Snapshots in time

Who we are Rady Children’s Hospital – San Diego

A 442-bed pediatric-care facility.

The largest children’s hospital in California

U.S. News & World Report Ranked Among Nation's Best in 10 Pediatric Specialties

Each year, 68,000 intravenous (IV) lines are started at Rady Children's.

A blood pressure cuff for a preemie's tiny arm is about the size of an adult's finger.

Who am ISheldon Gilmer, Interface Engineer, Rady

Children's Hospital

13 years experience with Integration

HL7 v2 Certified

5 years experience with Device Integration

What is this presentationSnapshot of where we are today, with a go-

live of our Device Integration project on 9/25/2011

Lessons Learned from Clinical, BioMed, Network and Nursing Admin teams

Scope of Device Integration project, split into phases

“RCHSD views the integration of biomedical device data into its EHR as a critical success factor to clinician adoption, and down the line, as a key to enable the identification of care improvement opportunities that are otherwise invisible without the benefit of discrete data in the context of the entire patient record. “

Albert Oriol, CIO

Rady Children’s Hospital, San Diego

How we initiatedDevice Integration Our Epic Project – Inpatient Phase, had included

Device Integration as a major component

Multidisciplinary Team was asked to facilitate vendor selection

RFP and Vendor Selection process over 3 months

We chose the vendor based on flexibility, cost effectiveness, an architecture that would enable Rady Children's vision, and willingness to partner -Nuvon

What we thought we knewScope & Type of Devices Integrated

Deployment Architecture would be a mix of:

Bedside Mounted devices (UGH!)

Appliances in IDF’s

Servers

What we didn’t knowNetwork Traffic Load and Data Volume were

unknown

Hospital Departments Serviced – would we pilot a single department, or go Big Bang?

What we thought we were going to doGet device data from these devices and send

it into Epic:

Patient Bedside Monitors

Ventilators

Infusion Pumps

Challenges with VentilatorsDevice Integration is part of the Inpatient

Documentation wave of Epic

Focused on devices with Nurse Interaction

Nurses don’t record data off of Ventilators, RT’s do

We decided to postpone Ventilator integration until a later point in time.

Challenges withInfusion Pumps Infancy stage of the Infusion Pump Device Integration.

We have a server that already collects data from the wireless Infusion Pumps.

Our solution : utilize Infusion Pump server, and deliver collected event data through Nuvon architecture into Epic.

Problem: software not ready from infusion pump vendor

Hello BioMed!Prior to this project, the IT and BioMed

teams experienced erratic communications

Regularly scheduled BioMed/IT/Network team meetings to discuss common issues, problems concerns

We gave BioMed Team a voice in the IT Department, made them feel more comfortable and like they belonged

Where we liveIM Division

CIO

Business Applications

Interface Team

Clinical Applications

Clinical Documentation

Team

Ancillary & Support Services

BioMed

Infrastructure & Customer Support

Network Services

What we learned fromBioMed about MonitorsWe had a mix of Patient Monitor software

revisions, each generated a slightly different HL7

We had three types of vendor consolidation hardware:

Central Stations

Headless Central Stations

Database Servers, which some Central Stations connected to.

Portable & Fixed monitors mixed on units

How we got a Test Lab We knew that we would need a Test Lab, but did not know

its full scope until after additional discovery with the BioMed team

Device Test Lab is the most important part of Device Integration

The Test Lab is a permanent part of our Device Integration solution

BioMed devices are purchased for the Test Lab, and reserved for troubleshooting purposes

Certified devices for Test Lab, can supplement clinical supply as needed

Challenges WeEncountered in the Network Highly segregated network which does not allow broadcast

between subnets

Network Remediation Project was a concurrent project affecting half of our deployment locations

Separate BioMed network which had not yet been fully remediated

Each Nuvon appliance location needed access to both the Unit BioMed network and the Rady Children’s main network

Got cable drops in four locations that did not have crossover connections from the BioMed network to the main Rady Children’s network

Network Best Practices Added Network Team to regular IT/BioMed

meetings

Reviewed Network Change Schedule for any changes that would affect Device Integration Project

Network Team member scheduled to be available whenever we do configuration work on the Device Integration system

Network Team reviews Device Integration change schedule

What our solution looks like Supports 408 Philips InteliVue Monitors, in 12 Units, across 3

buildings; and 300 Alaris SmartPumps (part of Phase II)

10 Pair of Nuvon Appliances, in IDF’s

4 Philips DBS, each to 1 pair of Nuvon Appliances (4)

6 Philips PIICs, 3 to each pair of Nuvon Appliances (2)

1 Philips PIIC in the ED, to 1 pair of Nuvon Appliance (1)

1 Philips Patient Link, to 1 pair of Nuvon Appliances (1)

1 Nuvon HL7 Gateway, designated appliance pair (1)

1 Nuvon Appliance Pair reserved for Alaris SmartPump GateWay, part of Phase II (1)

2 Windows Server VM’s

Zero new bedside mounted devices (YEAH!)

Clinical Documentation Epic Inpatient Doc Flowsheets

Epic build is owned by the ClinDoc Team, but assisted by the Interface Team

Clinical Leadership had concerns about workflows that required hands on review of the implementation to resolve, meaning that we had to build it first and show it to them in Test environment

PACU had different workflows and needs

Scope of deployments Deployment in these departments:

NICU

CC (Critical Care)

MedSurg

Hem/Onc & BMT

Medical Beds

ED

PACU – Different workflows and device definitions

OR (Phase II for Anesthesia Carts)

Epic Device Mapping Fixed Devices are attached to the Bed

Fixed devices automatically attach to the patient when the patient is put in a bed.

Each fixed device (bedside monitor) is mapped from the physical location to the Epic bed

QA of mapping is co-owned by ClinDoc, BioMed and Interface Teams

QA of mapping includes from the port to Epic, but not the monitor

Bedside Network

Port

Central Monitoring

Station

Nuvon Appliance

Epic

How it works in Epic

Admit Patient in Epic

Attach leads to Patient

Turn on monitor

Data shows up in Epic

Data Validate

Select Parameters to

Validate

Switch to Flowsheet

View

Monitoring the system We connect Nuvon to Central Stations and DBS, so no HW

level monitoring of the Patient Monitors (or SmartPumps) Monitoring infrastructure is in place, so as we expand into

Anesthesia carts, Ventilators, etc., we will be able to monitor at the device level

Nuvon appliances are all self-contained and route data between themselves and Epic. Nuvon server is separate and only used for management and monitoring dashboards.

Nuvon Alerts are sent to our paging system, and email Monitor / Alerting consoles for Nuvon are setup in BioMed

and NOC Monitor Alerts go through our Nurse Call system, not

Nuvon **

Where we are today Epic Inpatient and Device Integration Go-live is 9/25/2011

QA process co-owned by BioMed, ClinDoc and Interface Teams

MDDS Rule is under review and Policies are pending [Rady Children’s]

IT owns the Nuvon Hardware, but BioMed owns the cert process, as per our [pending] policy

Device Support/Issue Resolution for joint BioMed and IT tickets currently underway.

All 408 monitors are filing data into Epic Test environment!

What the future looks likeAnesthesia machines in Q1 2012

Alaris SmartPumps in Q2 2012

Ventilators in Q3 2012 (?)

Evaluating other classes of devices (cardio, feeding pumps, insulin pumps, etc.)

Nuvon infrastructure is scalable to support future growth, while minimizing new equipment footprint.

Important Lessons Create Test Lab to include all versions of

firmware/software combinations for BioMed Devices

Engage BioMed team from the beginning

Get Change Schedules cross reviewed with Network team

Recruit Clinical Champion to help get the important messages out

Collaborate with Clinical Leadership on understanding workflows, and impact to workflows

Review and Test workflows; repeat

Contact me:Sheldon Gilmer

Interface Engineer

Rady Children’s Hospital

3020 Children’s Way

MC 5083

San Diego, CA 92123

Office 858.966.7530

Mobile 619.813.8000