Transmission Tangles: Getting Data From Device to Record
As healthcare organizations with maturing clinical IT systems devote more energy to considering the range of data to include for the sake of better care, attention is turning to the higher accuracy, efficiency and timeliness associated with transmitting output from medical devices directly into EHRs.
CMIOs and healthcare technology managers face multi-layered, long-term challenges in their attempts to reap interoperability benefits, including industry's slow pace of adopting data standards for patient care devices to the risks of using wireless technology, as well as the financial dilemma of balancing interoperability benefits against retrofitting or replacing hundreds of devices that typically have a decade or two of useful life.
For Baystate Health, significant clinical operations depend on getting data into the EHR, says Steve Merritt, MS, infrastructure engineer at the three-hospital system based in Springfield, Mass. More than five years ago, he says, Baystate recognized the importance of medical device data integration "to move people more toward using the EHR, and using it more effectively."
NorthShore University HealthSystem has embarked on that same path as part of a drive to make its EHR "the source of truth about the patient's health experience," says Arnold Wagner Jr., MD, CMIO of the four-hospital network based in Evanston, Ill. "We want all the information to end up successfully, safely and quickly in one place."
Achieving interoperability with nearly countless medical devices in the provider setting is complicated by at least two layers of transmission problems to resolve:
Concerns about the lack of uniform, standardized ways of interfacing devices to EHRs led Merritt to become involved with the IHE project in 2006. Baystate had so many different devices from different vendors that "it was not cost-effective or efficient to build one-off interfaces," he says. The solution had to be a framework that vendors could follow in designing their products and a companion structure for the provider to use the IHE framework to get standardized device data into the EHR. Merritt now helps guide IHE development as co-chair of its planning committee on patient care devices.
Only about 20 vendors currently support IHE frameworks, says Merritt. But, with a five-year technology road map anticipating the devices it wants to hook up to the EHR, Baystate can "be more forward-looking in what types of devices we want. It helps to talk to all the vendors in advance to request that their devices support the IHE initiative."
Meanwhile, the health system is building a network intake using IHE standards, which is half the battle regardless of what vendors do, Merritt emphasizes. For example, even if a patient monitor did not fully conform to IHE, just using a standard HL7 interface offers "a very general method of interfacing the equipment," which is a better starting point than the total customization required for a device output not written to any type of standard. And the receiving side is ready once the device end is resolved.
The chosen vendor will provide an interface engine and "take responsibility for building and maintaining all the interfaces to all of the various gadgets," says Wagner. "They take the output from devices capable of outputting signals and translate it into a digestible form [for the EHR]."
Hospitals also can retrofit equipment with middleware that performs the conversion to IHE standards, says Sloane. Given that the devices may be otherwise well-functioning and could last many more years, facilities can start with a wing or unit, implement direct data integration using middleware, but then require standards be built into replacements or new types of devices, he says.
One drawback to that approach is that "the middleware company is now literally in the middle of the warranty and safety support," Sloane cautions. In the event of a failure, the device maker and EHR vendor on either side may both say their products work fine.
Compared with data integration challenges, the means of data transfer may be secondary. Baystate is setting aside the wireless/wired issue as separate from "the foundational problems of actually getting the data into standardized formats, standardized nomenclature and vocabularies," says Merritt. "If we solve that problem, then we can attack the transfer mechanisms and figure out the most optimal way of getting the data from the devices to the destinations."
NorthShore has an internal wireless network for most traffic, including nurse call phones and about 1,000 computers on carts wirelessly interfaced to the EMR, with a robust antennae structure "that can take all the load we're throwing at it, and then some," says Wagner. The eventual solution for device/data transmission, however, will be up to the contractor chosen for the data integration expansion. "Honestly, we don't care about wireless or hard-wired at the moment. All we care is [data] get in the network."
"Wireless does seem more convenient, but there are some advantages to wired," he adds. For instance, information going into the EMR has to be reliably associated with the patient, and one way to do that is by physical location, usually a bed assigned through the hospital's patient management information system at admission, says Wagner. With a wireless enivironment, there has to be another identification method and confirmation of the information source.
Merritt considers a wireless network "not as dependable as the wired network yet." For example, "someone's phone call on a wireless handheld device would actually take more precedence over any other traffic," he says. "When they built those standards, they weren't really thinking about these other use cases where we now want wireless medical devices."
Wireless medical devices, it seems, will only continue to be both a benefit and hurdle for the collection, storage and communication of patient data.
CMIOs and healthcare technology managers face multi-layered, long-term challenges in their attempts to reap interoperability benefits, including industry's slow pace of adopting data standards for patient care devices to the risks of using wireless technology, as well as the financial dilemma of balancing interoperability benefits against retrofitting or replacing hundreds of devices that typically have a decade or two of useful life.
For Baystate Health, significant clinical operations depend on getting data into the EHR, says Steve Merritt, MS, infrastructure engineer at the three-hospital system based in Springfield, Mass. More than five years ago, he says, Baystate recognized the importance of medical device data integration "to move people more toward using the EHR, and using it more effectively."
NorthShore University HealthSystem has embarked on that same path as part of a drive to make its EHR "the source of truth about the patient's health experience," says Arnold Wagner Jr., MD, CMIO of the four-hospital network based in Evanston, Ill. "We want all the information to end up successfully, safely and quickly in one place."
Achieving interoperability with nearly countless medical devices in the provider setting is complicated by at least two layers of transmission problems to resolve:
- Efforts to foster data standards for myriad device types and brands won't meet immediate needs. The way information is represented in a device—its format, nomenclature, vocabulary choices—seldom match how it is represented in an EHR or another receiving system. And, nascent industry standards to fix are only beginning to show up in products. Such adoption also affects future purchases; providers face the choice of non-standard interfacing of existing devices or employing standards as devices are replaced.
- There is a higher risk in reliably routing signals from devices wirelessly vs. a wired connection. For one thing, the common standard for wireless transmission only can manage a finite amount of bandwidth before it starts playing traffic cop, and built-in priorities for what gets through first favor the cellphone enivironment over competing traffic like medical monitors. Associating patients with the data also is a separate hurdle in wireless approaches that typically doesn't enter into wired modes of delivery.
IHE drives standards
Data formats for patient care devices are being addressed by Integrating the Healthcare Enterprise (IHE), the interoperability initiative that supports a registry of participating manufacturers along with functions—such as infusion volumes, PACS images and drug data—that their devices are able to support, says Elliot B. Sloane, PhD, executive director of the Center for Healthcare Information Systems at Drexel University and an IHE board member.Concerns about the lack of uniform, standardized ways of interfacing devices to EHRs led Merritt to become involved with the IHE project in 2006. Baystate had so many different devices from different vendors that "it was not cost-effective or efficient to build one-off interfaces," he says. The solution had to be a framework that vendors could follow in designing their products and a companion structure for the provider to use the IHE framework to get standardized device data into the EHR. Merritt now helps guide IHE development as co-chair of its planning committee on patient care devices.
Only about 20 vendors currently support IHE frameworks, says Merritt. But, with a five-year technology road map anticipating the devices it wants to hook up to the EHR, Baystate can "be more forward-looking in what types of devices we want. It helps to talk to all the vendors in advance to request that their devices support the IHE initiative."
Meanwhile, the health system is building a network intake using IHE standards, which is half the battle regardless of what vendors do, Merritt emphasizes. For example, even if a patient monitor did not fully conform to IHE, just using a standard HL7 interface offers "a very general method of interfacing the equipment," which is a better starting point than the total customization required for a device output not written to any type of standard. And the receiving side is ready once the device end is resolved.
'We're not waiting'
For providers that are intent on acting now, however, standardization via IHE may not be the answer. "That would be lovely if it happened, but we're not waiting," says Wagner. NorthShore is poised to select a vendor that will be charged with facilitating the interface and data aggregation work in its own way. This month, the health system is starting a major device integration project with anesthesiology machines first and then IV pumps.The chosen vendor will provide an interface engine and "take responsibility for building and maintaining all the interfaces to all of the various gadgets," says Wagner. "They take the output from devices capable of outputting signals and translate it into a digestible form [for the EHR]."
Hospitals also can retrofit equipment with middleware that performs the conversion to IHE standards, says Sloane. Given that the devices may be otherwise well-functioning and could last many more years, facilities can start with a wing or unit, implement direct data integration using middleware, but then require standards be built into replacements or new types of devices, he says.
One drawback to that approach is that "the middleware company is now literally in the middle of the warranty and safety support," Sloane cautions. In the event of a failure, the device maker and EHR vendor on either side may both say their products work fine.
Compared with data integration challenges, the means of data transfer may be secondary. Baystate is setting aside the wireless/wired issue as separate from "the foundational problems of actually getting the data into standardized formats, standardized nomenclature and vocabularies," says Merritt. "If we solve that problem, then we can attack the transfer mechanisms and figure out the most optimal way of getting the data from the devices to the destinations."
NorthShore has an internal wireless network for most traffic, including nurse call phones and about 1,000 computers on carts wirelessly interfaced to the EMR, with a robust antennae structure "that can take all the load we're throwing at it, and then some," says Wagner. The eventual solution for device/data transmission, however, will be up to the contractor chosen for the data integration expansion. "Honestly, we don't care about wireless or hard-wired at the moment. All we care is [data] get in the network."
"Wireless does seem more convenient, but there are some advantages to wired," he adds. For instance, information going into the EMR has to be reliably associated with the patient, and one way to do that is by physical location, usually a bed assigned through the hospital's patient management information system at admission, says Wagner. With a wireless enivironment, there has to be another identification method and confirmation of the information source.
Merritt considers a wireless network "not as dependable as the wired network yet." For example, "someone's phone call on a wireless handheld device would actually take more precedence over any other traffic," he says. "When they built those standards, they weren't really thinking about these other use cases where we now want wireless medical devices."
Wireless medical devices, it seems, will only continue to be both a benefit and hurdle for the collection, storage and communication of patient data.