Title: Back To The OR Future: The Perioperative Systems Performance Acceleration Tool
1Back To The (OR) Future The Perioperative
Systems Performance Acceleration Tool
- Jeff Sutherland, Ph.D.
- CTO, PatientKeeper, Inc.
- Co-Investigator, OR of the Future, University
Maryland Medical Center - Co-Chair, HL7 Orders and Observations Technical
Committee - Tim Ganous
- Grants and Program Development
- University of Maryland Medical Center
2 Operating Room of the FUTURE TATRC
- TATRC Telemedicine and Advanced Technology
Research Center US Army Medical Research and
Materiel Command - Operating Room of the Future TATRC Grant
Portfolio - Conferences
- White papers
- Research agenda
- Grant awards
3University of Maryland Medical System
- University of Maryland Medical System (UMMS)
- 300,000 patients a year
- University of Maryland Medical Center
- Shock Trauma Center - 7,000 admissions per year
- Organ Transplants (Kidney largest in country /
Pancreas-second largest) - Cardiac Care (1,000 open heart cases per year)
- Weinberg Building, new 400,000 square foot
medical facility opened November of 2002 - 19 new Operating Rooms
4Medication Error
Dispensing
- Patient safety incidents are the 3rd largest
cause of death in the U.S. exceeded only by heart
disease and cancer.(JAMA, July 26, 2000, p 483) - Inpatient medication error is the 4th leading
cause of death. Outpatient error is much larger. - 83 of medication errors can be eliminated by
automation of orders and medication
administration. (Leapfrog Group)
Transcribing
Administration
Orders
Source Gartner Group, 2002
5Error Rates per Million
Anesthesiology-Related Deaths (3.4 PMM)
VA Wireless Wrong Patient Incidents (5.65 PMM)
Source Robert Galvin, MD, General Electric Co.
David Classen, MD, Acad Med 7710,
2003 Malcolm et. al. HIMSS 2000
6Cognitive Gap Causes Medical Error
- 1497 Vasco da Gama 100 die of scurvy (63)
- 1601 English sea captain James Lancaster
tries lemon juice experiment on some ships. 110
die of scurvy (40). Test
ship stays healthy. - 1747 British Navy Physician James Lind tries
similar experiment on HMS Salisbury. Men
cured within a few
days with citrus juice. - 1795 British Navy adopts citrus juice policy
and all scurvy is eliminated on military
vessels. Limeys went on to rule the seas. - 1865 British Board of Trade adopts citrus
juice policy on merchant marine vessels and
eliminates all commercial scurvy .
It took 264 years from first successful treatment
until elimination of scurvy on long ocean
voyages.
7Recent Example
- 1886 Relationship between stomach bacteria and
ulcers observed (Johns Hopkins monograph) - 1950s New York Hospitals cure ulcers with
antibiotics - 1980s Dr. Barry Marshall publishes results
(1983 and 1987) after drinking H. pylori - 1990 National Enquirer (March 13) front page
article, Breakthrough Pill Cures Ulcers
sparks revolution in treatment - 1991 Annals of Medicine report similar results
to Marshalls - 1994 NIH endorse antibacterial ulcer
treatment as standard therapy
It took 108 years from first study until
endorsement of standard therapy for ulcers.
8Average Cognitive Gap
Professor Paul Ewald notes, the dependence of
medical progress on that National Enquirer
report does not inspire confidence in the
portrayal of medicine as a science that deftly
roots out truth from the evidence.
- 17 years average time from knowledge to
practice in medicine - 40000 new clinical information web pages a day
downloaded by Dr. John Halamka for Harvard
Medical students - lt3 years half-life of physicians knowledge
9Medication Errors Are The Tip of the Iceberg
- Cognitive gap between evidence based medicine and
healthcare provider knowledge is significant - Follow-up is haphazard. 50,000 unnecessary
amputations a year occur in diabetics in the U.S - Monitoring of clinical pathways in a hospital is
sporadic at best. - Frustration, cost overruns, medical error, and
suboptimal treatment are endemic
Medication Error
Disease Management Error
10Surgery needs disease management
- Major components of medical error related to
surgery - Cut medication error
- HIMSS 2000
- Reduce surgical infections
- IOM 2003
11Perioperative Systems DesignOperating Room of
the Future White Paper Review
- Throughput needs to be optimized
- New technology needs to enhance, not disrupt
- Knowledge inside and 24 hour situational
awareness - Informatics enables five out of eight components
of TATRC Perioperative Systems Design Schema
12UMMS Initial TargetsPerioperative Process
Points of Pain
- 1. Case needs to be understood and placed in the
schedule - 2. Supplies, instruments, and equipment for OR
and case carts are prepared the day before
surgery - 3. Surgery schedule and case carts subject to
random change - 4. Staffing issues detected and resolved in real
time - 5. Patient flow tracked, analyzed, and optimized
- 6. Automated alerts nag providers until done
properly - 7. Bed management and discharge tracked and
optimized
13Informatics Strategy Needed Applications on
Demand
- Nested timelines require informatics support for
clinical interaction with patient at multiple
points. - Mini-applications are needed at each point in the
timeline that are optimized for institution wide
workflow - Applications must run on mobile devices or
desktops, wireless or wired - Tools are required for end-user creation and
update of template applications - Radical change is necessary
14How Other Industries Do It
- 2 out of 3 trucking companies have disappeared in
recent years. - Survivors track costs down to every activity on
the loading dock and the truck. - Roadway Express sorts shipments from many
customers and terminals, then loads rearranged
goods into outbound trailers. - A barcode swipes the waybill, the location, and
the ID badge of the loader. Years ago this would
have been scrawled on paper. - Everything is automatically tracked, monitored,
and optimized.
Source Cone, Edward and Carr, David. Unloading
on the Competition. Baseline, Oct 2002
15How We Will Do ItBig Workflow Defined
- Big Workflow crosses multiple applications and
multiple vendors - Similar systems have been implemented in
manufacturing and other vertical application
domains - Workflow must be managed across vendor products
and business processes modified globally without
changing vendor systems
16Big Workflow is Federated, Heterogeneous,
Distributed, Enterprise Workflow
- Any server on the Internet can host any component
- W3C standards (http protocol, XML everywhere)
- No single point of failure
- Any system that supports an XML remote procedure
call can participate
17Complex Adaptive Systems cas
Chaos Fragmentation
Unarchitected Systems
2003 Workflow/Agents 1996 Components 1993
Business Objects
cas Self Organization
Frozen
1980 Classes 1970 Procedures
Typical healthcare system is frozen
18Workflow/Agents
Wireless Devices
XML
HTML
HTML
Mobile Framework
Mobile Metadata
Mobilizer Layer
Metadata
XML
XML
Business Logic
Workflow Engine
Application Model Layer
XML
Synthesized Patient Object
Domain Layer
Persistence Layer
Data Access
19Enterprise Workflow
Process Templates
1. Treat a patient
Process Manager
2. Who is responsible?
3. Where is their worklist?
Policy Manager
LDAP
4. What happens next?
5. Insert work item.
Worklist Proxy
Workflow Engine
Worklist
6. Do it!
20Big Workflow Engine
- A Workflow Engine is a lightweight process that
- Has an intuitive user interface
- Can step through Workflow process
- Puts Work Items on user Work Lists
- Typically runs a department in an enterprise
- Can run on any server in the enterprise
21Big Workflow Performer
- A Performer is a human or a machine that has a
WorkList that may be filled with WorkItems by one
or more WorkflowEngines - A Performer may delegate pieces of work to
another Performer, i.e. act like a WorkflowEngine
22Big Workflow Observer
- Observes a set of workflows in the enterprise and
is able to report on their current state - Specialized type of Performer and there may be
several types of Observers - A WorkList observes itself
- An archival Observer
- A statistical Observer generating summary
statistics - An Observer waiting for a subsidiary workflow to
get done
23Big Workflow Can Orchestrate Enterprise
Mobile Clients
Mobile Framework
1. Single User View 2. Integrated business
functions 3. Workflow across all participants 4.
Decision Support
1
3
Workflow Agents
Mobilizer Server
2
Other backends
PatientKeeper
Cerner
Meditech
Cerner
Meditech
Meditech
Cerner
4
Decision Support
24Perioperative Systems Design
- A rational approach to managing the flow of
patients - Can be envisioned as a nested set of timelines
- At each point, physical infrastructure and work
processes impact the progress of patients along
these timelines - Can be conceptualized, studied and optimized like
any industrial process
25Perioperative Systems Process Acceleration Tool
(PSPAT)
Pre Hosp
Intake
Pre Op
Intra Op
Post Op
Post Hosp
- Information Uptake - at each step gather critical
information - Calculation Set evaluate information against
schedule, protocol and plan - Reaction Set intervene in patient flow to
improve throughput and safety
26Innovations in Disease Management IVentura
Health Institute/PatientKeeperNIH/SBIR Fast Track
- Translation of clinical research into clinical
management - Integrated disease management protocols stored on
central server - Specially developed risk assessments, treatments
recommendations, outcome measurements, and
quality of care markers delivered to PDA at point
of care - Process and outcome measures will be assessed
- Economic benefits of cost of care vs. outcome of
care will be measured
27Innovations in Disease Management IIUniversity
Maryland Medical System/PatientKeeperDOD/TATRC
Operating Room of the Future
- Perioperative system design team analyzes
movement and treatment of patient - Clinical rule-based workflow engine will track
patient care pre-operative, intra-operative, and
post-operative processes - Patient location determined by RFID devices
- Patient workflow status appears on any device
- Care flow process generates automated alerts to
key clinicians and staff - Monitoring of
- Patient throughput improvement
- Cost reduction
- Patient care enhancement
- Decrease in medical error
28Core Technology RF ID Locators
- Radio frequency identification (RFID) is
automatic data capture technology - Data captured from tags is transferred between
distributed readers and a host environment via
wire or wireless serial communications links - Readers and tags communicate using low power
radio frequency (RF) signals - Items may be tracked automatically and without
human intervention - Capturing the location of patient, staff, and
equipment in real time is an essential component
of PSPAT
29Core Technology A Workflow Engine
- Models the current state of perioperative system
processes - Seeks required information from multiple data
sources related to each step the patient goes
through in the perioperative process - User interfaces for the workflow engine will be
Web-based, PDA-based, and Wireless
30Evaluation Criteria for Workflow Engines
- Several generations of workflow engines are
deployed today (Manolescu and Paul 2003). - Object Management Group Workflow Management
Facility (OMG 1998) and emergence of web services
standards, has led to third generation workflows
systems based on embedded components - Embedded workflow engines are the current
technology of choice - Vendors technologies need to interoperate with
workflow engines
31Core Technology Virtual Information Repository
for Workflow Engine Access
- Key Concept A package of information that
flows with the patient through every point in the
perioperative process - Reused of factory automation systems design
architecture for Boeing Computing Services. - Applying findings in other industries to
perioperative systems design will dramatically
improve performance and safety of the OR of the
Future
32Core Technology Rules Engine Provides
Intelligent Agent Support
- Maintains knowledge (present or historical) of
the state of all patients - Can detect scheduling and other issues across all
patients in real time - Can be updated as problems are uncovered
33Core Technology Alerting SystemEnsure Timely
Completion of Clinical Events
- Comprehensive alerting system to send messages of
any type to any device type - Interoperates with rules engine
- Alerts may request actions or information and
store results in clinical database
34Core Technology Reporting System Access Outcomes
Data in Real Time
- The state of each patient is stored in a clinical
data repository along with important state
transitions for future analysis - Queries determine
- improvement in outcomes over time
- efficiency of scheduling and utilization of
resources - the frequency of adverse events
35Specific Research Objectives - I
- Evaluate use of digital workflow engines in high
velocity surgical care environment and measure
impact on efficiency, patient safety, and human
factors in the perioperative environment - Develop clinical and patient care rules engine
that will make an industrial based workflow
engine functional in the perioperative
environment - Incorporate CAMIS Operating Room Information
Suite (developed by the Cleveland Clinic) which
provides tools to facilitate operational
awareness in and around the surgical environment
36Specific Research Objectives - II
- Develop sensory arrays and tracking technology
required for the workflow engine to be aware of
the deployment and status of objects in the
production environment. - Develop user interfaces to access critical
patient information and to allow perioperative
staff to guide the outcomes developed by the
workflow engine. - Evaluate the use of the digital image of the
perioperative environment created by the workflow
engine as a new and unique telesurgery view
that will enhance the sense of presence for
remote participation in surgery.
37PSPAT Flexibly Integrates Multiple Systems
Direct Connection To CDR
Web Portal Integration
HL7 Integration
RFID Tracking Patients Carts Staff
Feeder Systems Scheduling CAMUS
PatientKeeper Mobilizer
Workflow
Web Portal / Web Services
Milllennium Objects
DBOne
Synapse
CDR
CernerMillenniumRepositories
MEDITECH Repositories
HL7 Messages
38Implementations That Work TodayPartners/Brigham
Example
Handheld(CK and CAS)
PK CKWeb App
Clinical Results (Labs Radiology)
Patient Census, Schedules, and Medications
PartnersWeb Service
Charges and Schedules
PartnersLMR
IDX
BICS
IDX interface available, but not yet live at
Brigham Medications not yet implemented
39Thank You