Lab Soft News

How Hackers May (of May Not) Be Successful in Changing Healthcare

I recently came across an interesting op-ed piece by Sean Parker, the entrepreneur who became a billionaire by investing in Silicon Valley start-ups (see: Sean Parker: Philanthropy for Hackers). In the article, he defines the hacker culture in the following way:

Hackers share certain values: an antiestablishment bias, a belief in radical transparency, a nose for sniffing out vulnerabilities in systems, a desire to “hack” complex problems using elegant technological and social solutions, and an almost religious belief in the power of data to aid in solving those problems. Hackers are popularly considered to be troublemakers, but they are also dedicated problem solvers, as interested in discovering holes in systems as they are in exploiting them for personal gain. By identifying weaknesses in long-established systems, they have successfully disrupted countless industries, from retail and music to transportation and publishing.

I have documented in Lab Soft News the failures of Microsoft in the past (Health Vault) to enter the healthcare market (see: Microsoft Purchases Healthcare Search Engine; Microsoft Renames and "Integrates" Its Healthcare Software Line; Implications of the Kaiser-Microsoft PHR Deal; Amalga Makes Inroads in the EMR World; Microsoft's Amalga/HealthVault Strategy Becomes Obvious). I will assume here that the Microsoft culture represents hacker values or at least did so in the past. The company, although still profitable, has been eclipsed from a technical and strategic perspective by by Apple and Google (see: Mobile: It Changes Everything).

I have been toying with the question of why "hackers," represented in part by Microsoft or other IT companies, have had difficulty "disrupting" the healthcare industry using hacker values such as transparency, a nose for system vulnerabilities, and a belief in using data to solve problems (Software to Healthcare: Israeli innovation disrupts medicine). I have come up with the two following possible theories:

• Hospitals are organized with a "top layer" consisting of executives who mainly manage revenue. Most of them are not physicians and have little detailed knowledge about how physicians and nurses care for patients. The management style of hospital executives is conservative, partly because of the regulated nature of the industry. Regarding IT, they have recently deployed EHRs that I think often inhibits the efficiency of physicians and nurses (see:Ten Reasons Why the Current Hospital EHR Model Is Unsustainable; Veteran Clinician Critiques the Current EHR -- Both Good and Bad). Their interest in big data and analytics has only recently been stimulated but is largely confined to tools to manage revenue.
• The "bottom layer" of hospitals is occupied by physicians and nurses who deliver care to patients although all major financial and product buying decisions are made by the executives. EHRs that are designed mainly to optimize hospital billing rather than clinical efficiency have been imposed on them by hospital executives. 

In my view, our healthcare system will not be easily changed by "hackers" with disruptive technology. I base my conclusion, in part, on past failures by companies like Microsoft and Google to offer products that appeal to healthcare consumers. Such companies often lack an understanding of the culture and organization of hospitals and other healthcare organizations. However, I also think that we are on the cusp of radical health solutions involving smart phones linked to devices attached to the wrist. They will be used to monitor physical activities and also have, or will have, sensors to monitor pulse and blood pressure and even perform lab testing such as blood glucose levels.

Such mobile-generated data can be reported to physicians but will not necessarily be integrated with the medical records that are maintained in physician offices, clinics, and hospitals. Moreover, there is little enthusiasm at the hospital executive level, nor at the EHR vendor level, to integrate patient-generated data with hospital and physicians office data. Such integration can also be technically daunting because most hospital system are based on aging technology. In short, much of the formal healthcare delivery system is insulated from "hacker" ideology and consumers have little power to change the system.

UPMC Tries to Stifle Local Press Coverage in Pittsburgh

The University of Pittsburgh Medical Center (UPMC) has been sorely vexed by the city newspaper, the Pittsburgh Post Gazette, with regard to some of its articles such those addressing the salaries of its executive officers. It thus decided to ban sales of the newspaper in the hospital gift shops (see: UPMC hospitals ban sale of Post-Gazette from their gift shops). Below is an excerpt from the article:

Some UPMC hospitals are banning the Post-Gazette from sale in their gift shops, a move UPMC spokesman Paul Wood said was precipitated by “fairness issues” in the newspaper’s coverage of the health system. At least three UPMC hospitals...[in the system] say they will no longer sell the newspaper.T wice in recent years, UPMC executives have canceled the health giant’s advertising in the PG, citing dissatisfaction with the way UPMC was covered in the news pages and how it was portrayed in editorials and editorial cartoons.....''We believe that our coverage of UPMC has been fair-minded in every respect,'' said David M. Shribman, the newspaper's executive editor. ''Every entity in every town feels aggrieved at some point by what a good newspaper writes. It's part of living in a free society where the exchange of news and information is prized, not punished.'' But health system officials have often criticized stories, editorials, and editorial cartoons published in the Post-Gazette in recent years, most frequently in its coverage of the ongoing contract battle with insurer Highmark and, in years past, about the health giant's real-estate holdings and its business practices.The Post-Gazette also recently published stories about UPMC’s transplant program being placed on probation over its handling of donor organs (see: UPMC put on probation for transplant practices)....

I was not knowledgeable about the UPMC/Pittsburgh Post Gazette controversy regarding real estate (see: UPMC's sometimes controversial appetite for real estate). Here's an excerpt from one of the relevant articles on this subject:

Starting in 1982 in a single building that it didn't own, UPMC over 30 years has acquired and expanded most of the major hospitals in the region, built or purchased a network of 13 senior communities and hundreds of cancer treatment centers, rehabilitation and outpatient clinics and doctors' offices. The result is that UPMC is now Allegheny County's single largest private property owner in terms of the value of that property....with 656 acres worth $1.6 billion based on the 2002 assessment, 86 percent of it exempt from taxes, according to a six-month review by the Pittsburgh Post-Gazette. No other charitable organization comes close, with the University of Pittsburgh a distant second with $1 billion in property. UPMC now owns 8 percent of Allegheny County's $16.67 billion of tax-exempt land. As a purely public charity, it avoids paying a combined $42 million in property taxes in Allegheny County to municipalities, schools and the county.

Put all of this kerfuffle in the context of the city of Pittsburgh challenging the non-profit status of UPMC (see: Pittsburgh lawsuit challenges UPMC's tax status). The lawsuit was dropped by the city, partly because of its "budget-busting" implications (see: Peduto says city dropped UPMC lawsuit to help nonprofit payment talks). Here's a quote from the article:

It's hard to say whether or not the city or UPMC could have won the lawsuit and won the inevitable appeal,” said John Burkoff, a University of Pittsburgh law professor. “One thing that everyone would agree on is it would take years, and it would take a lot of money to fight a lawsuit like this. This certainly seems like a sensible strategic decision to me.” [Pittsburgh Mayor] Peduto and Pittsburgh's state-appointed financial overseers have said an agreement with nonprofits is critical for the city to close a $60 million gap between its revenue and its capital needs.

The bottom line for me is that some mega health systems like UPMC, an essential component of "big medicine," seem to no longer care much about how they are perceived in their home cities by local government or media (see: The Institutionalization of Healthcare; Consequences of Big Medicine?; Physician Private Practice Declines; the Last Barrier to Emergence of "Big Medicine"; The Transition to "Big Med": Need for Emphasis on Standardization and Cost). This is characteristic behavior for monopolies. It's only the "profits" for some of the non-profit hospitals that really count.

High Deductible-Health Plans Causing Hospital Billing Problems

You can file the follwing news in your predictable folder. High-deductible insurance plans are causing billing problems for hospitals (see: High-deductible plans change how hospitals interact with patients). Below is an excerpt from the article:

High-deductible plans are changing the way health systems interact with their patients, from where they get care to how they're presented with their bills....Healthcare providers are collecting $0.18 to $0.34 on the dollar from patients with high-deductible plans....Once a bill exceeds 5% of household income, a patient's propensity to pay drops to nearly zero....The average deductible for employer-sponsored coverage is now at $1,200, and it's even higher for exchange plans....[At least one hospital] has introduced a 25% prepayment policy for self-pay patients as well as those who will owe more than $1,000 or 20% of the cost of their scheduled procedures. Vendors, too, are offering products that will allow providers to have financial conversations with patients before any care is delivered. At the meeting, technology company Simplee announced that it is expanding its online payment platform to include tools that allow patients to get real-time, pre-service cost estimates and then explore financing options. While health systems are taking different approaches, more providers are initiating financial conversations before treatment begins, including financial literacy education....The MetroHealth System in Cleveland is among the systems that hasn't seen an increase in bad debt associated with high-deductible plans. But commercial plans account for only 22% of the county-owned system's revenue....Moreover, Medicaid expansion in Ohio has reduced the number of self-pay patients to 6% in 2014 from 18% in 2012. But MetroHealth is fielding more calls from patients with questions about their bills.

So we now see hospitals requiring partial prepayments and providing online payment platforms in order to improve their collections. Hospital executives should have been able to anticipate this problem as employers shifted to high-deductible plans to decrease their healthcare costs. Who would have thought that employees would be better able to bear these costs than the companies that employed them? 

Hospital billing systems are a mess (see: Two Reasons Why Medical and Hospital Bills Are Such a Mess). As I pointed out more than six years ago, the prices charged by hospitals are also largely irrelevant and designed mainly to manage reimbursement from the health insurance companies when they covered most of the bills (see: Why the Prices Charged by Hospital for Inpatient Care Are Irrelevant).

We are moving away from a system under which health systems negotiated discounts with the insurance companies. So here's how I would characterize the hospital side of "conversations" with patients prior to admission: (1) we are not exactly sure what the cost of your procedure will be; (2) we can't present the billing data to you in a way that you will understand; (3) we also can't present data to prove that the quality of our services is superior to that or our competitors. Please tell us how you intend to pay for your share of the bill under your high-deductible plan.

Topics that should be entering into these patient discussions are value and transparent pricing that have not previously been on the table. Starting with complex surgical procedures, there should now be major movement toward hospitals that offer patients (and their health insurance companies) a fixed, highly competitive price quote for a surgical procedure. In such an environment, it does not seem unreasonable for the hospital to request prepayment of some portion of the patient's share of the bill.

FDA Clears iPad App for Preoperative Orthopedic Surgery Planning

I came across an interesting article recently about the use of an iPad for pre-operative orthopedic surgical planning (see: FDA clears iPad app for pre-operative surgical planning). Below is an excerpt from it:

Israel-based Voyant Health, a subsidiary of Germany-based medical technology company Brainlab, received FDA clearance for its iPad app, called TraumaCad Mobile, which helps orthopedic surgeons with their pre-operative surgical planning....With the mobile version of TraumaCad, digital templating can now be accessed from any web browser or iPad, enabling surgeons to be more productive while also providing access to data for better inventory management. TraumaCad Mobile imports medical images from hospital imaging systems or secured cloud storage via Brainlab’s Quentry image sharing service. It also calibrates the images, enables users to measure lengths and angles of the images, visualize the results of the operation, and save the plans in the cloud. The app also offers a library of templates that surgeons can use to plan surgery. Surgeons can also share their plans with each other using Quentry. The device allows for overlaying of prosthesis templates on radiological images, and includes tools for performing measurements on the image and for positioning the template.

Orthopedic surgery is an obvious choice for iPad support given that such surgery always involves radiology images and often also the insertion of prosthetic devices. Hence, as noted above, the need for a visual overlay of prosthetic templates on radiology images and measurements to ensure a good fit of the device. An iPad is ideally suited for such tasks. One of its advantages is its portability so that the surgeons can plan surgical procedures when on rounds without the need for desktop computers.

It's also very interesting that Volant/Brainlab has combined its iPad app with secure cloud storage where a library of the necessary prosthetic templates is available. Case files and surgery planning documents in the cloud can also be shared with colleagues. I have been emphasizing the criticality of cloud storage in healthcare for more than six years (see: Finally, A Clear Definition for Cloud Computing). Unfortunately, hospitals and EHR vendors have not been interested in cloud storage nor system interoperability because of their narrow vision and vested commercial interests. Vendors such as Volant/Brainlab have been moving aggressively into this space. Congress and the market will eventually force the healthcare industry to adopt interoperability and cloud storage but this will may well end up being too little too late. Physicians' pursuit of apps blended with cloud storage will probably be better satisfied by companies such as Voyant/Brainlab with products such as TraumaCad Mobile.

Hospital Telemedicine Provides Opportunity for Pathologists to Interact with Patients

For many years, pathologists have lamented that they are afforded few opportunities to interact directly with patients, serving rather as consultants to clinicians. I think that the opportunity has now arrived for them to do so using hospital telemedicine platforms. A couple of days ago I blogged about how the Cleveland Clinic was extending its telemedicine system called MyCare Online to link all hospital physicians to their patents as well as to Ohio residents (see: Cleveland Clinic Launches Web Site to Offer Physician Visits to Ohio Residents). Video visits by physicians with patients, of course, have been available for many years but not on a broad basis. Telemedicine in the past has found the most success serving patients in rural areas or those who were not readily accessible such as those in penal systems. Telemedicine is now commonly referred to as mobile health or m-health.

I think that this Cleveland Clinic announcement represents a significant turning point in telemedicine because it is being offered by a prestigious hospital on large scale to support patients visits. In my opinion, the rationale for the wide-scale adoption of this technology is obvious. Patient services can be delivered efficiently without the need for expensive physical facilities. The process is certainly more convenient for patients who do not need to travel to the hospital. They can chat with their physicians sitting at home and using their smart phones. By embracing this service on a broad basis, the Cleveland Clinic must now address factors such as how to increase physician comfort with the technology as well as potential physician resistance. Patient interest in m-health will undoubtedly grow.

To restate the obvious, MyCare Online as well as other systems that may be launched by other hospitals now provide the opportunity for pathologists to consult directly with patients who will seek such interactions. The most obvious set of patients will be those with complex diseases such as cancer. Pathologists could review with patients the gross and microscopic images of their lesions and discuss the cellular characteristics of malignant disease as well as lab test interpretation. A similar case can be made for radiologists. Given that this would be a new opportunity for patients, there also needs to be a marketing effort on the part of the hospital to familiarize patients with the opportunity. Only a a small of them would be probably interested but those who want to schedule such diagnostic consultations would greatly benefit from them.

Cleveland Clinic Launches Web Site to Offer Physician Visits to Ohio Residents

Cleveland Clinic has extended the functionality of its MyCare Online platform from its previous function, second opinions (see: MyConsult Online Medical Second Opinion), to Ohio residents for urgent care (see: Cleveland Clinic opens up its mHealth platform; Cleveland Clinic launches urgent care video visits app for Ohio residents). It also serves as a telemedicine platform for current patients to be seen by their physicians. Below is an excerpt from the press release discussing this change:

The Cleveland Clinic is taking MyCare Online out of beta and opening up mHealth access to anyone in Ohio. The online service is available through the Cleveland Clinic MyCare app, downloadable from the health system's web site, Apple's App Store or Google Play. It offers 24-hour-a-day access via secure video link to a healthcare provider through a mobile device, tablet or desktop PC, at a cost of $49. American Well is providing the technology platform and healthcare professionals for the 24-hour telehealth hotline. Some of the health system's doctors have been testing MyCare Online with their patients, primarily for post-surgical checkups.“It’s tremendously more convenient, because people can be seen from home or work. For certain conditions, there’s no need to drive anywhere,” Peter Rasmussen, the clinic's medical director for distance health, said in a press release..... (To see a video of Rasmussen using MyCare Online, click here). MyCare Online “makes the geographical location and time of day a patient needs care largely irrelevant,” added Rasmussen, a neurosurgeon and director of the Cerebrovascular Center at Cleveland Clinic. 

MyCare Online seems to have evolved to serve patients in the following way: a site for patients seeking a second opinion from Cleveland Clinic physicians; a site for existing Cleveland Clinic patients to be seen by their physicians; a site for Ohio residents seeking urgent care. This is a logical progression for a telemedicine service as staff physicians grow familiar with the technology and also as a means to smooth out technical kinks in the system. 

Interestingly, it has been announced that MyCare Online can sync data from Apple’s HealthKit. This allows patients, if they choose, to share their self-collected health information with the provider during their online visit. A few months ago, Cleveland Clinic Innovations, a business unit at the Cleveland Clinic, partnered with the Global Healthcare Innovations Alliance to launch a new e-commerce platform called ADEO. Through the ADEO website, both caregivers and patients can purchase healthcare tools including patient-facing mobile apps. The store quietly launched last October.

It's also interesting that the Cleveland Clinic turned to American Well to provide its video network rather than developing its own network. So now we see a large health system like the Cleveland Clinic offering physician services to its own patients as well as urgent care to all Ohio residents. This will obviously provide an opportunity to recruit more patients for the system. In a previous post, I discussed how the Clinic was branching out from its previous commitment to specialized care to more general care and MyCare Online is an important step in achieving that goal (see: Cleveland Clinic Broadens Its Mission and Reduces Costs).

VA Nurses Could Practice Independently under Senate Bill

We are still experiencing some of the fallout from the recent VA and military hospital scandals (see: Why the Military and the VA Healthcare Systems Are Not Amenable to Change; The Challenge of Quality Lapses in Military Hospitals; Here's One Possible Solution). The most recent news is that that the U.S. Senate is considering a bill to allow nurse practitioners employed by the VA system to treat patients independently including prescription writing (see: VA nurse practitioners could practice independently under Senate bill). Below is an excerpt from the article:

Senate legislation is looking to empower nurse practitioners across the Veterans Affairs Department to practice independently of physicians, regardless of laws in individual states. The goal is to mitigate physician shortages and reduce patient wait times that have been plaguing the VA. The provision would allow nurse practitioners—including midwives and mental healthcare clinical nurse specialists—to prescribe some drugs and treat patients without a supervising physician. Maryland last month became the 21st state to allow nurse practitioners these privileges. The remaining states require them to have a collaborative agreement with a physician.....Complaints of long wait times at VA hospitals and outpatient clinics across the U.S. and an attempted cover-up led to the resignation of VA Secretary Eric Shinseki and prompted lawmakers to pass VA healthcare reforms, including relaxing a rule that allowed veterans to get private care paid for by the government....The Senate bill would also expand a pilot program where “intermediate-care technicians” practicing within the Defense Department would get priority placement at VA healthcare facilities that have the longest wait times....A bill before the House also aims at addressing personnel shortages. That bill would allow certified registered nurse anesthetists to practice independently.

I have posted previous notes endorsing the idea of enabling nurse practitioners (NPs) to operate more independently (see: A Solution to the PCP Shortage: Nurse Practitioners; Future key Role of Nurse Practitioners in Primary Care). Part of my reason for supporting this change is that they could serve as a partial substitute for primary care physicians (PCPs) who are in short supply in some parts of the country. It is understood that NPs should not be placed in clinical settings where the practice requirements exceed their ability to deliver high quality care.

Much of the pressure not to allow NPs to practice independently has come from organized medicine. It's no surprise that the federal and state governments are willing to expand the roles of NPs. The federal government is trying to improve healthcare delivery in the VA system after all of the recent bad press. It may be difficult to recruit physicians for the system. State governments are also anxious to improve healthcare delivery in rural areas. It will probably be easier to recruit NPs for these settings than physicians, particularly if the personnel are raised in the area. One gets the impression that the lobbying power of organized medicine is decreasing in the face of some of the quality and access problems we are seeing. Here's a link to a web site that claims that the AMA spent $2,072,441 in political contributions in the 2014 election cycle, ranking only 131 of 16,875 organizations reviewed.

Virtual Rounds as a Means to Engage Patients' Relatives in Key Discussions

One of the challenges of engaging the family members of seriously ill patients is that they may not be available at the time of rounds when the patient's care team is discussing the case. Thomas Jefferson University Hospital seems to have come up with one workable solution for this problem with their adoption of what they call virtual rounds. This idea was discussed in a recent article (see: Virtual rounds let families offer input on care from afar). Below is an excerpt from the article:

When Karen Giatto's mom was admitted to Thomas Jefferson University Hospital in Philadelphia last winter for the second time in three weeks, the family already knew the bad news. Her bladder cancer had metastasized to her lungs and elsewhere. The issue was, what were her best options? These were decisions her mother wanted Giatto and her sister involved in making. Those options needed to be discussed with members of her mother's care team during daily rounds in the hospital each morning....Instead, the two daughters stayed home and still made five of their mom's visits with her care team, thanks to a pilot telehealth program called “virtual rounds” that Jefferson initiated last October. Patients and doctors connect with family members using an iPad computer equipped with a video camera and telehealth software....Dr. Judd Hollander, associate dean for strategic health initiatives at Jefferson, said about two or three patients a day use the service, which is an adaptation of teleconferencing technology by Blue Jeans Network....The Philadelphia hospital has used the system to link as many as four family members at a session, with one as far away as California....Jefferson started with cancer patients, because their stays are typically longer, so the service would be of most use to them and their families. But the hospital is expanding virtual rounds to other departments and should be available on demand to all patients in the hospital by the end of this summer.

There are obvious technical and professional challenges associated with having discussions with relatives of seriously ill patients via video conference links. Tough treatment discussions with the family in such cases are difficult even in a live setting. Intensive training of medical staff will surely be required for video interactions. However, such challenges are not a good excuse for avoiding the use of the technology. This would seem to be a very important communication opportunity, particularly for academic referral centers where family members may not live in the local community. 

I was interested in what features would be offered by the Blue Jeans Network such that Jefferson would choose them over other the numerous other providers of conferencing systems. The company seems to be active in healthcare in general and lists on its web site some of the various types of healthcare use cases that it supports (see: Blue Jeans for Healthcare):

• Connect conference rooms at various oncology centers for knowledge sharing.
• Allow psychiatrists to meet with patients at home through a web browser.
• Enable doctors with iPads to videoconference into the office from home in emergency situations.
• Host group therapy sessions for oncology patients, enabling them to connect remotely through video conferencing.
• Help physicians on the road to connect with the room system at their clinic using the Blue Jeans app.

Genomic Analysis of Brain Tumors Now More Important than Histopathology

I began speculating about eight years ago that molecular imaging could potentially rival the diagnostic importance of histopathology but this has certainly not happened yet (see: The Role of Molecular Imaging Versus Histopathology in Diagnosis). However, we have been tottering on the brink of a major transition whereby genomic analysis of tumor tissue is beginning to rival histopathologic analysis in terms of diagnostic significance. This flip may have just taken place in terms of brain tumors according to a recent article (see: Brain Tumor’s Genetic Makeup Critical in Treatment, Research Finds). Below is an excerpt from it:

Doctors can more effectively treat many brain tumors by first ascertaining their genetic characteristics, rather than studying tissue samples under a microscope, the standard practice, two teams of researchers [recently] reported ....The findings could alter diagnosis and treatment decisions for thousands of patients, experts said....Prognosis is going to be more accurately delineated by these kinds of genetic subtypes, outstripping the value of looking through a microscope.....Doctors working to treat other types of cancer, particularly breast cancer, have already established genetic subtypes to help guide treatment....The two reports....focused on gliomas, which account for roughly a third of brain cancer cases. Some gliomas become aggressive....[but] doctors have not had a rigorous way of identifying which tumors will become deadlier before they do so.....Both teams found that the tumors could be grouped into a few categories, which could be determined by looking at a handful of genetic glitches. Tumors with one genetic profile, for instance, were relatively slow growers and responsive to drug treatment, making them good candidates for chemotherapy alone, rather than combined with radiation. Tumors in another category grew relatively slowly but were not as responsive to drugs, suggesting that combined therapy was best. And those in a third category were nascent aggressors, for which the prognosis is usually dim. But catching those tumors early will at least give families time to enroll in experimental trials, the researchers said, and will give patients and their families more specific guidance on which treatments and trials may be most suitable.

There are two major goals for analyzing the genes of a malignant lesion. The first is to predict its biologic behavior, considering whether it will invade surrounding tissue and metastasize. If so, it needs to be treated in a more aggressive way. The second is to determine the most effective therapy for it and, more specifically, what type of drug to treat it with. Many modern chemotherapeutic agents are designed to take advantage of the  genetic mistakes in the tumor (see, for example: Cancer Immunotherapy Meets Companion Diagnostics). For about a century, one of the major roles of a pathologist, using formalin-fixed, stained tissue sections and a microscope, has been to answer these questions. The focus of this note is to consider the way in which genomic analysis and companion diagnostics will affect the role and status of pathologists and histopathology as we move into this era of precision medicine. 

At this time and in line with research such as that reported above, I would say that the tools of precision medicine can only improve the diagnostic acumen of surgical pathologists. In support of this argument, I would draw an analogy with the role of hematopathologists who specialize in the diagnosis of diseases of blood, bone marrow, and lymph nodes. For at least three decades, they have used immunohistochemical (IHC) techniques to supplement and enhance their morphologic interpretation of blood cells and lymph nodes. It's important to note, however, that IHC testing is not as complex as genomic analysis. Pathologists may never be able to match the skill set and expertise of cancer researchers but they will become sufficiently skilled to augment their role as tissue diagnosticians. This will require modifications of the pathology training programs as cancer genomics becomes ever more sophisticated.

Hospitals Deploying Wireless Systems for Monitoring Patients

I have covered the topic of electronic monitoring of patients from two difference perspectives. First, I discussed the so-called e-ICUs (electronic ICUs) more than four years ago whereby small hospitals in larger health systems could support critical care beds with monitoring by nurses and physicians at remote hospitals in the same system (see: Telemedicine Transforms Intensive Care Units in Smaller Hospitals with Remote Monitoring). In another note about a year ago, I discussed e-monitoring of post-discharge patients (see: Keeping Tabs on Patients Post-Discharge Via Telemonitoring). Now comes news about hospitals wirelessly monitoring patients (see: Hospitals Find New Ways to Monitor Patients 24/7). Below is an excerpt from the article:

Hospitals are trying new early-warning systems to monitor patients for subtle but dangerous signs of a worsening condition. After surgery or during hospitalization for illness, patients are at risk for complications that can quickly turn fatal, such as a depressed breathing rate that can lead to cardiac arrest caused by over-sedation or an adverse reaction to narcotic pain medications. Patients can show signs of deterioration...as many as six to eight hours ahead of a cardiac or respiratory arrest, studies show. But the signs aren’t always picked up or acted upon by staff. Patients on general medical and surgical floors are usually not monitored 24/7 unlike patients in intensive care units, who are hooked up to multiple machines and monitors.

Among the strategies hospitals are adopting is a wireless monitor that slips under a mattress and alerts nurses to changes in breathing and heart rate. Another approach rates a patient’s risk of serious deterioration in real time based on lab results, vital signs and nurses’ assessments gathered from electronic medical records....Children's Hospital of Pittsburgh of UPMC has integrated PeraHealth's Pediatric Rothman Index with their medical emergency response team to deliver alerts to doctors and nurses when a patient is in critical condition, anywhere in the hospital, at anytime. ...[A recent publications indicated] that wireless monitors slipped under the mattress at Dignity Health’s California Hospital Medical Center in Los Angeles were linked to shorter hospital stays and a lower rate of “code blue” events....compared with units without the technology.

The monitors, developed by EarlySense also send alerts to nurses if patients get out of bed and when it is time to turn them to avoid skin breakdown....The cost of EarlySense varies depending on hospital size, and how many features it includes. It can range from $80,000 to $200,000 for a 30-bed unit. Pressure is mounting for hospitals to better identify patterns or changes before they get out of control. There is a national coalition of patient safety groups that is promoting continuous electronic monitoring of patients on narcotic pain medicines. 

It seems to me that one of the critical aspects of broader e-monitoring of patients is which healthcare professionals will be responsible for such monitoring and what actions are taken when significant problems are noted. These questions are most relevant for ambulatory care patients. For elderly post-op patients for whom such monitoring is most relevant, such monitoring would be the responsibility of the clinic responsble for post-operative care. Part of the benefit of such monitoring will be the inevitable lower number of readmissions on an urgent basis. Such readmissions have become a measure of the quality of care so that it's in the hospital's best interests to bear the burden of the cost of monitoring (see: Addressing the Hospital Readmission Problem; Hospital at Full Census; Surgery Patients Discharged Too Early?; Talking to Patients Helps Reduce Hospital Readmissions).

Relevant to wireless inpatient monitoring, the EarlySense web site makes the following statement: The two most important predictors for patient adverse events are Respiratory Rate and Heart Rate, and experts have begun to emphasize the importance of continuous monitoring of vital signs as a means of detecting patient deterioration (see: Early Detection). I am sure that these monitoring systems incorporate algorithms to generate alerts when readings suggest a critical problem. Thus, medical personnel stationed in the patient units can be electronically notified without constant surveillance of the wireless data.