1. Neil A Halpern MD Chief Critical Care Medicine Memorial Sloan Kettering Cancer Center, NYC Advanced informatics in critical care: The primary challenge inherent in future ICU design

2. Disclosers Medical advisor/consultant –Cardio Pulmonary Corp –Pronia Medical –Instrumentation Labs

3. I NFORMATIC ’ S S ECRET V ICTORIA ’ S S ECRET The seduction of informatics

4. 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

5. Three ICU-IT goals RTLS: Track assets (devices or people) Build a virtual device community Transform reams of data to meaningful & actionable information

6. UltrasonicRFIDIRMultimode Wireless Access Points and Sensors Computer Bedside Physiological Monitor (Stationary) Mechanical Ventilator (Mobile) Infusion Pumps (Mobile) Medical Applications Blood Products Meds Lab Specimen ICU Bed Wi-Fi UniversalLabsBloodMeds Bar Code Scanners Wired Jacks Multi-Parameter/Port Device Integrator Nurse Call POCT Environmental Sensors Supplies Images Pharmacy Central Lab Bar Code Scanner Auto-ID Tag Mini-computer Adaptor Wireless CardiologyRTLS ADT EMR Alarms

7. RTLS Inventory & Asset Management

8. Real Time Locating Systems/Solutions (RTLS) RTLS: wireless tracking of tagged items Mobile Asset tracking Improve workflow Integrate with other systems

9. Monitors Vents Pumps SERVERS Monitor Vent Pumps Monitor Vent Pumps Monitor Vent Pumps Monitor Vent Pumps Where is it? RTLS Asset Management Where is it? Is it being used? Where is it? Is it being used? Is it leaving ICU?

10. Penguin in Atlanta Zoo

12. ICU GPS system

13. IR Wireless Access Point Pt in CT Scan Pt in IR Wireless Access Point Pt in ICU WEDNESDAY, SEPTEMBER 19, 2012 - 9:15 a.m. Pt in ICU CT SCAN Wireless Access Point PATIENT TRAVELS ICU ROOM

14. Build a Virtual Device Community

15. 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

16. Bernoulli Ventilator Management System, Cardiopulmonary Corp, Milford, CT Wireless Bridge

17. Bernoulli Ventilator Management System, Cardiopulmonary Corp, Milford, CT Wired Multiport Bridge

18. Monitors Vents Pumps Vent Pumps SERVERS Virtual Ventilator Community, Alarm delivery Data storage Monitor Ventilator Vent

19. Bernoulli Ventilator Management System, Cardiopulmonary Corp, Milford, CT

20. Transform data to meaningful & actionable information

21. NC CENTRAL STATION Monitor Vent Pumps Where is it? Is it being used? Monitor Vent PumpsMonitor Vent Pumps Monitor Vent Pumps ALARM INFO Bed 1 Bed 3 Bed 4 Bed 2 1 3 2 4 Monitors Vents Pumps Nurse Call EMERGENCY ALERT MARQUEE NC Nurse Call Delivery Server Alarm Delivery System

22. 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

23. NC BED 4 VFIB NC CENTRAL STATION Monitor Vent Pumps Where is it? Filter Where is it? Is it being used? Monitor Vent PumpsMonitor Vent Pumps Monitor Vent Pumps ALARM INFO Bed 1 Bed 3 Bed 4 Bed 2 1 3 2 4 Monitors Vents Pumps Bed 1  Heart Rate Bed 4 VFIB Alarm Delivery System Bed 1  Heart Rate Bed 4 VFIB EMERGENCY ALERT MARQUEE NC Alarm Delivery Server NC FILTER

24. The devil is in the details!

25. Primary Informatics Challenges Evaluate many technologies Connectivity envelope Association Time synch, interoperability & data synch Medical devices are informatics platforms Roll out Maintaining & upgrading

26. 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

27. Hi Tech Evaluation Many similar products Evaluate over a short time period Discern subtle, but meaningful differences Figure out the cost, initial & long-term

28. You have 15 minutes, no slides, no sales pitch, just tell us what you got! BUZZZZZZZ Speed Dating for Technologies NEXT!

29. 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

30. Primary Informatics Challenges Evaluate many technologies Connectivity envelope Association Time synch, interoperability & data synch Medical devices are informatics platforms Roll out Maintaining & upgrading

31. Putting It All Together...

32. or not...

33. 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 Five Steps to Creating the Smart ICU

34. UltrasonicRFIDIRMultimode Wireless Access Points and Sensors Computer Bedside Physiological Monitor (Stationary) Mechanical Ventilator (Mobile) Infusion Pumps (Mobile) Medical Applications Blood Products Meds Lab Specimen ICU Bed Wi-Fi UniversalLabsBloodMeds Bar Code Scanners Wired Jacks Bar Code Scanner Multi-Parameter/Port Device Integrator Auto-ID Tag Mini-computer Nurse Call Adaptor POCT Environmental Sensors Supplies Wireless Connectivity Envelope

35. Hospital and ICU Systems, Servers and Applications Network Servers and Routers Hospital Network ICU Network Bed 3Bed 4Bed 6Bed 1Bed 2Bed 5Bed 7Bed 10Bed 11Bed 13Bed 8Bed 9Bed 12Bed 14 Network Servers and Routers Hospital Network Device Managers RTLS Telemedicine Alarm Distribution Smart Displays Administrative Clinical Electronic Medical Record ICU Middleware

36. Primary Informatics Challenges Evaluate many technologies Connectivity envelope Association Time synch, interoperability & data synch Medical devices are informatics platforms Roll out Maintaining & upgrading

37. 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

38. MEDICAL DEVICE: STATIONARY (MONITOR) FIXED LOCATION/ IP ADDRESS Association of Devices & Patient Alarms Location/ ONLY Location/ NAME NO LOCATION/ NEEDS NAME MEDICAL DEVICE: MOBILE (VENT, PUMPS) Name MRN Location - ICU Room Number ADT EMR DEVICE MANAGER ALARM MANAGER vs. PT

39. Primary Informatics Challenges Evaluate many technologies Connectivity envelope Association Time synch, interoperability & data synch Medical devices are informatics platforms Roll out Maintaining & upgrading

40. Monitor Vent Monitor Vent Monitor Vent Monitor Vent Vents SERVERS Webcam Disparate ICU devices & systems not in sync! Pumps Monitors Time Pumps Vents 9:10 Webcam 9:05 Pumps 8:50 8:55 9:10 8:50 Webcam 9:05 Monitors 8:55

41. Monitor Vent Monitor Vent Monitor Vent Monitor Vent Vents SERVERS Webcam Time Server Pumps Monitors Time Pumps 9:00 Webcam 9:00 Vents 9:10 Webcam 9:05 Pumps 8:50 Monitors 8:55 Vents 9:00 Webcam 9:00 Pumps 9:00 Monitors 9:00 9:00

42. φβηψτϵϴαρμωζγωζγβηψφβηφβφρμηψρμηψβηψτ ϵϴαρμωζγβηψφβηφβηψτϵαρμηψτϵαρμρμηψ ALARMS - 743203048 - ALARMS - 43038634663980 Connectivity Envelope ICU Electronic Flowsheet ICU Bed Device Data and Alarms: Interoperability Adaptor/ Wireless Mini- computer EFS/Alarms what the … did that vent say to me? Data Storage Electronic Flow Sheet Alarm App Web Servers φβηψτϵϴαρμωζγβ ηψφβηφβηψτϵαρμ ALARMS - 7403048 - ALARMS - 463980 Conversion on Outbound or Inbound NOW - I understand! VENT Medical Device

43. Interoperability Enable seamless & secure access to health info Provides specs, tools & svcs for interoperability IHE Connectathon: Standards based interoperability for vendors & users of HIS

44. Connectivity Envelope ICU Electronic Flowsheet 7906530 4379054 32 Servers ICU Bed Device Data and Alarms: Data Synch Data/Alarms Data Storage VENT Bar Code Scanner Adaptor/Wireless Auto-ID Tag Mini-computer EFS/Alarms “Respiratory Rate” ≠ “fR” Electronic Flow Sheet Web STOP Alarms Alarm App Crosswalk for data synch: Respiratory Rate = fR “Respiratory Rate” = fR

45. Primary Informatics Challenges Evaluate many technologies Connectivity envelope Association Time synch, interoperability & data synch Medical devices are informatics platforms Roll out Maintaining & upgrading

46. Infusion Pump: The Dark Ages One-time Purchase

47. Infusion Platform: The Modern Era MIDDLEWARE PUMP PHARMACY EMR Infusion Pump: The Dark Ages SERVER ACCESS POINT OFFSITE BACKUP PUMP SERVER PRIVACY

48. Building the Infusion Pump System Medication Library Medication Orders Alerts Dosing Protection Wireless Communication MemoryBack-upHandheldsPrivacy

49. MIDDLEWARE PUMP PHARMACY EMR MEMORY Medication Orders Dosing Protection Medication Library Infusion Platform: The Modern Era ACCESS POINT OFFSITE BACKUP PUMP SERVER Alerts Wireless Communication

50. MIDDLEWARE PUMP PHARMACY EMR MEMORY Infusion Platform Costs $$$$ $ $$$ Ongoing Costs for Software Updates & Licenses $ ACCESS POINT OFFSITE BACKUP PUMP SERVER $

51. Primary Informatics Challenges Evaluate many technologies Connectivity envelope Association Time synch, interoperability & data synch Medical devices are informatics platforms Roll out Maintaining & upgrading

52. WORK IN PROGRESS Roll out

53. 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

54. Primary Informatics Challenges Evaluate many technologies Connectivity envelope Association Time synch, interoperability & data synch Medical devices are informatics platforms Roll out Maintaining & upgrading

55. Hospital and ICU Systems, Servers and Applications Device Managers RTLS Telemedicine Alarm Distribution Smart Displays Network Servers and Routers Administrative Clinical Electronic Medical Record ICU Middleware Hospital Network ICU Network Bed 3Bed 4Bed 6Bed 1Bed 2Bed 5Bed 7Bed 10Bed 11Bed 13Bed 8Bed 9Bed 12Bed 14 Network Servers and Routers Hospital Network UPGRADED REPLACED BROKEN HEAVY TRAFFIC

56. ITBioMed Engineering ICU Team Hospital Admin We didn’t do nothin’ except upgrade the system! Who broke it? We had to fix this! No one communicates with each other!

57. Closing thoughts Data analytics Security Dark data Future proof The box: In or out The “Bottom line”

58. 432696538042514267 5789657906304682110385 4322378566597724267 5789604349077657905 43269642514267538042517 1122378566597724267 Data Analytic Center 4322378566597725696538042514267 5789604349077657906304682110385 What data do we want to analyze? What about PHI? What message do we want to show? Data from devices, applications & calculations? WOW! Too much data!

59. Hawaii Security: Real or a Joke? NSA, Washington DC TOP SECRET 790 653 043 790 543 2 790 653 04

60. 79065 39440 43790

62. Dark Data

63. 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

64. Avoid future chaos “Future-proof”

65. “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

66. Thinking Outside the Box

67. Thinking Inside the Box. G R E A T Thinking Outside the Box. E H L P S S A V E O U T C O M E G E C E T X E L C D R U S C U R I N G D A T H R C A N C E R S

68. 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

69. 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

70. Thank You!