It's busy in the surgery department of Vanderbilt University Medical Center, and an anesthesiologist has responsibility for four procedures in various stages. With his iPhone monitoring all at once, and a camera view inside any of the four rooms available with one tap, the doctor is in constant vigilance.
At a Cleveland Clinic hospital, a patient is recovering fitfully in a private room, but is not alone. A predictive rapid-response computer application has identified him as a risk for medical deterioration, and before his blood pressure can sink or heart rate spike, worrisome vitals will pop up on the mobile devices of response-team members circulating throughout the facility and mobilize them pre-emptively.
Quietly and expertly, mHealth applications are starting to penetrate the inpatient environment with unique ways to perform existing work better and more efficiently, as well as contemplate services that were not possible otherwise. Much of the hoopla around mobile apps is about monitoring people at a distance, independent of location. But mobility is a boon as well to activities playing out in a defined, close range.
Hospital distances are measured in meters rather than miles, but it doesn't lessen the challenge of quick reaction time to fast-breaking medical urgency. Cleveland Clinic has had a response team deployed for about four years, but now it's testing new technology that will score patients for whom vigilance is warranted and conditions are tracked for "the harbingers of something untoward about to happen," says Will Morris, M.D., associate chief medical information officer at Cleveland Clinic. Mobile devices provide an exceedingly quick response tool to get responders to the scene in a hurry, Morris says [see The E-Hospital].
In surgery, the trend is toward anesthesiologists' serving in medical direction roles in up to two operating rooms, or up to four with the deployment of certified registered nurse anesthetists. Through a system via iPhones developed by Vanderbilt in 2009, remote monitoring is on the scale of "a wall away," says Brian Rothman, M.D., associate director of perioperative informatics and an attending anesthesiologist. "Things change very quickly, so we need that second-by-second care [from nurse anesthetists] extending back for medical direction by an attending anesthesiologist" [see An Inside Look].
The attending can be elsewhere when something requires his attention, but "elsewhere" doesn't mean a different floor or another building, Rothman says. "It means that instead of being in Room 12, I'm in Room 13. Or if I am supervising four CRNAs in Rooms 10, 11, 12 and 13, and I'm standing in the hallway, I'm not in any of the rooms." Responsibility for anesthesia services extends to pre- and post-op care at opposite ends of the operating department, "and it's a football field; it's at least a quarter mile around."
Mobile health technology has been most visible as a health care consumer tool, and generally the hospital is the last leg of adoption for advances where "consumers adopt them first, educate their doctors, and doctors slowly begin to adopt them, which means their hospitals adopt them," says Christopher Wasden, managing director in the health care strategy and innovation practice of PricewaterhouseCoopers. But some hospitals are employing mHealth for patients to navigate through their journey. "In essence it's a mobile patient advocate in your pocket, to help understand what's going on and how to manage the process."
At hospitals in the Sentara Healthcare network in Virginia and North Carolina, patients and their families can download an app to their personal smartphones that uses GPS technology to show where they are and any destination they need to find, says Elise Spoto, director of information technologies. In the works is a planning tool marrying the app with Sentara's electronic health record system that will inform patients and families about such things as inpatient test times and places, or when a hospitalist is expected on rounds.
"The intent is to lay out a daily schedule, not only to give the patient an idea of what the day would look like, but then also communicate [that] … to the patient's family," Spoto says. That could, for example, help family members schedule a visit when the patient is in bed or when they're most likely to see a doctor for a status report.
An "e-hospital" is laid over Cleveland Clinic's bricks and mortar, says Morris. It's "an electronic hospital within a hospital in which you have another set of eyes that are monitoring and making sure that our patients are getting the best care, not only at that instant but what might happen in 15 minutes — predicting patients who might be getting in a little bit of trouble."
Breathing begins to quicken. Blood pressure starts a slow slide that might not catch an eye for a few crucial minutes. But with the e-hospital layer paying close attention, "You put it together with a clinical picture and you're able to say, 'OK, Mrs. Smith is actually looking as though she's getting septic.' And before she becomes overtly septic, drops her blood pressure, and has the nurse running in and recruiting people to come to the bedside, you can proactively manage that patient."
The approach leverages electronic health systems, decision-support machinery behind the scenes and uncomplicated wireless information transmission, all advances that rapid-responders did not have at their disposal mere years ago. It adds up to a level of performance not possible until now.
"For patients who have a condition, you don't want it to spin out of control when it becomes critical or severe. You want to manage it up front … so that [for] a patient who might be getting an infection, you treat him earlier, before the body starts decompensating." Prevention through monitoring "is very much enabled by an integrated technology environment, and I'd say mobility is one such endpoint experience in which this care can be rendered."
An inside look
A patient undergoing a surgical procedure at Vanderbilt had steady, stable vital signs for about four hours. But then a note popped up on the mobile phone of attending anesthesiologist Rothman — who was around the corner — displaying a suddenly low blood pressure reading. One tap on "view case" took him into the room via a video feed.
"The room, which should have been very placid, was actually extremely busy; a resident was working very hard, and what that led me to do was head directly to the room." It was a situation calling for the supervising anesthesiologist, but no one had the time to call him — they were all working on the patient. But the homegrown VigiVU app seized that role.
At work was a simple range setting for that patient's vital signs — "any systolic range under 95 I want to know about" — and the moment that happened, a notification was pushed out to him. "It allowed the provider to take care of the patient, but it also enabled me to go in at the right time." It turned out that the case went from superficial skin procedure to major vascular procedure: a diseased carotid artery ruptured, and the surgeon stanched the blood with his finger. That, in turn, reduced blood pressure, which then required a completely different anesthetic.
The app doesn't control any equipment remotely or enable him to take actions en route; nor does it replace or supplant normal staffing or their activities. But for the attending, "it gives you situational awareness to bring you into that moment and identify situations more quickly, potentially where it would prompt you to go into the room to help medically direct."
Highly prized: accessing, interacting with data remotely
Rating benefits of mobile technology % of responses
Improved access to view only patient information: 66%
Improved access to reference information: 59%
Ability to enter/modify patient information: 42%
Ability to access clinical decision support tools: 39%
Improved patient safety: 28%
Ability to streamline number of devices used by clinicians: 19%
Don't know: 14%
Return on investment or other financial impact:s 7%
No benefit: 1%
Source: 3rd Annual HIMSS Analytics Mobile Technology Survey, 2014