EMR and Device Integration

June 23, 2007

Biomedical/Bedside/ICU Device Integration

In the words of the guru Tim Gee – Medical Connectivity Consulting “Medical device integration is a critical (and an often overlooked) part of EMR planning. To be successful, any plan must take into account many more considerations beyond getting an HL7 feed into the EMR. Multiple stakeholders including nursing and clinical/biomedical engineering must be engaged. Putting together a successful long term plan requires negotiations across traditional hospital silos, and an in depth understanding of point-of-care workflows, medical device connectivity and device vendor offerings and product strategies”.

The benefits of automatic data collection (heart rate, invasive/non-invasive blood pressure, respiration rate, oxygen saturation, blood glucose, etc.) from acute care monitoring devices have become so obvious that all hospitals now require that their clinical information system (CIS), anesthesia information management system (AIMS), electronic medical records (EMR), electronic patient record system (EPR), or other hospital/healthcare information system (HIS) provide interfacing capabilities to biomedical devices – in order to ensure that key vital signs are stored in the Centralized Data Repository (CDR) – to track patient progress over time.

Patient monitoring systems are among the first to be integrated; because each HIS require at least basic patient vital sign collection. Integration with anesthesia devices is a must for any AIMS. Data collection from ventilation systems is required in most cases for ICU systems. Infusion device data integration is becoming increasingly requested in cases where CPOE systems are implemented.

But connecting to bedside medical devices and collecting data in your CIS or EPR is not as simple as it may seem. Device interface development is a specialized task that consumes resources and diverts attention away from core competencies. Competitive issues make obtaining device protocols difficult and sometimes impossible. Incomplete connectivity results in frustration and decreased efficiency of the hospital.

The various questions you need to have when integrating devices with a HIS are as below:

Categories of Medical Devices for Integration:

Vital Signs or Diagnostics devices
Infusion Pumps
Dialysis devices
Anesthesia machines
EKG and EEG devices
Endoscopy devices
Glucometers
Urimeters
Bedside devices
Oximeters with Patient Monitoring and Alarm Systems
Ventilators
Ultrasound devices
Stress testing devices

Type of Device Connectivity to the HIS

Wireless/Mobile
Fixed

Format of Message feed from Device(s) to the HIS

HL7 format result messages with possible Images, etc across TCP/IP
Proprietary format messages across TCP/IP
Binary format data across USB or others

Format of Message feed to Device(s) from the HIS

HL7 format ADT messages across TCP/IP
Proprietary format messages across TCP/IP
Binary format data across USB or others

Frequency and Location of Device Data Feed to the HIS

Continuous (Periodic) Real-time – 1 message per minute or less
Manual (Aperiodic) or on-demand
Server-based – with storage for real-time data and polling-frequency options
Location:ICU or PACU
Timing Syncronization among all the connected systems is important

Grouping of Device Data in the HIS is based on:

Patient Chart sections
Department Needs and Security Roles
Common Device Parameters
Dependent Device Parameters
Device Monitoring and Asset Tracking
Display and Storage of the data – claims, clinical encounters, drug/pharmacy, lab, images – captured and mapped to a common format, possibly ASTM’s Continuity of Care Record (CCR).

Security Issues:

Caregivers need access to validate device data onto the patient chart
Audit trail and enterprise timestamps on device data
High speed secure network with firewalls to protect ePHI
FDA guidelines compliance
HIPAA guidelines compliance
JCAHO guidelines compliance
Legal guidelines compliance

Examples:

Vital Signs mobile devices feed patient data to the EMR and a senior RN can review results before they are attached to the patients’ charts.
Infusion Pumps drug/fluid delivery tracking in EMR for long term critical care.
Enabling medical devices, such as infusion pumps, ECG machines and glucometers, to wirelessly send data from the ICU to a patient’s medical record or to a physician
Home care chronic disease monitoring systems that provide patient feedback, patient monitoring and alerts (to both patients and physicians) to the EMR.

Software for Device Integration with the HIS:

Capsule Technologie’ DataCaptor is a generic, third-party software + hardware suite that provides the most complete biomedical device connectivity solution available on the market. DataCaptor has the largest library of supported devices – more than 250 diverse bedside devices, advanced features, and easy integration with hospital information systems.

Stinger MedicalIntegriti – provides a secure and mobile method of transmitting patient vital signs wirelessly to the EMR.
Current Capsule Technologie – DataCaptor – OEM partners include (among other HIS vendors of all sizes)

Epic Systems (EpicCare) ,
Philips Medical Systems (CareVue Chart/IntelliVue through DeviceLink),
Eclipsys Corporation (Sunrise Clinical Manager) and
Surgical Information Systems (anesthesia software and surgical system).

Benefits of Device Integration:

As in several hospitals; the reasons for integrating devices is to automate the flow of data and interface it to the HIS application:
• To reduce transcription/documentation errors. Currently, nurses manually transcribe the data from scratch pads or from the devices onto the patient report resulting in problems like indecipherable handwriting, data in the wrong chart, vital signs written on scraps of paper (hands, scrub suits, etc.) that get forgotten, and then there is sometimes considerable lag between readings and reporting.
• To decrease documentation time. Significant increases in productivity can be gained by an interface that allows the nurse to validate rather than enter the data.
• To support quality data collection (charts, images, vitals) and to provide increased surveillance for critical patients – even when the care-provider is not present at the bedside. This allows for safe collection of data over time, thus providing a more accurate and valid history of patient progress.
• To increase patient safety. Safety is enhanced by decreasing data entry errors, and by allowing the nurse to review data collected when he/she is not present at the bedside. In addition the data can be captured at an increased frequency creating a more accurate depiction of the patient’s condition.
• To enable research and quality control. Data can be collected for future analysis by de-identifying patient demographics.
• To provide better patient care and more physician – patient contact time. A silent factor of a hospital’s revenue is quality of patient care. One of the chief drivers of quality of patient care is the quality of information provided efficiently to the Physicians though which they can make those critical decisions.
• To securely and quickly share assessment, diagnosis, treatment and patient progress data across facilities/RHIO (regions)/states thereby enabling the patient to be provided the best care anywhere.
• To reduce patient, physician and nurse stress and legal issues.
• To provide complete and comprehensive data on patient charts.
• To enable future devices to seamlessly connect to the existing EMR.
• To prevent errors in diagnosis, prescription and medication, by basing decisions on the entire patient history/allergies, the latest medications and the latest technology that are available to the patient and the care provider.
• Clinical (or Diagnostic) Decision Support Systems [ CDSS ] and Best Practice systems are more effective with a comprehensive and secure digital files (historical patient charts).
• To increase security and prevent tampering of Patient Records – since all data is digital and secured via layers of Role based security, by HIPAA and by Digital laws – the security is much more comprehensive than a system with voluminous paper records and difficult audit trails.
• Finally, to improve overall hospital throughput and patient hospital-visit time, success ratios and Improving Patient Efficiency Throughput.

I’ve linked the Capsule Technologie-DataCaptor architecture diagrams below to show the data flow between DataCaptor (the server), Concentrator (the ‘router’ or Terminal box), the bedside devices and the HIS and other systems.

http://capsuletech.com/images/stories/products/ConnectDC_470
http://capsuletech.com/images/stories/products/DC_Overview_520.jpg

Note:This article is based on personal experiences and public information gathered from websites including Medical Connectivity Consulting and Capsule Technologies and other medical device manufacturer’s web-sites. Thanks to these companies for this public information and this document is intended solely for personal reading and understanding of this technology and is not for any commercial gain.

Since PACS is a type of “Device Integrator”, the following is an addition to the above article:


Radiology RIS, PACS and the EMR Integration

The PACS – Picture Archiving and Communication System – is a filmless method of communicating and storing Xrays, CT/MRI/NM scans, and other radiographs that are verified by Radiologists after being acquired by the Xray, CT/MRI/NM machines and other variants used in the Radiology Department. Images may be acquired from a patient in slices and with 3D or 4D image reconstruction – the entire patients’ full body scan may be visualized on diagnostic quality workstations. Key images, Radiology reports and low resolution non-diagnostic images are provided for viewing on any screen – securely across the internet. If bandwidth permits – in certain cases – entire diagnostic quality images may be viewable, securely across the internet.

The RIS – Radiology Information System – enables “Radiology” patient scheduling, reporting/dictation, and image tracking to ensure that the PACS and the Radiology machines are effectively utilized and the patients’ structured reports are immediately available.

The EMR – Electronic Medical Records System or Hospital Information System – provides a “global” view or patient historical folder of the patients visits or encounters with his/her care providers. From a “Radiology” perspective – the EMR sends ADT/orders to a RIS and receives results including patient images and data from the PACS (via RIS) – thus enabling access to that patients Structured Reports in a single uniform location in the EMR. Thus, images can be integrated with the radiology report, and with other patient information systems’ (such as laboratory, pharmacy, cardiology, and nursing) reports, thereby providing a comprehensive folder on the patient.

Key Features of a good PACS System are:

  • Modules for comparison study of prior patient images, along with similar cases
  • Modules for Computer Aided Detection using Clinical Decision Support Systems and Key Facets
  • Excellent Data Compression Techniques to ensure effective network utilization and high speed transfers of quality images to workstations and other systems.
  • Excellent EMR Integration based on IHE Integration Profiles, standard HL7, standard DICOM and the support for secure,high-speed access to patient images via internet
  • Standard Security Features along with audit trails and Integration with RIS and EMR security.
  • Modules for 3D and 4D reconstruction of CT slices, Image Enhancement and Quality Printing
  • Immediate availability of Images on network or CD/DVD for quick diagnosis and review by remote Radiologists/experts.
  • Excellent Short Term Storage with very low retrieval time latencies.
  • Excellent Long Term Storage with decent retrieval time latencies and predictable data recovery.
  • Excellent RIS Integration.
  • Extensively tested and successfully working in other hospitals for 2 years at least.
  • Multiple vendor modality Integration features.
  • Downtime plan with Disaster Recovery Support.
  • Easy Upgrade-ability of hardware/storage to ensure almost infinite storage based on hospital need
  • Support for Patient De-Identification and Reporting off the PACS/RIS for data analysis.

Now that you have (selected) the PACS and RIS systems, here is the list of questions you should have regarding integration with the EMR:


EMR and RIS/PACS Integration Issues:

  • RIS/PACS features and limitations
  • Modality support for DMWL (Digital Modality Worklist – ensuring correct patient scans at modality)
  • Key Data Mappings between the RIS, PACS and EMR (eg. Study-DateTime, PatientID,Provider, Study Status, Accession number, etc.)
  • Department Workflow changes (Types of Orders, Downtime Orders, Unsolicited Results, Billing, etc.)
  • Data being displayed in the Modality Worklist and when does this worklist get updated?
  • Historical data import, cut-off dates, access policies to legacy data, etc
  • Security, User access and integrating the PACS/RIS users with the EMR users to enable secure web access to images.


Note:
The above article is based on personal experience and is not for any commercial gain.

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Cool MS SQL Server Tools

October 15, 2004

Sqldiag – Sqldiag is a utility used for report generation and collection of diagnostic information on database server / operating system configuration parameters. Sqldiag gathers the information, even if Microsoft SQL Server 2000 services are stopped. The report generated by Sqldiag contains the following information:
Complete dump of all SQL Server error logs; Registry information, related to SQL Server; SQL Server system dll versions; Output, generated by: sp_configure, sp_who, sp_lock, sp_helpdb, xp_msver and sp_helpextendedproc; Information about all system processes (master..sysprocesses); Information about all user processes and connections (including Input buffer SPIDs and Dead locks); Information about operating system parameters (including reports about: OS version, Video display, Drivers, DMA, Memory, Services, IRQ and ports, Devices, Environment and Network); Info about the last 100 user’s queries. The Sqldiag utility is installed to the \Program Files\Microsoft SQL Server\MSSQL\Binn directory by default.

Profiler – Profiler is the executable for SQL Server Profiler. SQL Server Profiler is typically used for monitoring SQL Server events, such as debugging T-SQL statements and stored procedures and troubleshooting problems (by capturing them in a real-time and replaying later).

Sqlmaint – Sqlmaint is a maintenance utility. Sqlmaint performs a set of tasks, specified by the DBA, on one or more databases (for example backup databases, update statistics, rebuild indexes, DBCC check).
The Sqlmaint utility is installed to the \Program Files\Microsoft SQL Server\MSSQL\Binn directory by default

bcp – A utility used for the interactive process of bulk coping of data between the SQL Server 2000 instance and data file (format information file should be specified or a default bcp.fmt should be used instead). The bcp utility is the typical example of a “two-way” tool, i.e. copying data “into SQL Server instance” or “out of SQL Server instance” is allowed. Alternatively, bcp can be used for copying data:
Between SQL Server instances with different language collations; To or from a view; Returned from a T-SQL query (to data file); Between the Microsoft SQL Server and database servers of other vendors; Between the SQL Servers working on different processor architectures; To or from a database table (including temporary tables); Between databases within one SQL Server instance. The bcp utility is installed by default to the \Program Files\Microsoft SQL Server\80\Tools\Binn directory

itwiz – itwiz allows the Index Tuning Wizard to be executed from a command prompt. Index tuning using an itwiz is similar to tuning via Index Tuning Wizard with a user interface. The itwiz utility is installed to the \Program Files\Microsoft SQLServer\80\Tools\Binn directory by default.

osql – A utility for interactive Transact-SQL scripts and stored procedures execution. It uses ODBC libraries for communicating with the database server. Osql can be started directly from the operating system command prompt and uses a standard output device (monitor, by default) for displaying results. The osql utility is installed to the \Program Files\Microsoft SQLServer\80\Tools\Binn directory by default.

Simple Enabling/Disabling Constraints/Triggers on the entire SQL 2000 Database
sp_msforeachtable “ALTER TABLE ? NOCHECK CONSTRAINT all”sp_msforeachtable “ALTER TABLE ? DISABLE TRIGGER all”
sp_msforeachtable @command1=”print ‘?'”, @command2=”ALTER TABLE ? CHECK CONSTRAINT all”sp_msforeachtable @command1=”print ‘?'”, @command2=”ALTER TABLE ? ENABLE TRIGGER all”