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Back To The OR Future: The Perioperative Systems Performance Acceleration Tool

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Title: Back To The OR Future: The Perioperative Systems Performance Acceleration Tool


1
Back 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

3
University 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

4
Medication 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
5
Error 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
6
Cognitive 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.
7
Recent 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.
8
Average 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

9
Medication 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
10
Surgery needs disease management
  • Major components of medical error related to
    surgery
  • Cut medication error
  • HIMSS 2000
  • Reduce surgical infections
  • IOM 2003

11
Perioperative 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

12
UMMS 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

13
Informatics 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

14
How 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
15
How 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

16
Big 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

17
Complex 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
18
Workflow/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
19
Enterprise 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!
20
Big 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 

21
Big 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

22
Big 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

23
Big 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
24
Perioperative 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

25
Perioperative 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

26
Innovations 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

27
Innovations 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

28
Core 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

29
Core 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

30
Evaluation 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

31
Core 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

32
Core 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

33
Core 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

34
Core 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

35
Specific 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

36
Specific 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.

37
PSPAT 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
38
Implementations 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
39
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