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.


Is it Knoppix or PCLinuxOS time?

September 19, 2006

Not yet tired of windows? Well, read on to find out the next gen O/S out there…

* New capabilities – creating a remastered custom Live CD/DVD and booting from a USB flash

Let’s see where do I start…

Well, my machine crashed – it’s a new Acer – http://global.acer.com/4152 NLCI (4150 or 4650 series) laptop- and the problem was maybe some virus, because the ntoskrnl.exe was corrupted, and the drivers just stopped loading after a few seconds of boot time, bringing the hard disc to a halt and the screen to a frozen white screen (talk about the old blue screen being upgraded by MS!!!)

Time to look around for a boot-able and repair kit right! I tried – got an XP cd and installed XP onto a different partition – but the next day – that too went into the same loop like the above.

Then, I found out that maybe the hard disc may have got some permanent damage – thanks to all the travel lately.

I look around for a solution other than DOS obviously and I find the best free O/S ever!

Knoppix — the free open source Linux O/S that boots and runs from a CD/DVD (like PCLinuxOS 2007), with automatic hardware detection, recognizing all the devices – Graphics Card, Sound Card, USB, CD, DVD, RAID, Modem, Lan Card, printer-scanner(hp all-in-one), pcmcia cards, sd card(gateway works with PCLinuxOS), bluetooth(works with PCLinuxOS), wireless(works with PCLinuxOS),modem, external camera, webcam – you name it and its a solid system that detects, installs and boots fast (PCLinuxOS 2007 boots in 30 seconds), and runs quickly on ordinary hardware! It can even mount my NTFS hard disc in read mode (ntfs-3g driver supports read and write of NTFS files) to copy files to my USB so my critical files are saved in no time. Of course, part of the recovery process is being able to write CD and DVD’s which Knoppix (and PCLinuxOS) supports with a right click menu.

Knoppix – a flavor of Debian Linux – http://www.knopper.net/knoppix/index-en.html or http://www.knoppix.net/ – is a 640MB bootable Live CD with a collection of GNU/Linux s/w, which brings up a Windows like user interface, connects to the internet (after a minor config) through a DSL or Cable modem and voila – I’m online via Mozilla, Opera or Konqueror. Knoppix 5.1.1+ is a debian flavour of the Linux O/s with the Linux kernel 2.6.19+ , KDE 3.5.5+/GNOME 2.16+, ntfs-3g and it has all the flavours of a true windows system with OpenOffice2.1+ – (Word-documents,Excel-spreadsheets,PPT-presentations) , PDF reader, kaffeine (media player) and GIMP (for those mspaint users), picasa from google, a host of ntfs data recovery tools and good card games!

PCLinuxOS 2007 TR4is a free open source Linux O/S (flavor of Mandrake/Mandriva Linux with Linux kernel 2.6.22.10+, KDE 3.5.7+/GNOME 2.16+, Open Office 2.3+, 3D windows support), has all the above software modules, and it is much better than the Knoppix version as of PCLinuxOS 2007 TR4 versus Knoppix 5.1.1 – since PCLOS can be remastered and installed on a usb flash drive very easily.

Live CD Knoppix (like Live CD PCLinuxOS) uses on-the-fly decompression to load into memory, the required modules, from bootable CD/DVD, so the CD is locked by knoppix and you can’t use it for writing or DVD viewing although they have the CD/DVD writer software and the movie viewer software and I can use an external DVD/CD writer/reader to perform CD/DVD burns/reads. You can install the PCLinuxOS 2007 TR4 Live CD to a USB flash drive The other pluses to these Live CDs are: There is already an available messenger – thanks to secure GAIM (now Pidgin) – which can connect to Yahoo, Google Chat, AOL, etc. among others. Kopete is better than other messengers due to WebCam support, but need Knoppix/PCLinux installed to the hard disc. You can also create custom bootable CD/DVDs/USB flash, since the default live CDs are built for a read-only O/s (from the CD) with default options.

Want to listen to quality music? – using StreamTuner on Linux you can listen to live internet streamed (128 to 256kbps) quality radio on xmms, from around the World for free!!!

Security – you can install the necessary Mozilla addon’s and the shorewall or firestarter firewall to boost your experience.
VLC, Gxine, Amarok and Mplayer are very good multimedia programs covering all the needed experience.

Acrobat 8 is available for Linux for the pdf community.

Open Office or Star Office are not perfect but are decent Linux office solutions.

If you are wondering about install time – there is none – since the OS just boots of a CD/USB, you can use all the features of a full fledged O/S, and if you need, you may install the O/S to hard disc in 10 minutes.

So what are the minimum requirements of this new O/s (Vista beware!)

· Intel-compatible CPU (i486 or later),
· 32 MB of RAM for text mode, at least 96 MB for graphics mode with KDE (at least 128 MB of RAM is recommended to use the various office products),
· boot-able CD-ROM drive, or a boot floppy and standard CD-ROM (IDE/ATAPI or SCSI),
· standard SVGA-compatible graphics card,
· serial or PS/2 standard mouse or IMPS/2-compatible USB-mouse.

Before you comment, please note:

  • I know I could have called Acer – http://global.acer.com/ support – since my laptop is within warranty – well, I didn’t call because I needed internet connectivity – not further delays and postal issues with mailing my hard disc out.
  • Knoppix and PCLinuxOS have very good multi-session KDE3.5+/GNOME 2.16+ windows environment which I wanted compared to a lite-r environment like DSL Linux (http://www.damnsmalllinux.org/ – that’s another topic – 50MB linux – usb/mini-cd boot) – another reason not to go for a usb boot was the laptop bios was not upgraded by the manufacturer and the way to upgrade bios is only through a working Windows XP !! Latest: I finally got a usb floppy drive and got my BIOS upgraded, also I created a custom Live CD of PCLinuxOS 2007 TR4 and copied it to a USB flash which is now bootable (don’t forget to install th MBR) and working for Acer 4152 and Gateway MX 6124 laptops.
  • I downloaded Knoppix 3.6 from a friends cable connection and burnt the CD in 10 minutes and was online on my Acer 4152 NLCI laptop in 15 minutes: Latest: I downloaded Knoppix 5.1.1 Live DVD and PCLinuxOS 2007 TR4 Live DVD – PCLinuxOS rates better with custom Live DVD/USB flash boot support.
  • All of the needed drivers and software including Gaim, Office(Word,Excel,PPT), PDF viewer, printer-scanner drivers, rss reader, were on the CD so nothing to install – unlike ms windows, where a plain o/s is useless!!!

Knoppix 3.6 Problems and PCLinuxOS 2007 TR4 Advantages:

  • The laptop CD/DVD drive is being fully used/locked and I cannot eject it – when I log into the Knoppix Live O/s. This is by design, since the modules are dynamically loaded from the CD. You can burn custom CD’s by downloading the necessary softwares by apt-get
  • I downloaded PCLinuxOS 0.93 and later upgraded to PCLinuxOS 2007 TR4 and they install to hard disc easily with a single click, also they have a neat way to create a custom Live CD/DVD, which can be created in 20 minutes flat using mklivecd/k3b
  • Webcam with messenger is an issue with gaim – PCLinuxOS 2007 fixed this problem with a new version of Kopete and many more web camera tools.
  • WPA Wireless security is not supported with default ndiswrapper, you may still have to use the windows wireless card drivers – otherwise PCLinuxOS 2007 makes secure wireless a breeze, with support for secured 128 bit WEP.
  • The apt-get feature (combined with Synaptic of PCLinuxOS) of most Linux flavors (yast in OpenSuse) is great to keep your specific O/S features upto-date and remove broken packages. The control you have over your custom machine software is simply great.
  • I can’t access the SD Card inserted in the proprietary Acer Laptop Texas Instruments SD/MMC Card Reader – but I can connect the Kodak digital camera via USB and the photos can be uploaded. Latest: PCLinuxOS 2007 TR4 has a fix for many Gateway laptop SD card reader issues in their support forums for most SD cards and multi card readers.
  • I can’t read MS Visio documents (but this in development and I will use visio converted to jpegs till then).
  • Open Office is not yet a very mature software and cannot reasonably compare to MS Office 2003 in either features or printing of Excel documents.
  • PCLinuxOS 2007 has Beryl which is a decent 3D windows manager with nice 3D windows effects – but 3D windows is still not a very refined concept and I would suggest uninstalling the compiz and beryl 3D software.

Well, that’s it from me, see ya… Keep your Knoppix CD/DVD or PCLinuxOS CD/DVD/USB ready…. as we say in Linux there is true consumer choice even though I personally vote for PCLinuxOS 2007 TR4

Oh ya.. Knoppix supports clusters and a multi-computer version is out called “ParallelKnoppix” which converts a host of windows machines into a Linux Cluster Farm. Descriptions are here – http://idea.uab.es/mcreel/ParallelKnoppix/ http://www.knoppix.net/wiki/Cluster_Live_CD

Howto? – Another useful site to learn to use Linux – http://www.linux.ie/articles/tutorials/

Some more flavors that receive good desktop Linux reviews are

Other good sites with helpful linux links: