Covid-19 has exposed worrisome gaps in care delivery at the bedside—with the demands of the country's epidemic revealing the shortcomings of many existing systems and approaches, especially in intensive care.
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"These gaps existed long before Covid-19, yet they have remained barely visible due to the heroism of clinicians rather than the design of safe systems," said Peter Pronovost, a physician and Chief Clinical Transformation Officer at University Hospitals (UH) in Cleveland, Ohio.
"To meet the planned surge of Covid-19, hospitals expanded capacity in their hospitals or planned field hospitals that looked hauntingly similar to the 1918 field hospitals," Pronovost said. "Yet most of these new beds lacked monitors and a command center to continuously monitor each patient's vital signs, such as oxygen levels, heart rate, and respiratory rate. As a result, nurses go into a patients' room, and manually check vital signs every couple of hours."
Why a data feed isn't enough
Even organizations that have turned to technology and analytic solutions to mitigate this lack of integration may not be able to address two major challenges of uncoordinated and disconnected components of care.
First, some e-ICU solutions don't provide in-the-moment visibility into which patients have what intervention. Second, the aggregation of e-ICU data can compound problems as it scales up. The more frequent the output from the data feed, the harder it is to process and normalize the data from disparate devices. The number of patients for whom a frequent stream of data must be processed and normalized further exacerbates the challenge of integration.
UH deployed a solution, not a dashboard
The technology UH deployed, the Talis Advanced Clinical Guidance (ACG) Perfusion System, integrates these components of care delivery. The goal of the system was not simply to generate a dashboard view of ICU utilization. Instead, it was to ensure that each patient is monitored in real-time and benefitting from best practice.
The ACG tool connects all devices in the ICU environment, including but not limited to EHR, heart-lung-blood monitoring machines, and lab systems. Jeff Sunshine, a physician and UH's Chief Medical Information Officer, said that the system's ability to hide the complexity of this challenge from the end user is key to its acceptance: Clinicians only see data in a single, intelligible view that comes straight from the point of care to their mobile device, rather than an emailed report from a centralized command center.
Smart alerts embedded in the system bolster the value of this integration. For ICU patients on ventilation, this is an essential step in addressing acute lung injury. "For people with lung injury on a breathing machine, the main intervention to reduce a patient's risk of dying is to give a person breaths based on how tall they are rather than on how much they weigh, so we do not over-distend the lungs, causing further injury," Pronovost said. "Yet less than half of the patients on ventilators receive these life-saving small breaths because the ventilator that pumps the air into to person's lungs does not know the patient's height. That information is in the EHR, which does not electronically connect with the ventilator."
However, the ACG system makes that connection and then enables in-the-moment compliance and decision support to ensure patients receive those small breaths.
2 keys to implementation
Pronovost and Sunshine concede that UH benefits from unique assets in rolling out solutions like this. UH leadership is committed to the kind of game-changing transformation of care delivery that this e-ICU solution represents.
However, Sunshine said those advantages could easily have been undermined without attention to two key factors:
- Technology-enabled solutions can't be the responsibility of a single set of stakeholders. Planning and implementation can't rely solely on IT, but neither can it rely solely on clinical end users. Everyone needs to be involved in the conversation on an ongoing basis.
- Don't underestimate sound fundamentals of nuts-and-bolts implementation. "These details put most people to sleep, but you have to be able to figure out what exactly needs to show up on the user interface and what plugs need to go where in a room," Sunshine said. "Advanced preparation means a lot downstream."
Moving beyond point solutions toward a true health 'system'
The Talis ACG system is one of several technologies UH has employed in an effort to build a truly integrated delivery "system"—that is, in its most basic form, a set of parts interacting to achieve a goal. Other implementations address complementary remote patient monitoring, population health management, and just-in-time training needs.
"Health care is far from a fully functioning system," Pronovost said. "It is reactive and transactional rather than proactive and relational. It has built the parts, but the goals remain ambiguous and the parts are not connected into a system of systems. If nothing changes, these gaps will endure after Covid-19. To improve clinical, economic, and experiential outcomes, the time has come for health care to embrace systems engineering and this may be one of the enduring legacies of Covid-19."
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