The Converged Wireless Hospital a progress report Annual VAHIMSS Fall Conference

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The Converged Wireless Hospital(a progress
report)Annual VAHIMSS Fall Conference

• October 16, 2008
• Rich Pollack
• VP CIO
• Division of Information Services and Clinical
  Transformation
• Virginia Commonwealth University Health System

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Virginia Commonwealth University Health System
(VCUHS) - Richmond, VA
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VCUHS

• Medical College of Virginia Hospitals
• MCV Hospitals is the teaching hospital component
  of the VCU Health System
• 779-bed academic medical center with 2,200
  Nursing Staff
• Full activation of the new Critical Care Hospital
  will provide 275 replacement beds
• 600 physician, faculty group practice
• 80k visits/year Level 1 Trauma Center ED
• 30k admissions/year in 45 inpatient units
• 500k visits/year in 85 outpatient clinics

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VCUHS

• VCUHS Education
• 656 Residents and Fellows engaged in 70 training
  programs
• 728 Medical Students taught by 791 faculty
  (clinical, teaching, administrative)
• Schools of Dentistry, Medicine, Allied Health,
  Nursing and Pharmacy on Campus
• Information Technology
• June 2008 VCUHS recognized as CIO 100 honoree
  by CIO Magazine for using information technology
  to create business value

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Critical Care Hospital
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Critical Care Hospital

• The 184 million Critical Care Hospital is the
  largest capital construction project in the
  history of the VCU Medical Center. The all
  private room hospital houses 232 adult patient
  beds and 43 neonatal rooms, increasing the
  medical centers ratio of private to semi-private
  beds from 37 percent to 70 percent.

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Critical Care Hospital

• 15 levels
• 368,000 square feet
• 275 beds

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Former Space Challenges
MRICU (Medical Respiratory ICU) Locations on Main
Hospital 4th Floor
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New Space Challenges in the CCH
MRICU (Medical Respiratory ICU) Critical Care
Hospital 4th Floor
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Nursing station
MRICU (Medical Respiratory ICU) Critical Care
Hospital 4th Floor
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Creating a parallel project effort

• Findings at beginning of 2006
• No provision made for IT infrastructure beyond
  Cat 6 cabling
• Naïve assumption of simply bringing over existing
  PCs/Phones/network gear
• No consideration of wireless and other new
  converged technologies
• No appreciation of the impact of radical change
  in nursing unit geography has on communication
• Little participation by I.T. in a holistic way
• Lack of imagination to create a Digital
  Hospital
• Little budget for additional IT costs

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Creating a parallel project effort

• Remedies
• Engagement of CIO and Sr I.T. leaders to
  determine and specify requirements
• CIO educates the CCH steering committee on the
  fallacy of prior technology assumptions and need
  to contingency fund the now known IT needs (4M)
• Introduction of the concept of a single collapsed
  antennae infrastructure for all wireless needs
  (InnerWireless)
• Assignment of an I.T. nurse (critical care
  trained) F/T to project (nurse liaison)
• Provision of a I.T. project manager experienced
  in new hospital technology activation (single
  point of contact)

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Creating a parallel project effort

• Approach
• Contracted with IT Project Manager to work with
  building construction management, architects,
  contractors, vendors, clinicians, senior
  leadership, and information systems groups
• Formed IT project team reporting up to the CCH
  steering committee
• Engaged IT nurse liaisons to work with clinicians
  on future hospital workflow and nursing
  requirements
• Conducted technology fair for clinicians and
  leadership to expose them to latest technology
  solutions

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Critical Care Hospital(Clinical Liaison Role)

• Attend and participate in all of the Critical
  Care Hospital project meetings
• Meet regularly with the architects and unit
  management teams to discuss build and design of
  the new hospital
• Meet with units to review staff requirements for
  fixed and mobile device usage
• Discuss how new unit design will dramatically
  change the way clinicians practice and socialize.
  Focus has been to address current clinical
  workflows and the integration of new technologies
  to facilitate future workflows in the expanded
  space

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Critical Care Hospital(Clinical Liaison Role)

• Promote and attend vendor meetings for mobile
  devices, nurse call systems, communication
  systems, bedside monitors, telemetry equipment,
  and middleware solutions
• Educate and work with the architects Revisions
  recommended to make provider sub chart areas
  compatible for desk space and mobile device
  storage
• Focus on system design that will ensure a safe
  environment and a successful transformation

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Critical Care Hospital

• Approach (contd)
• Developed IT infrastructure budget and secured
  senior leadership approval for procurement of
• Hardware and services for wired and wireless
  network
• InnerWireless DAS for WWAN and WLAN services
• PCs, network printers, computers on wheels,
  tablets
• Ascom wireless phones and middleware for
  integration with nurse call and patient
  monitoring
• Developed detailed project plan for procurement,
  deployment, and move management for existing
  devices

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Critical Care Hospital IT Objectives

• Install a passive Distributed Antenna System for
  all wireless services in the CCH
• Support many services across a broad spectrum of
  frequencies
• Move from discrete to centralized AP locations
  for 802.11 and WMTS
• Provide ubiquitous computer access throughout the
  CCH
• Support transition to nurse and physician
  documentation in EMR
• Deploy wireless VOIP solution for nursing and RT
• Enhance unit communications and patient care
  workflow in transition from a pod to nearly
  25,000 sq ft per floor

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InnerWireless Scope

• Wireless LAN (802.11 a/b/g) support within the
  Critical Care Hospital totaling 367,792 sq ft.
• Philips Wireless Medical Telemetry support
  deployed on floors SB1, 2, 3, 7, and 10 totaling
  116,045 sq ft.
• Supports all wireless services in the frequency
  range 400 MHz to 5 GHz
• Excluded from scope
• ground floor (future ED expansion)
• elevator shafts and motor rooms
• enclosed stairwells
• first floor public restrooms

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Critical Care Hospital DAS

• InnerWireless
• June 2007 - Contracted with InnerWireless
• Project phases
• Scope definition
• Design
• Procurement
• Installation
• Testing and acceptance
• March 2008 - Completed installation and final
  testing of DAS

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Critical Care Hospital DAS

• CCH floor 4 above ceiling cable routing and DAS
  antenna placement

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Critical Care Hospital DAS

• Design Phase Signal Prediction
• 10th floor Wireless Medical Telemetry (WMTS)1400
  MHz

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Services Supported by InnerWireless
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InnerWireless DAS

• Implemented one infrastructure in the CCH for all
  wireless services in the frequency range 400 MHz
  to 6 GHz

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InnerWireless Design
Percentage of Coverage Area to Meet or Exceed
Designed Signal Level
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Critical Care Hospital DAS

• By final hospital activation in mid-November
  2008, the following services will be injected
  into the DAS portal
• Philips Wireless Medical Telemetry support
  deployed on floors SB1, 2, 3, 7, and 10 (116,045
  sq ft)
• Wireless LAN (802.11 a/b/g) support for all
  floors (367,792 sq ft)
• Verizon voice and PCS data services
• Two-way radio for hospital plant operations and
  security
• Paging services for clinicians
• Wireless clocks controller

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CCH Device Deployment Planning

• Floor plans marked for PCs, computers on wheels,
  network printers, label printers
• Used for network drop configuration
• Facilitated planning meetings with nursing

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CCH Ubiquitous Computer Access
approx 140 computers on wheels (new existing)
approx 470 PCs (new existing)
sub-chart outside pt. rooms
typical nurse station
clinician work rooms
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CCH Wireless Communications

• Wireless Phones
• Performed evaluation in 2007 of Vocera versus
  Ascom for use by CCH nursing
• Completed site visits to Sentara Leigh and
  Sampson Regional hospitals to review Ascom
  implementations
• Completed pilot of Ascom FreeNet phones and
  middleware in Cardiology/Telemetry unit in
  February 2008
• Procurement of Ascom phones, middleware, services
  for installation, integration, training and
  deployment from Hill-Rom in July 2008
• Integration with Emergin (Philips patient
  monitoring alerts) and Rauland-Borg nurse call
  system completed August 2008
• Nursing staff training currently underway
• Phones deployed in CCH upon unit move-in

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The NICU problemFrom Baby Barn to a
racetrack

• Reconciling radical changes in geography with
  breakthrough technology

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NICU (Neonatal ICU) Locations on Main Hospital
6th Floor
NICU (Neonatal ICU) Locations on Main Hospital
6th Floor
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Nursing station
NICU (Neonatal ICU) Critical Care Hospital 6th
Floor
NICU (Neonatal ICU) Critical Care Hospital 6th
Floor
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NICU Move to a Single Room ModelAdvantages

• Controls environmental (noise/light) exposure to
  infants that effects development
• Creates privacy for families
• Promotes Interdisciplinary care for the infants
• Mobile communication system provides visitors the
  means to communicate between clinical staff and
  the families

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Alarms in the NICU Single Room
ModelDisadvantages

• Closed doors can reduce the ability to hear
  patient alarms by clinical staff
• Most medical equipment does not broadcast alarms
  outside of the patients room
• Device alarms are very disruptive to the infants,
  many device volumes are decreased to reduce
  environmental stimulation
• The NICU environment generates many alarm
  situations
• 90 of the NICU alarms are generated by movement
  (artifact, false alarm) and are not a true
  clinical alarm condition
• A device alarm notice is not detailed enough to
  distinguish a True from a False alarm
  condition Staff has to respond to the patients
  bedside for each generated alarm and eyeball
  the waveform displays

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Wireless Remote Waveform Solution

• Nature of the alarm should be sent to clinical
  provider anywhere in the NICU environment
• Real-time alarm streaming on a mobile wireless
  device
• This allows the clinician to view the actual
  patient waveforms, distinguish between true and
  false alarm conditions, and prioritize a
  response to the patients bedside

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Cerner Smart Room
Future Smart Room concept
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Cerner CareAware
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Critical Success Factors

• Notify vendor and hospital services early for
  injection of signal to InnerWireless - long lead
  times for signal surveys, cable path coring, and
  equipment procurement
• Develop partnership with clinicians early on and
  include them in device strategy, placement,
  collection of special requirements, and training
  program development
• Test early and often all devices attached to
  wired and wireless networks before hospital
  occupancy
• Pursue a comprehensive IT strategy that insures
  the proposed budget encompasses all projected
  needs
• Develop and communicate wireless network usage
  policy
• Coordinate with patient monitoring vendors on use
  of network drops

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A Cutting Edge Environment

• ASCOM over DAS is unique we are the first
• VCUHS has one of the most complex and
  sophisticated Wireless NW weve seen Cisco
• High reliance on wireless devices of all types
  (e.g. Computing devices, Telemetry, Waveforms,
  voice devices, etc.)
• Lots of hard work, planning heroics to get
  us ready

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Challenges to opening the CCH

• Device deployments delayed 5 weeks due to back
  orders of furniture, etc.
• Compressed time frame for setup, testing
  Heroics!
• 5th Floor network closet reconstruction
• Dust, heat, destroyed 2 ASCOM servers, severely
  damaged Cisco switch (100K device)
• Unknown bug in IOS
• Resulted in ASCOM failure work around found
  root cause still being diagnosed by Cisco ASCOM
• Lead lining of OR resulted in changes to
  Innerwireless RF modulation and coverage
• Have only one WLAN engineer
• Need 2 additional Wireless Engineers to support
  our environment (per Cisco)

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Somewhat Painful Lessons Learned from CCH

• Need to be there at the onset to insure an
  adequate IT infrastructure budget. Its
  new. Its very complex. And its not cheap. And
  most facilities/construction folks havent got a
  clue.
• Staffing for support
• Need for a true Clinical Engineering group (not
  just BioMed maint.) to partner on the device
  connectivity
• IT needs their own highly skilled wireless
  network engineers
• Mobile devices and COWs will need far more
  proactive on-site weekly support if they are not
  to end up being discarded
• Its all about nursing workflow. Do it correctly
  up-front to determine device needs and locations.
  Especially when the geography is changing.
• Make sure that clinician expectations for IT are
  grounded in reality. Their vision may not yet
  match mature product technology.
• Integrating 4, 5 or 6 different vendors is the
  infrastructure equivalent of pursuing best of
  breed clinical system integration.
• GE Monitor alarm feeds
• Emergin middleware feeds
• InnerWireless DAS feeds
• Ascom nursing phones OR COWs OR Tablets

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• and manage it as professionally as you would any
  major system implementation.

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Questions?