Healthcare, Embedded and Connected

The Internet of Things is enabling healthcare leaders to achieve objectives through better collection and reporting of data.

This article appears in the June 2014 issue of HealthLeaders magazine.

Technology is now in the process of not only tracking many everyday objects in healthcare, but also allowing those objects to sense and report things in a connected way to unprecedented degrees.

This technology is informing applications such as patient wayfinding, robotic transfer of supplies, interactive or informational displays throughout hospitals, and badges that employees or patients can carry or wear to optimize patient care and patient experience.

Wayfinding is essential in large medical facilities such as 395-bed Boston Children's Hospital, which built its own mobile phone application, MyWay, to help patients physically navigate their way through a campus consisting of 12 interconnected buildings with 150 total floors.

"It can be a bit of a maze, particularly when patients were going to a new doctor, clinic, or lab they hadn't been to before," says Naomi Fried, PhD, chief innovation officer of Boston Children's Hospital.

The app provides a step-by-step guide for a patient who may be walking from a parking garage to a particular doctor's office, a capability particularly important while the hospital is undergoing renovations, Fried says.

The app provides turn-by-turn directions much as an in-car navigation system does, and in its next incarnation, with the help of Cisco in-building technology, will also put a blue dot on the map indicating present location, hospital officials say.

"We see the Internet and the capability to leverage technology very broadly defined as a game-changer in the hospital," Fried says. "We are expecting to leverage technology to enhance the patient experience."

Patients aren't the only ones carrying mobile devices that sense or report their location in hospitals. For several years, hospitals have used network-connected robots to deliver meals, medicines and supplies, and to remove trash and soiled laundry using autonomous robotic tugs made by companies such as Aethlon.

Over time, such tugs have allowed newer hospital buildings to be redesigned so that not as much staging space is needed to temporarily store trash and laundry, but rather to be continuously picked up, according to officials at El Camino Hospital, a two-campus system with 300 beds in Mountain View, California, and another 143 beds in nearby Los Gatos.

"Being in the heart of Silicon Valley, we do have many examples of the technologies that are used, such as palm scanners for registering patients," says Ken King, chief administrative services officer at El Camino Hospital. "We have robotic CyberKnifes. We have da Vinci robotic surgery systems. We have robotic systems in our lab. So most of these things are integrated to work well with one another in the facility."

Featured in a report on 60 Minutes in January 2013, El Camino has 20 robot tugs deployed in multiple departments. "We made the decision early on to use robots because our prior hospital building was a vertical building of about 1,100 gross square feet per bed," King says. "Our new hospital building is about 2,300 square feet per bed, and it's very horizontal. In our old building we had trash chutes and linen chutes and vertical transportation that allowed us to move products."

Eighteen months prior to occupying the new building, El Camino's leadership team had considered adding 12.6 full-time equivalent employees, but by opting for the tugs instead was able to save $377,000 in 2008 dollars, King says. "That has significantly grown as our cost of labor has increased over the last five years, so the savings continue to be realized," he adds.

The tugs can also navigate portions of the old El Camino Hospital still in use, King adds. Implementation was very simple and relatively inexpensive, he says. "We had to install relays at doors and elevators and integrate it with our wireless infrastructure that was already designed, so that made the decision a lot easier to use the tug robots," King says. "The CAD plans that we had designed that guided the building of the building were also used to guide the tugs." Along with their preprogramming, the tugs use an array of sensors to notify operators if they get blocked, a rare occurrence.

"They do take control of the elevators. That was something that took a little adjustment for our staff, and we did make adjustments," King says. "We were fortunate in our building design that we had a significant amount of elevator capacity.

"The robots do communicate as they travel down the hallway, and they announce their arrival when they get to a point, and staff are very adept now when a robot arrives at the nurse's station—the staff just grab what they need out of it and send it right back to home, and they go back and automatically charge on the battery stations."

As the Internet of Things rolls out throughout healthcare, it is incorporating the next generation of real-time location services, traditionally used to track critical assets such as wheelchairs or infusion pumps, as well as movements of staff.

At Nemours Children's Hospital, a 100-bed facility in Orlando, Florida, that opened in 2012, the Versus ID badges worn by providers are now integrated with technology provided by GetWellNetwork, which supplies the interactive patient care and entertainment systems for the hospital.

Nemours collaborated with its technology providers to integrate the badges and the patient TVs so that when a provider enters the room, the TV displays a picture of the caregiver plus his or her credentials. "They're able to quickly know, 'That's my nurse; that's who's supposed to be here,' and again bring that sense of comfort, that this person really does belong here and that's who they are," says Jackie Gustafson, director of IT applications at Nemours.

"When we went into the contracting phase with GetWellNetwork, we threw at them a lot of ideas that we had, and they agreed to put up a portion of their own R&D dollars to help move this forward, because it was one of the firsts," Gustafson says.

Another integration links the nurse call system with the Versus badges, so that when a nurse enters a room on any sort of call, including code blues, the badge cancels the call. "They can go immediately to the patient's bedside and begin work without having to stop and cancel that call," Gustafson says. "To be able to just walk in and take care of business without having to cancel the call, or have to work with an alarm going off in the background makes it efficient for the caregiver and reduces disruption to the patient and family."

Another benefit of this integration is that a child who may have befriended another patient on the floor is less upset because the code blue down the hall gets canceled quickly, Gustafson says.

Behind the scenes, nurses coming on shift assign themselves as the nurse providing care for that room, so not just any nurse's badge entering the room will silence the alarm. At shift change, the nurse signs off being assigned to that room and the next set of caregivers signs in, Gustafson says.

Although this system is in use only in private rooms, an extension of the technology will eventually allow use in oncology settings with multiple patients per room. "The next iteration of this technology will improve the sensor specificity beyond the room level to the bed level," Gustafson says. Sensors at the head wall of each bed would properly record events at that bed without recording events at any of the other beds in that shared space, she says. "That is something that we're looking at for those additional spaces," she says, citing preop, postanesthesia care units, the emergency department, and infusion areas. "We're not there yet, but that's coming."

Gustafson also notes that every time a caregiver crosses a threshold that cancels an alarm, that event is recorded. "If there is ever a situation where a parent should say, 'I pushed that call button an hour ago and nobody has come,' we can pull that report and we're able to review it and potentially share it with the patient or the parent to say, 'Here's the time the nurse call button was pressed.' "

Nemours doesn't precisely know the return on investment of these innovations, but the innovations are aligned with the business mission of the hospital.

"For us it really was about that patient experience, that patient- and family-centered care model," Gustafson says. "We were really looking at our Family Advisory Council and saying, 'What would make this experience ideal for you?' "

The Internet of Things is also making inroads in ambulatory care. Aided by embedded digital technology, a simple piece of paper can serve multiple duties.

Sanford Health, an integrated health system with 39 hospitals, 140 clinic locations, and 1,360 physicians, uses these pieces of paper to keep tabs on patient flow through its facilities.

At Sanford's newest clinic, which opened in April in Moorehead, Minnesota, patients receive such a paper at registration. The paper indicates the room assignment and includes a map. "We're going to allow a patient the option to go straight to their own room rather than waiting for an escort or waiting in the lobby," says Jeff Hoss, vice president of clinical operations, Sanford Clinic Fargo.

The paper has a badge attached to it that sends a signal to certain sensing receivers in the clinic, and also activates timer algorithms to monitor patient flow. For instance, when the patient reaches the exam room, that time gets logged.

"We're trying to provide the staff who work in this environment with an indicator of, 'Are you in flow?' " Hoss says. " 'Are you just outside of the variation that we would want to see within the flow? Do we need additional resources?' It gives us a little bit of predictive opportunity." These milestones can also build in waiting time when necessary, such as allowing a patient to sit calmly in an exam room so as to get an accurate blood pressure reading, Hoss says.

"Everything is standardized. We've removed as much variation as we possibly can in this process. We're hoping that the days that patients come in and say 'I had to wait an hour to see my doctor' is something in the past, rather than a common standard practice."

As the Internet of Things continues its spread through healthcare, Hoss notes that providers will continue to learn as they go.

"Going blindly into this type of process is a very difficult task," he says. He recommends collaborating with technology partners such as the one Sanford uses, Intelligent InSites, which specializes in real-time operational intelligence solutions for healthcare workflow.

"They're a local business that has developed the architecture for operational intelligence which works with various different tags and badge providers from other vendors," Hoss says. "They're the real platform of this. It's the database. It's the real guts to the software that will help us with this whole thing."

Reprint HLR0614-7

This article appears in the June 2014 issue of HealthLeaders magazine.