Cedars-Sinai is improving nursing workflow by integrating devices around the hospital with its electronic health record.
This article first appeared in the December 2016 issue of HealthLeaders magazine.
At most hospitals, standalone devices capture such vital signs as pulse oximetry, weight, temperature, and blood pressure, but values from these devices must be reentered into the EHR manually, creating extra work for nurses and introducing data entry error possibilities.
Enter Cedars-Sinai, a nonprofit academic medical center in Los Angeles with 886 licensed beds, 2,100 physicians, 2,800 nurses, and thousands of other healthcare professionals and staff. At Cedars, device integration is already eliminating much manual work.
In a talk at the 2016 HIMSS conference, Jennifer Jackson, Cedars-Sinai director of clinical engineering and device integration, described the origins of the initiative, the outcomes of which she is now in the process of preparing for publication in a peer-reviewed journal. She is also preparing a paper about previous work integrating IV pump data into the health system's EHR.
In the case of pump integration at Cedars-Sinai, the Electronic Medication Administration Record (EMAR), which lives inside the EHR, pushes the medication order information to the pump. In that sense, the EHR programs the IV pump. The pump sends data back to the patient's EMAR. However, the EHR does not start and stop the IV pump itself. That still needs to be done by a nurse. The nurse reviews the settings prepopulated into the pump by the EHR before starting the pump.
"On both ends it saves us a lot of time and it also now removes a high degree of potential error when it comes to data entry and the timing of that data entry," she says. "We're now in the process of reviewing the data and seeing how significant the results are."
Cedars-Sinai first connected infusion pump systems to EHRs in June 2014, adding pulse oximetry integration in August 2016. Although she cannot yet disclose the outcomes of the infusion pump integration, Jackson says it involves significant avoidance of medication errors.
"Our approach to device integration is somewhat holistic," Jackson says. "We look very carefully at not just a movement of data points from one system to another system. In the case of pulse oximetry, a system that we just implemented, it wasn't enough for us just to export the SpO2 and pulse rate into the EHR. We also wanted to capture and be able to distribute the alarm settings. For us that was a single project."
Another aspect of the integration involves patient-controlled analgesia (PCA) pumps.
"When we say device integration, it's not just looking at how to get the data points into the EHR. It's also looking at what kind of alarms are more actionable information. Do we need to get to those caregivers in a meaningful time?"
"We measured their pulse oximetry, just to make sure, to monitor the patient's respiration, so that we can intervene should that patient start to have an adverse reaction to the opioid in their PCA pump," she says.
A drawback and annoyance of standalone devices' alarm systems is that, often, the only person hearing that alarm initially may be the patient, as nurses attend to other patients in their care. Alarms can be routed to a nurse's workstation or portable communication device to speed intervention, Jackson says.
"The expectation that the nurse or someone will always be available to intervene the moment that device starts to alarm is a large expectation," she says. "Actually, we're asking too much of our care workers to always be waiting for the next alarm. And when we say device integration, it's not just looking at how to get the data points into the EHR. It's also looking at what kind of alarms are more actionable information. Do we need to get to those caregivers in a meaningful time?"
Therefore, at Cedars, data such as pulse oximetry not only integrates with the EHR, it also integrates with Cedars' alarm management system. "We're often shocked at how few medical device manufacturers have actually thought through this kind of integration," Jackson says. Once these integrations were in place, "we know that we've been able to intervene and possibly save lives.
"It could be something as simple as the patient just dislodged their nasal cannula, but that caused their SpO2 to go down," Jackson says. Nurses could then reenter the patient's room and ask the patient to reinsert the cannula to receive the proper amount of oxygen.
Jackson describes the device integration initiative as "my career. I've been very passionate about it." At Cedars, the initiative's executive champion has been Linda Burnes Bolton, RN, vice president of nursing and chief nursing officer. "She did a lot of the precursor work to identify device integration and some technologies that we actually leverage for the alarm notification process," Jackson says. "She and some of her fellow CNOs got together and said nursing care should be at the highest level that it should be in terms of quality of care in the era of EHRs and newer technologies that are impacting the workflow."
Over time, vendors themselves are filling in some of the device integration gaps. For instance, San Antonio, Texas-based AirStrip Technologies has been building and offering a vendor- and data source-agnostic enterprisewide clinical mobile interoperability solution incorporating devices such as fetal monitors into dashboards viewable on iPads and other information-viewing devices. AirStrip investors include Dignity Health, Hospital Corporation of America, St. Joseph Health, and the Gary and Mary West Health Investment Fund.
There is also an effort underway at the national policy level to help with device interoperability issues, including draft guidance from the Food and Drug Administration in January 2016, "Design Considerations and Premarket Submission Recommendations for Interoperable Medical Devices," intended to be a nonbinding set of guidelines to interoperability of medical devices with each other and other health information systems. "There's a lot of different agencies that are looking at interoperability and each agency has its own hammer, and the FDA's hammer is safety," says Matt Patterson, MD, president of AirStrip.
The draft FDA guidance has broad industry support, and may help extend the work of trailblazers such as Cedars-Sinai to all of healthcare.
Scott Mace is the former senior technology editor for HealthLeaders Media. He is now the senior editor, custom content at H3.Group.