Scott Brown's presentation -- Patient monitoring: technology adoption and connectivityI'm Scott Brown and I work at the Royal Cornwall Hospital as the capital investment manager, where I'm responsible for approaches in medical equipment. So the talk today is mainly around that: it's a strategic replacement programme for patient monitoring across the organisation. So I've been in the NHS about 30 years now; in fact it's 30 years this year in October. I started off as a biomed, done different roles and I’m now in capital planning. But also five years ago I set up a company called Health Tech Solutions, the idea being to do some consultancy work. That’s broadened out into doing training for biomeds and nurses as well. So that'll be celebrating five years this year as well. So, lots of things I've been involved in.

So on to patient monitoring. Start with a slide. I always like to start with a quotation and this one is: "Everything should be made as simple as possible, but not simpler." This is by Albert Einstein. And actually I think this is the ethos of what I'm trying to do with the patient monitoring. We've got patient monitoring at the moment which has got standalone physiological measurements, but all of the other information, as Andrew and other people have said about this morning, is on different systems and they're not all brought together. So if we can bring all of that data to one screen that just makes it so much simpler for the clinician and actually makes it better for the patient. And being better for the patient is why I joined the NHS.

A bit of background and context to this, so patient monitoring is used in lots and lots of areas within the hospital. This slide actually is a training scenario. This is an anaesthetic machine with a patient monitor on it. And actually the two delegates that are in this photo are actually here today, because I met them a few moments ago. This operating theatre is not a real theatre, although it's designed as a theatre. And it's quite famous because it featured in Holby City and Casualty many, many years ago.

Now, back in the day when I started in patient monitoring, 30 years ago, we had very little in the way of monitoring. We've got a Hewlett Packard 78352a here. So this was monitoring in our theatres. This was the extent of monitoring! So a patient monitor with a green screen did ECG. One set of alarms, no configurability, that’s it, leads one, two and three. And then we had the Von Recklinghausen ossillotonograph to do our blood pressure. So the only other two things that were monitored were temperature. And temperature was monitored by the anaesthetist putting his hand on the patient: yes the patient's warm, that’s OK. And then oxygen concentration: has the patient turned blue? If they’ve turned blue, we'd better up the oxygen a bit. So we had no gas monitoring and no monitoring at all. That’s moved on a lot now. In those 30 years, we've now got any number of parameters we monitor.

So this has come from the Anaesthetists Association of Great Britain and Ireland, their 2015 document, which talks about the minimum requirements for patient monitoring for patients undergoing anaesthesia. So you can see here, we've got pulse oximetry. So we're looking for oxygen saturation in the haemoglobin in the blood, non-invasive blood pressure, ECG. If we’re ventilating a patient then we want to look at inspired and expired oxygen and of course end-tidal CO2 to make sure we're ventilating the patient sufficiently. Nitrous oxide is always on the list, although very rarely used in anaesthesia nowadays, sometimes for paediatrics, but it's there anyway. And then volatile anaesthetic agents, so we want to know how much sevoflurane, isoflurane, desflurane, we’re giving to the patient and the effects on the anaesthesia. And then because we’re monitoring the patient, we make sure we don’t deliver any barotrauma by monitoring their airway pressure. So we’re monitoring the pulmonary airway pressure.

If we've got patients who we've given a nerve block to, to block pain, such as bupivacaine, then we want to monitor that activity with a peripheral nerve stimulator. So this can be a standalone device or now it's starting to be built into monitors. And the guidance changed a couple of years ago, 2017, on this, whereas at one point it was just ad hoc monitoring throughout the procedure, the guidance as of 2017 monitoring should be continuous using a train of four pulses, which gives us a numerical value. And it should be monitored from the start of the procedure all the way through the procedure until the patient wakes up and actually onwards into recovery, so monitoring throughout that time period, which also then links into having trend information available that starts in the anaesthetic room, through the theatre and into recovery. Temperature monitoring, actually a bit more sophisticated now than putting your hand on the patient. So we have values for that and we may record more than one temperature. And then BIS monitoring, so we've got the depth of anaesthesia we can monitor independently using a BIS monitor. So this looks at the EEG waveform measured at the forehead and we’re looking for a numerical value. We’re looking for a high amplitude, low frequency waveform. And also then we might want to monitor invasive pressure, so arterial blood pressure or central venous pressure. So you can see we've moved from two parameters now to 10 or more parameters. And sometimes there's more on top of that as well, depending on what procedure is being undertaken.

So the key to this of course is data. Data is everything with this. And how we get that data to our clinicians is important. So that’s the connectivity, which is the conduit on how we connect that data to the patient. So you can see on this taxonomy here, we've got the physiological data right at the bottom, which we've just talked about. But also it's useful with our patient monitor: we might want to bring up these results. So, as Andrew was talking about at the beginning when he was talking about integration in theatres, this also applies in critical care units. Clinicians are doing their ward round in the critical care unit, or actually even in the operating theatre we might want to pull up the lab results. So we can then download that to our patient monitor and get the lab results. We may want to get some images as well. So, as Andrew was talking about, moving from one part of the theatre to the other, we could do that at the same monitor. So we just keep at the same monitor and we've got all this data. And then any medications that the anaesthetist gives the patient, so nerve block, painkillers, etc., updating the medical notes, all of that can be seen on the one screen.

So we can integrate all this stuff together. And to do that we need a set of rules to operate, to communicate between these systems. So we need a protocol. And this provides us with a framework for the exchange of information and sharing and retrieving of data to link with our patient monitor to our hospital systems. And we've got lots of different hospital systems. HL7, hospital level 7, is a standard that has been developed by a not-for-profit organisation, which was founded in 1987, based on the open systems integration model, which has got seven different levels. It starts at the physical level, as you can see: data, network, transport. And then the real level we’re interested in is the integration level at the application level.

So we’re going to talk a little bit about that now. And I'm certainly not an expert in this field. I pass that to my IT colleagues. But I am learning quite a bit about it. So, at the physical level, right at the bottom, this is how we communicate the data at a physical level across the physical medium. So this might be a twisted-pair copper wire. It may be at the ethernet. But actually could also be things like fibre optics as well, where we can get much bigger bandwidths and much better dataflow. And then we've got physical addressing, so how we communicate that data from one end to another. If we're moving it across a network then we've got an IP address.

So that’s a location where we can transmit the data to and from. And then within a system where we've got nodes, where we have within one system, we can go and use the transport, which talks about end-to-end communication, synchronisation, connectivity, etc. And then at a higher level, we look at connection between one network and another, so this is the session level. So, again, this is the inter-host communication between one network and another network, because we have multiple networks within the organisation. And then moving up to level 6, this is where we can have data encryption, compression and preparing the data ready to the application. And the application of course is at level 7. So this is where we link to our laboratory information system, our EPMA records, histology records, all sorts of systems.

So HL7 in the NHS goes back quite a way actually. The Department of Health published this document, The Power of Information, in 2012. So that’s seven years ago now. And we're slowly starting to get into the NHS and we’re developing some systems within our organisation and, hopefully, this patient monitoring system will then help to revolutionise that. So this is about not only data available to our clinicians. So, you can see here, we've got an information centre in the middle where all the data from the systems comes in, but we should be able to communicate that. And then different people will need different levels of access. So there needs to be some granularity in that data.

So, obviously, your GP may want to have access to some of that stuff, but he won't need to know what the anaesthetist has been doing during the middle of a procedure. And also some of that information is available to us now. As a member of the public, I'm entitled to get information on what's been happening to me. There are limits within that. But actually that’s quite useful for me and it helps me manage my health because if they're concerned about blood pressure then I can take steps to do that. And then of course pooling that data, we've got the big data stuff, haven't we? So anonymised data can then go to look at epidemiology, to look at disease, the study of disease, populations and research projects. So pulling all this data together is really important and it's helping to drive healthcare provision forward.

So one of the ways we’re moving to now is WiFi. Lots of WiFi in the hospitals through WiFi protected access. And this has gone through different levels of development as encryption has got better, but also people hacking into the systems have tried to challenge it and we've done our best to improve that. And lots of systems just have WiFi access. The laptop I use on a day-to-day basis, I have no physical connection. I use WiFi to the hospital network. I can connect up to our asset management system. I can connect up to our server. I can connect up to the photocopier and printer down the road. But also then if I want to take it to the operating theatre, I can get all that information in the operating theatre without connecting it so I can do audits and things like that. So that’s also going to link into our patient data. And we've started to do some of that collecting data. We've got a nerve centre and things like, which have got data through the WiFi system.

So this is a security protocol and programme to ensure privacy of that data, because we need to ensure, although we need to collect the data, we need to ensure that it's only available to the right number of people. So WPA was the first system. It then evolved to WPA2 and there are different variations on that. There's a TKIP and then a more revised version, which is AES, the advanced encryption system. And that’s used by the US Government actually, so that’s a level of security. But both of those WPA2 systems are still prone to brute force attacks. And part of that is because there's no limit to the number of attempts you can make at the password. So all somebody needs to do is to set up a big computer system to fire data at it until it gets into the system.

WPA3, which is now being introduced, and we'll probably start to see that coming into medical devices in the next year or two, has got some way around that in that there needs to be an interconnection with the infrastructure every time a password is attempted, or a guess is made at the password, and so we can set limits on it. So we can say after five attempts you're shut out. So that actually will improve things a lot. I've not seen any systems with WPA3 yet, but as these patient monitors and things improve, they’ll be developing that and coming along. So that’s something that we’ll need to look out for.

This project - so going into a little bit more detail now - is a strategic replacement programme for patient monitoring. So we've got an ageing asset base of patient monitors. What we want to do is stick to one manufacturer and then we've got the interconnectivity and that minimises patient safety risk because training is easier, maintenance is easier. It's just got lots and lots of benefits.

So Royal Cornwall Hospital has got three sites. The main site here, which was the district general hospital, it's now got 22 operating theatres, 22 across the three sites, two catheter labs, a critical care unit, a coronary care unit and paediatric HDU. And then we've got an emergency department at this site and then an urgent care, which is a sort of a step down ED, at our site in West Cornwall, which is in Penzance. Population of about half a million, but it varies, doesn’t it, in Cornwall? So we are under constant pressure in Cornwall. During the winter, we have winter pressures because we've got an ageing population, so there tends to be higher illnesses in the ageing population during the winter. And then in the summer, of course, we get an influx of visitors so that population will double in the summer. So bed capacity and challenges around the system are prevalent.

So where are we now? We've got Philips as our patient monitors at the moment, which we've been very happy with. We've got their central stations. But we've got dedicated networks, which are linked to the manufacturer, so no links to the hospital, just within the system. And we've got a Philips CareVue system in our critical care equipment. We've got measurement service, or bricks as they're called, some small monitors about this size, which we can move then from monitor to monitor. So we can start off in the anaesthetic room, move that into the patient monitor in the theatre, into recovery and if necessary into critical care after that. And that trend data follows that around. So we’re keen to continue to have that technology because that’s quite useful.

Drivers for change, so first of all the ageing asset base. So our big monitors in theatres in critical care go out of support in 2020, so next year, and then two years after that our smaller monitors throughout the site. So effectively we’ll have about 120 monitors which we need to replace and three central stations. So it's a big project. We’re looking at about probably £2-3 million, which we’ll do over a period of two to three years. And currently we've got no communication with any patient information systems. So these are standalone devices just doing physiological measurements.

So I know Milton Keynes is famous for its concrete cows, but we've got COWs in the hospital. For our EPMA, for our medical prescribing, we've got the COWs: computers on wheels. These are laptops on these little trollies which go around. In the theatres, they're bolted on the anaesthetic machines and you’ve got to make sure it's on the right side for the right anaesthetist. But in critical care and in wards, they wheel these COWs around.

So who are the main stakeholders? And this is the big change for us. Traditionally with patient monitoring it's been clinical technology or medical physics, depending on how you call it, linking with the clinical people and then some finance in the background to fund it. But this will be our first project involving IT. Because of that infrastructure linking into all the hospital systems, we need good engagement with our IT colleagues. So we've got four stakeholders in this project. And it's exciting and I can see this is as the way we’re moving forward now for lots of our projects. And a little bit later on, I'm going to talk about a new role which I've started to see and I think we’re going to look to get in our department as well.

So key stakeholders, clinical, obviously is the important one, so we've got engagement with critical care, with coronary care, with neonatal unit, but also theatres and some wards, paediatrics, a whole range of clinical areas, recovery, etc. We’re looking at a broad range of parameters as well. So how we've gone about this is we've used a statement of requirements. This is something that the supply chains have produced, which basically lists all the parameters that they can think of. And then we've got all of these clinical users to fill out these spreadsheets saying how many of these do you want, so how many monitors do you want with ECG, what size screen do you need, what do you want it to connect to, how many invasive pressure channels do you want, that sort of thing. And then I took these back and did some challenge around them because I thought right, coronary care: do you really not want ST-segment analysis? I think you probably do, so let’s go and have a look at that again. So we did a bit of sense checking around it. And then this has formed sort of the basis of what we’re getting to our companies to tender for.

So that’s the clinical side. And then because IT is such an important thing, it's what systems do we want to exchange and share data with. And this is a two-way exchange of data. So the FHIR standards use - that’s the fast interoperability exchange standards, based on HR7 - so we talked about HR7, so this is how we can have a platform to move data from one system to another. Also, linking into GS1 barcodes because our patient identification straps now are barcoded with GS1, and we've got that linked to our RFID system for medical devices. So in theory we should be able to track the devices around the hospital. And they're interested in secure data transfer, whether that’s via a wired LAN, so hardwired, or via WiFi.

And then clinical technology, we've got an interest in this obviously because we're going to keep this stuff going. So design and reliability of equipment, can you provide technical support, all of those sorts of issues. Availability of spare parts and is Brexit going to be an issue. We need to think of that. And then the final people: procurement and finance. Now, this might seem like an odd slide, but it's an artist called Titian, who went to the Venetian school of art, Italia, in Italy in the 1600s. And it's of Pope Paul III and his two grandsons, Alessandro and Ottavio. So this is the alliance you have with the finance people. The Pope down there is obviously the holder of the purse strings, so that’s our director of finance. Alessandro, he's the procurement lead: is this giving us value for money, is this the best thing? And then the other person, Ottavio there, that’s me going in saying can I have £2m for this project. And it's no, you can have a million. Well, that’s not going to do it, so we negotiate.

So objectives to identify a supplier if we want seamless integration to our systems, we want resilience. So if we can use our own hospital network rather than a manufacturers' network, that enables us to adapt it and provide the infrastructure and also meet our changing needs. So here's an example. So we haven't identified a supplier yet, but this is Mindray, who've kindly allowed us to use this slide. So we've got our critical care examples here: our Hamilton ventilators, which is a project I've just finished working on. Braun Infusomats, which is our volumetric pumps. We've got our patient monitoring systems there and then all of our IT at the top. So we've got EPMA is our prescribing; WinPath is our laboratory system; hospital information system is PAS. Then we've got Maxim who is our patient records and we've got PAX there as well. So lots of different systems we want to integrate with.

We've done our statement of requirement, which is our clinical aspect. The questionnaires: because IT and clinical technology have got different needs, we've done separate questionnaires to the suppliers. Three suppliers returned and were interested to come and take the next stage. So we invited them to bring a series of monitors to a show and tell event with stakeholder engagement and we had brilliant engagement. I expected ten, half a dozen, people maybe turn up. We had over 80 people turn up to this event: clinical people who'd come to look at this. So that was brilliant.

Data collection, so we planned a meeting for the day after to just go through the half a dozen questionnaires and say these are the ones we want to invite back. But actually we're having to do a bit more data analysis now because we had 80. So the plan is to shortlist to two and invite them back for clinical evaluations. So these will be in the emergency department, operating theatre, critical care and actually we've now added neonatal because we think that’s a specialist area. And then we’ll have a decision which is evidence based to take the project forward. So then we have a replacement programme - and I anticipate this is likely to be over three years maybe - informed by the end of support dates, informed by risk ratings on our Datex system. But also linked to patient flow because that’s important when we start changing technology, we need to make sure that that technology flows with the patient.

This is just a warning. We've had the WannaCry thing so we have to make sure that the cybersecurity is in place. And the previous speaker talked about that. And this is the new role I've talked about. So I see this now as a connectivity engineer or an IT clinical scientist, who’s able to bridge that gap between the two departments. And we've started to see one or two job adverts coming out for this and I'm thinking we're going to probably get something in our department to do that. And actually for younger members here that might be an area to start to pursue.


Dr. Scott Brown's presentation at the EBME Expo: Patient monitoring: technology adoption and connectivity.

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