Getting the data stream flowing: Hospitals want monitoring devices and EHRs to communicate

Nurses at Ephraim McDowell Health's two hospitals in central Kentucky until recently had to copy raw data from monitoring devices into each patient's electronic health record. “The nurse would be trying to monitor the patient on the vital-sign monitor as well as doing documentation in the EHR system,” said Becky Blevins, project manager for information systems at Danville-based Ephraim McDowell.

That began to change in 2012 when the system retained a software developer to translate electronic data from the vital-sign and other monitors directly into the EHR. The shift sharply reduced human transcription errors. Now, it is “like the cellphone,” said Dr. Anjum Bux, an anesthesiologist with Ephraim McDowell. “You don't know how you lived without it.”

But the process is still incomplete. “Right now, we're doing a paper record of the anesthetic in the OR,” Bux said. The hope is to have the EHR grabbing the data during an operation within 12 to 18 months.

Concerns about the lack of interoperability between competing EHR systems are rising to the top of the health information technology agenda in Washington. HHS' Office of the National Coordinator for Health IT issued a report last month blasting both vendors and providers for blocking the exchange of data between rival EHRs and rival healthcare systems.

But that report ignored similar problems that prevent clinical-monitoring devices such as ventilators and electrocardiograms from communicating with EHRs. They create data that in theory should pass to the patient's record. But it often doesn't happen. Instead, nurses must manually transcribe the data, introducing another arena for hospital error.

That disconnect has created new opportunities for vendors selling software solutions to link up the non-communicative systems. Vendors also say linking devices to EHRs will allow clinicians to monitor data automatically, controlling drug dosages from afar and providing a record for analyzing and adjusting a patient's care plan. It can “(take) out any chance of user-entered error,” said Jeff McGeath, vice president of software solutions for Iatric Systems, which provides one such product.

Connecting monitoring devices and EHRs is likely to become a growth business over the next decade. Technology research firm Gartner predicts a 35.5% compound annual growth rate for devices that can communicate through the “Internet of things” between 2013, when sales totaled $19.9 billion, and 2020.

The first target is ensuring device data flow into the EHR. Roughly 18% of hospitals have purchased medical-device integration software, McGeath said.

Even the more sophisticated healthcare systems in the country are facing device-EHR integration problems. Geisinger Health System in Danville, Pa., for instance, has integrated its dialysis and anesthesia units and plans to integrate data from its intensive-care unit into its full EHR beginning this summer. But total integration between its inpatient-unit devices and patient EHRs won't happen until 2018.

The nurses have “been our interoperability device interface,” said Jean La Valley, a senior technical analyst at Geisinger. Greater integration will allow them to devote more time to patient care, he said.

Nurses bear the brunt of making up for monitoring devices' failure to stream data into the EHR. A March 2015 poll commissioned by the West Health Institute found that 69% of 526 nurse respondents believed documentation took time away from patients, and 46% believed errors were likely to arise in such circumstances.

Even when the data make it onto the EHR, they are not always usable. For instance, waveform data from many EKG machines show up in the EHR as a digital picture. For hospital executives, that's doubly annoying. Cletis Earle, chief information officer at St. Luke Cornwall Hospital in Newburgh, N.Y., said the pictures are “data hogs” that take up too much space on the hospital's computers. Dr. John Pirolo, chief medical officer at St. Thomas Health in Nashville, noted the pictures are difficult for computers to understand and analyze.

The waveform issue creates a small skirmish in getting the data imported at all, which requires tricky choreography between devices and software. Few EHR suppliers have created easy data interfaces.

Officials at St. Luke Cornwall and Ephraim McDowell complain early versions of Meditech's EHR can get only slices of data by clicking a specific button. Their systems cannot accept real-time streaming data. Meditech says it has created 200,000 interfaces.

Pirolo at St. Thomas Health, which uses Cerner and Athenahealth, notes that every new piece of monitoring equipment requires a new interface with the EHR. “If a new ventilator technology emerges that provides enhanced safety features that we would like to implement, we will be forced to rebuild the entire middleware layer to connect the new ventilator to the EHR,” he said.

Streaming data between a wireless monitoring device and an EHR presents an additional headache in hospitals that weren't built with wireless connectivity in mind. For example, they may have copper pipes, which can cause interference, or signals are unable to penetrate deep underground or through lead-walled rooms. “As patients move from one location to another,” Blevins said, “we need to ensure that that wireless connectivity is going to continue to pick up that signal.” Incorporating new wireless devices requires testing performance each time, he added.

Problems can sometimes arise unexpectedly. Leaky microwave ovens have knocked computers off the Internet at Geisinger, for instance, said Robert Murcek, the system's director of network infrastructure.

Complicating matters is the sheer number of devices that need to be herded onto a network. Anyone who's tried to pick up cellphone reception at a football game will be familiar with the problem: Too many devices trying to access a network at the same time slows everyone down, which can pose hazards in a healthcare environment.

Still, software vendors and some manufacturers are excited about automating many clinical-support activities that involve monitoring devices. At a March event, Bakul Patel, associate director for digital health at the Food and Drug Administration, touted the agency's efforts to help create interoperable devices.

The agency has recognized 25 device standards and has deregulated several types of devices—most critically, medical-device data systems, which transfer and display data from medical devices. The device category was, as recently as 2011, in the agency's Class III—or most risky—category. Progressively, the agency has lowered requirements for the category. Now it's completely unregulated.

“The regulatory path seems straightforward and pretty clear to me,” said Robert Jarrin, senior director of government affairs at Qualcomm, praising the direction the government had taken over the past few years. Jarrin says solving the interoperability problem will require the cooperation of multiple stakeholders, including agreement on standards.

But the marketplace isn't there yet. Buyers grouse about a lack of information about what they're buying. La Valley, for instance, noted that many vendors claim to sell “enterprise” wireless devices that will interact with all the network environments in a hospital. Yet Geisinger's device-purchasing experiences have amounted to a “school of hard knocks” in terms of learning what would and wouldn't work, he said.

Some medical-device vendors, meanwhile, blame buyers for failing to conduct a careful analysis before purchasing new equipment. Welch Allyn's Senior Principal Engineer, Steve Baker, noted that his company rarely receives detailed quote requests from hospitals concerning interoperable devices. For example, it's surprising to see requests for electronic certificates that can list every device on a hospital's network .

The Center for Medical Interoperability has pulled together many of the nation's largest health systems to serve as a counterweight to vendors that maintain proprietary standards which create the “illusion of interoperability.”

It is difficult to mix and match devices from different vendors, St. Thomas' Pirolo said.

Hospitals remain hopeful about the promise of getting their monitoring devices and EHRs to talk to one another. It could make hospital processes more efficient by using the data to conduct the equivalent of time-and-motion studies, Pirolo said.

And clinicians such as Geisinger's La Valley believe more data flowing into the EHR will give hospitals a new tool for detecting patient deterioration early on. “What if you could have a supercomputer look at that (data) for an entire population, even if a doctor hasn't ordered that a nurse check on that patient?” he said. “This is the next generation of medicine, not one with less doctors, but one that is better informed because something is always looking at the data sets.”