The Internet of Things is a hot topic these days, perhaps the hottest. Everyone is singing the praises of this emerging technology and telling stories of how it will make things better, especially in healthcare.
But, are our hospitals ready for this technology and can they make use of it as it emerges?
Sadly, I would argue “no“.
The basis for this opinion is founded after a series of medical adventures that I personally experienced.
Allow me to share some background before I continue with the technology discussion to add some context to the story.
Since December 28, 2016, I have been in two different hospitals for a combined total of 21 days over three visits. My case began with an acute pancreatic attack. Basically, a gallstone. For a person of my age, it is not too surprising to have a gallstone. It is fairly common.
Upon admission to the first hospital, medical imaging was performed to see what was happening inside me. The MRI revealed the gallstone. So, the process was to operate and remove the gallstone by sending cameras and tools down my throat through my stomach and into the duct where the stone was lodged and then drag it out the same way. This surgery was easy and uneventful.
The next step is to perform an incision-based surgery to remove the gallbladder, which is a common procedure and typically performed in a same day process, in and out. However, instead of scheduling the surgery right away, more imaging work was ordered for me including a CT scan and an ultrasound. A tumour was seen on my pancreas, which caused the doctors to refer me to a second hospital that specializes in cancer.
Now weeks later, on March 21, 2017, I was prepped for surgery at the second hospital. They removed my gallbladder, spleen, and a portion of my pancreas laparoscopically in a process of minimally invasive surgery. I recovered slowly and was discharged.
After being at home for one week, and returning to remote work levels, I had what doctors call, a post surgery complication, in fact, several of them. Suddenly, intense pain invaded my body caused by a partially collapsed lung, pneumonia, and pancreatic fluids leaking into my abdomen and chest cavity, where they should never be, so an ambulance run back to the second hospital was in order and more CT scans, intense antibiotics, painkillers, and a third surgical event to install a drain to egress the fluids from my body.
A month later as I write this story, I still have the drainage bag hanging out of my chest between the 2nd and 3rd ribs on the left side. I am free of pain and for the most part feel fine. Energy levels are low, mostly due to significant weight loss, down 42 pounds since March 21st, which is desired and necessary. Albeit it a difficult diet program.
Now, let’s return to the core topic about whether or not hospitals are ready for the Internet of Things (IoT).
Anyone who has spent any time in the hospital knows how terribly boring it is and with medications and distractions, even reading becomes a challenge. My decision was to treat the hospital visits like a science project and learn as much as I could with regards to the use of advance technology and the readiness to deploy IoT networks for hospitals. So, I had my wife drag in my iPhone 7+, iPad 3, chargers, and numerous accessories. Both devices had Wi-Fi and cellular connectivity, so I could test and probe the viewable networks with my analysis tools, research the technology online, as well as download manuals for the medical equipment used. I studied how MRI, CT scanners, and ultrasound all worked. I opened the MyChart program that the hospital permitted me access too so I could see my complete medical history including radiology images. I used the time well and learn a great deal. I invested perhaps 80 to 100 hours into this research. Did I say I was bored, well this science project approach gave me something meaningful to do and it was fun. I built spreadsheets and logged all tasks.
While I was at the first hospital for five days, no bed nor room was available, so they parked me out in the hallway for three of the days beside the nurses’ station. I had a drape to provide some privacy, but this afford me the best opportunity to observe nurse and doctor workflows and processes.
At the second hospital, I logged all my vital statistics into my spreadsheet every time they were taken during the two weeks. I had vitals taken over 70 times during the 15-day span of my two stays. As well as another 35 times at the first hospital.
The state of the equipment used to collect my vital statistics was terrible. On 97 out of the combined 105 occasions, more than one machine or technology was needed to complete the collection of vitals. It all should have been done with just the one device. We had broken temperature sensors, broken blood pressure cuffs, and regularly defective or broken pulse oximeters. These issues meant that the on-duty nurse had to waste time finding stand alone oral or ear thermometers, paper strip based temperature sensors called Tempa-DOT, or a second or even a third machine, to complete the simple task of collecting vitals. This was highly inefficient and consumed two or three times the amount of time needed to actually perform the task. Since these machines were not connected to any networks, the data was recorded with a pen and paper and manually entered into my patient profile chart later. Again, a very inefficient and potentially error prone process. On one occurrence, the nurse believed that the machine on hand was all working properly, until it read that my temperature was 52° Celsius. This reading was off the scale. The nurse jokingly said that she was saddened to inform me that I was dead and about to explode, as a reading this high was not survivable. Of course it was wrong. But, a sense of humour is essential when dealing with continuously broken equipment that seriously hinders your professional work.
As a patient in a hospital, blood work is ordered daily and sometimes 2, 3, or 4 times per day. The nurses who collected blood had small handheld devices to scan your patient ID barcode, confirm your name and date of birth, and then print labels for the blood vials. These handheld devices and thermal printers were connected to a Wi-Fi network. Well, sort of. Logging on to this network to access the identified patient profile was an exercise in frustration. The nurse had to attempt the log-on perhaps 8 to 10 times for every patient. It took longer to log-on to the network then it did to collect the blood specimens.
Since both of my hospitals are teaching hospitals, the doctors performed rounds every day. They pushed a cart around the floor going room to room to check-in with patients. The cart is loaded with charts detailing medical history for each patient. This is the same approach to medical rounds that has been conducted since Sir William Osler created this process in the late 1800s. Again, all paper based and handwritten. No tablets or electronic devices, so no direct access to the patient’s electronic records. I observed the potential for errors and actually experienced mistakes during three events whereby I had to challenge nurses following medication instructions post of the rounds. What the doctors told me during their visit to my bedside was different compared to what the nurse was administering later. The nurses had to reconnect with the doctors and validate the instructions. Each time it led to corrections in the instructions so they matched the data entries to the verbal directives. The nurses made no mistakes, but the data entry process was either incomplete, missing information, or poorly defined resulting in confusion and errors.
The second point is the time lag between the doctor’s visits and the execution of the task. The doctor team is composed of surgeons, post doc students, and residence doctors, and they had to visit patients on two overflowing floors very early every morning. My visits were between 6:30 am and 7:00 am every day. That is a lot of patients to see and of course it takes time to do it properly and provide the individual patients with the level of care and attention that they deserve.
After the completion of rounds, the instructions needed to be manually entered into individual patient’s electronic profiles. The lag was a minimum of 2 hours and often 3 to 4 hours between the time of the team’s visit to the execution of the orders by the nurse. I am sure that if something was needed sooner, that they would have made it happen for a patient. But, the normal lag was several hours or more.
On the three days that I was discharged from the hospitals, this lag caused a break in the hospital’s procedures for releasing a patient. Understandably, the hospital wanted to turn the bed around fast and accept a new patient, so they wanted me out by 10:15 am and no later than 11:00 am – absolutely. However, the release instructions from the team as well as scripts for ongoing home treatment never showed up until past noon and closer to 1:00 pm. So, while the administration staff sternly instructed me to vacate the room, the practicality of executing this task is seriously flawed and impossible to align to hospital policy.
A lot of the equipment used within the hospital is old and has no connectivity capabilities at all. Now, to be clear, not every device must be connected, so a balance is needed to design a solution for what is needed and what is not needed. But, a lot of devices that you may wish to connect cannot serve this requirement so lots of upgrades and replacements are needed.
Now some equipment, such as a wheelchair, you might think needs no connection whatsoever to any network. However, wheelchairs are often left in odd places, are out of position to the floors they belong to, and cannot be found when you need one. So, an RFID tag to help with identification and geolocating a wheelchair is a smart idea.
One of my three discharge dates was on a Saturday. I was still very weak, so I asked for help and a wheelchair to get downstairs to the front door where my ride would pick me up. I also had my bag with clothes, bathroom items, and all my electronics. Since I was restricted to not lift more than 10 pounds, I needed help with the bag too.
Since it was a Saturday, there were no volunteers on duty and I would need to wait up to two hours for the first available porter (orderly) to help me. Discharging patients was the lowest priority for the porters. So, this scenario would aggravate the hospital’s prescribed discharge process even further and I would miss my pick up.
The desk administrator offered that I could use one of her wheelchairs from the floor and wheel myself down to the front door, but I had to bring the wheelchair back up to the 6th floor before I departed. This suggestion puzzled me as I would still end up on the 6th floor with no way to get myself back to the front door. Since I still feeling the effects of the hydromorphone, and I was not too smart at the time, I assumed that I was missing a key part of her logic. But, the wheelchair had to be returned to her floor where it belonged if I used it. Very odd. Now, RFID tags do not replace the help of a friendly volunteer or a capable porter, but it would help to get assets to where they belong, eventually.
When I used my RF planning tools on my iPad to probe the Wi-Fi networks on the floor from my bed, I was astonished to see 12 discrete networks, all with high signal levels, available in my room. Only one of these Access Points (APs) was a guest network, the remainder were all secured, but offering their SSIDs. As most are aware, Wi-Fi offers just 11 channels in North America, and only three of these channels are none overlapping (channels 1, 6, and 11). The remainder are overlapping and therefore have some level of impairment. So, to compound the scenario, with 12 disparate networks in contention over the same footprint, it was clear that these networks were negatively impacting each other. No wonder the log-ins failed so often.
From the manuals that I downloaded for my IV pump and for the vital signs monitors, I could easily see that the communications protocols were closed architecture and propriety. They did not adhere to open standards. So, the communications from devices that did work online were questionable at best. How secure were these devices?
Nurses complained about excessive latency leading to device time-outs, access not available everywhere, painfully slow data rates, and failure to log-in. All of these issues can be attributed to the hodgepodge of disparate Wi-Fi networks causing interference with each other.
Each department had its own budget and so they built their own networks. Nothing seemed to be shared or harmonized.
Every hospital is exposed to a variety of other RF networks. Supporting services such as police, fire, EMS, helicopters, and the leased rooftop cellular sites are all potential sources of inference to the internal use of medical equipment and the associated networks. New spectrum is emerging for these supporting services and therefore the situation will only get worse. One of the rooftop cellular installations was easily viewed from my room window. The wiring was a mess. It was not a professional installation like many others that I have seen. These criss-crossing cables, and poor installations create a far higher potential for RFI and radio interference.
During one of the hospital stays, we had a full power failure. It was January 1, 2017 at 8:00 am, so most of the senior hospital staff was off work for the holiday. The systems kicked in as expected, but the hospital was operating at reduced service levels – emergency lighting, critical systems, etc. I observed that my hospital bed was not operational, which makes sense as it draws a lot of amps to operate.
I heard from a nurse that the drug dispensing systems, a robot of sorts, was offline due to the power failure, but somehow, the in-room television was fully powered, albeit not operational since the channels were offline. The outcomes were that the eight student nurses filling in over the holidays were lost without computers to enter patient data into, and the three senior nurses overseeing the floor had to cope with their patient loads, calm the student nurses who were stressed, and address the issues of the missing medications.
An interesting implication was that many bedridden patients who needed to be turned to avoid bed sores could not be moved as the younger (smaller) student nurses used the powered beds to lift the patient vertical for re-positioning and then reclined them again. Without the help from the bed, they were not physically able to move the patients.
Some diabetic patients could not get their insulin medications in a timely manner and so the operations where in total disarray. Luckily, the power returned by 9:00 am. Why was my TV powered on UPS and the generator? Why was the drug dispensing system not powered? Why were the manual processes not in place and readily available?
In summary, the Canadian hospitals need to take several steps to prepare for the advent of IoT solutions before they implement these new technologies. These steps include, but are not limited to:
- Wi-Fi systems need to be rationalized and harmonized – in this case less is more
- Manual processes must be planned, vetted, and tested so they are available when the automation fails – and it will fail
- Workflows need to be reviewed and optimized to drive efficiency
- All systems need to be loosely couple, secure, and yet seamlessly and transparently integrated
- A holistic overarching strategy is necessary, built upon an open architecture and a standards-based approach
- All systems need to use TCP/IP, preferably IPv6
- These systems and networks, need to be driven by a unified vision and not built with a bunch of disparate purchases
- The legacy medical equipment and systems all need to be refreshed and compliant first, before buying any new solutions
- Education, changes to work flow, and extensive staff technology training, aimed at the digitization of work is required
The Internet of Things will drive great value, reduce costs, improve patient care, and help the medical staff perform their duties. It can be great. But the underpinning infrastructure must be solid and trusted before you can layer any new applications and technologies onto these core networks and systems.
The medical staff deserves our respect for their hard work and sometimes impossible tasks that they do for the public. Therefore, the public owes them the best tools, reliable equipment, and a proper work environment so they can focus on their patients rather than struggle to find workarounds for defective devices and poor networks.
About the Author:
Michael Martin has more than 35 years of experience in broadband networks, optical fibre, wireless and digital communications technologies. He is a Senior Executive Consultant with IBM Canada’s GTS Network Services Group. Over the past 11 years with IBM, he has worked in the GBS Global Center of Competency for Energy and Utilities and the GTS Global Center of Excellence for Energy and Utilities. He was previously a founding partner and President of MICAN Communications and before that was President of Comlink Systems Limited and Ensat Broadcast Services, Inc., both divisions of Cygnal Technologies Corporation (CYN:TSX). Martin currently serves on the Board of Directors for TeraGo Inc (TGO:TSX) and previously served on the Board of Directors for Avante Logixx Inc. (XX:TSX.V). He served on the Board of Governors of the University of Ontario Institute of Technology (UOIT) and on the Board of Advisers of four different Colleges in Ontario as well as for 16 years on the Board of the Society of Motion Picture and Television Engineers (SMPTE), Toronto Section. He holds three Masters level degrees, in business (MBA), communication (MA), and education (MEd). As well, he has diplomas and certifications in business, computer programming, internetworking, project management, media, photography, and communication technology.
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