medical Association, the Ontario Pharmacists’ Association, the Ontario Hospital Association and the Ontario Association of Community Care Access Centres declared their support for the healthcare computer network.

Ontario’s new Health Minister, Tony Clement, gave one of his first speeches in his new portfolio at the event, which was held at the end of February.

Clement noted that once a secure network is in place, and applications such as electronic patient records are developed, enhanced delivery of healthcare services is possible.

As benefits, he cited “fewer repeated patient histories, and fewer repeated diagnostic tests,” once physicians, labs and other professionals can communicate with each other over networks.
Clement said the network will be built using a modular approach, with components phased in over a period of time. He observed that technology has a habit of quickly changing, sometimes making massive investments obsolete. “Just when you think you have the answer, something new comes along... we favour an incremental approach, so we can be nimble if a new technology comes along. Then we can adapt.”

More specifically, the components will consist of:

• A security infrastructure to register and authenticate system users.
• A virtual private network for health service providers that will be fully compatible with Internet standards and capable of migrating to the environment when the Internet’s performance, security and reliability meet the requirements of Smart Systems for Health. This will occur only when Internet Protocol 6 (IPv.6) is fully supported by Ontario’s Internet backbone – most likely in four to six years.
• A secure e-mail service and on-line directory, to enable users to locate and communicate with one another electronically.
• Two information repositories, one containing personally identifiable health information, the other designed to store an anonymous version of this information for use by health researchers and planners. The first of these repositories will function as the basis for an Emergency Health Record (EmHR) for people who agree to the creation of an electronic record containing the critical health information most often required in an emergency. The second repository, called Comprehensive Health Data for Research and Planning, will be compiled from a variety of sources. This data will provide researchers and planners with access to a comprehensive and detailed pool of current and historical health service information. The anonymity of patients and health service providers will be rigorously maintained, according to the Ministry of Health.
• A portal providing access to health knowledge and education tools that will permit health service providers to access knowledge tools and ‘best practice’ information to improve health services.
• Uniform data and technology standards for the collection, storage and transmission of information. These standards will ensure that all users of the system can send and receive information without encountering compatibility problems.

Connolly noted that one of the first components to be let for tender is the messaging system. He said it’s more than a simple e-mail system, however, and will include instant messaging, interconnectivity and voice mail.

Moreover, it will include directory services – a database of all provincial practitioners. The RFP asks for the design of a registry and delivery of the solution. “We don’t yet know the best way of registering providers,” said Connolly, asserting that it’s a complex task.

The messaging and registry component will first be tested in a pilot project involving 7,550 users at 268 sites. These will include Ontario’s Community Care Access Centres, which coordinate long-term care throughout the province. Phase two of this project will involve a rollout to 150,000 users.

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Parents at home can use web-video to monitor babies at hospital

By Neil Zeidenberg

FRAMINGHAM, MASS. – A new telehealth application was recently launched at the Beth Israel Deaconess Medical Center in Boston that takes telemedicine in a new direction.

To date, most home-telehealth applications have allowed medical professionals at a hospital or healthcare facility to monitor patients in their homes.

By contrast, a new application called Baby CareLink enables parents to stay at home and use telehealth technology to monitor their premature babies at the Beth Israel Deaconess Medical Center. For perhaps the first time, the monitoring is going the other way – from home to hospital.

“For most parents, their baby’s admission is among the most challenging and distressing episodes in their lives,” said Dr. Charles Safran, co-developer of the system, and chief executive officer of Clinician Support Technology, an application service provider.

“The community created by Baby CareLink helps address the emotional needs of families by better connecting them with families and staff who have been through similar circumstances.” Moreover, being able to see their baby enhances the bonding between parent and child.

The patients are all high-risk infants of low birth weight, unable to eat on their own or breathe without the help of a respirator.

Baby CareLink connects parents to the hospital’s Neonatal Intensive Care Unit (NICU) through use of a home PC, videoconferencing equipment and a high-speed Internet connection. Parents learn how to utilize the secure Web site to monitor their babies, as well as schedule televisits and access medical information about their child’s condition.

In many cases, the knowledge and skills gained by parents during the hospital stay is lost or forgotten within the first few days following discharge. But Baby CareLink provides parents with information they need.

Baby CareLink originally used PictureTel 200 video boards in homes and PictureTel equipment at the hospital, but the developers have recently engineered IP-based videoconferencing using consumer grade USB-ready cameras and streaming video software.

The applications also makes use of the InterSystems CACHÉ database, a scalable e-database management system (e-DBMS) that links with the hospital’s information system. CACHÉ gives parents secure Web access to over 500 clinical topics related to newborns, in both English and Spanish, as well as updated photos, a baby growth chart and doctors’ notes.

The network improves a parent’s readiness to become the primary caregivers at home. As a result, the average hospital stay has dropped by 10 percent overall.

And among the smallest children, the average length of stay has dropped from 93 days to 77 days. At a cost of US$3,000 per day, that translates into huge financial savings for the health system.

“When you give parents the tools to care for their children, they become better partners in care. They are more comfortable, confident and competent in the care of their children. This allows them to take their children home earlier.”

Moreover, parent satisfaction has been dramatically improved. The number of parents who reported problems with their child’s care decreased by 75 percent after using Baby CareLink technology.

“By increasing the communication between doctors, nurses and patients, bridging the gap between home environment and acute-care setting, we allowed care to be transferred to the home more easily and everybody had a better experience,” said Dr. Safran.

To date, about 500 babies have been monitored using Baby CareLink. The technology is currently in use at eight U.S. hospitals; CST is in various stages of negotiation with other hospitals around the country, trying to get the product in use.

Baby CareLink began as a research evaluation project that was funded by the National Library of Medicine in 1997. The idea was to use Internet and telecommunications technologies to support the educational and emotional needs of families who had very low birth-weight infants (children of 1500 grams or smaller), who stay in the hospital on average 2-3 months.

Roughly 350,000 children are born premature every year in United States, or approximately 1,000 per 1 million. The rates for premature births have steadily increased over the last decade.

About one-third of premature babies are born early due to poor prenatal care, and another one-third are multiple births. One reason for the increase in multiple births is fertility technology (drugs, invitro fertilization). As more women wait longer to have children, there is more demand for fertility technology. For more information see www.babycarelink.com

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