airstrip_wp_encouraging coherence in healthcare technology_final_print-ready

AirStrip White Paper Series

ENCOURAGING COHERENCE IN HEALTHCARE TECHNOLOGY

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© 2015 AirStrip | www.airstrip.com

Until recently, mobile-enabled health (mHealth) consisted of multiple, stand-alone, native applications (apps) built to run on a specific device and specific operating system for a specific data source. The emergence and development of myriad apps has resulted in clinicians burdened with ‘app overload’ – different apps to perform different tasks on different devices.

AirStrip ONE® transcends the concept of the mobile application, replacing it with a powerful interoperability platform for care collaboration and health system innovation. This capability is critical to the transformation of patient care. The demands of the marketplace have quickly evolved since AirStrip OB arrived on the scene in 2006 as the first and only monitoring application that made live maternal/fetal waveforms available via mobile device.

AirStrip ONE embraces these demands, incorporating multiple disparate data sources, secure communication/texting, and the potential for analytics and clinical decision support. While access to live waveforms anytime and anywhere certainly has value to clinicians, it is not enough to address the fundamental lack of interoperability that severely limits the ability of health systems to enable care team coordination, accelerate decisions, and avoid unnecessary readmissions. This is the critical role that AirStrip ONE plays.

To appreciate the innovation that AirStrip ONE represents, consider London and the surrounding countryside in the early 1800s at the onset of the Industrial Revolution when rail transport was in its infancy. Small, private rail lines carried passengers faster and at a lower cost than carriages from surrounding villages toward, but not into,

London. The rail companies could not afford to acquire land in order to lay track, due to increased real estate prices near London’s urban core. Therefore, it became cost-prohibitive for rail companies to provide service into the congested part of London.

Various rail lines approached London from different directions and stopped abruptly. Rail passengers had to continue on foot or by carriage - often a significant distance - to their destination, deeper into the city or to another rail line. Rail, though a revolutionary innovation, was far from reaching its full potential for want of coordination. There were spokes made up of the individual rail lines serving countryside villages, but no hub.

The Metropolitan Railway in London addressed this inefficiency in 1863 when it opened the first line of the London Underground. Over time, a system of subways crisscrossed London connecting the existing rail lines. We know London’s subway system today as ‘The Tube.’ Rail offered cheaper, faster, safer, and more comfortable travel, but the subway linked these stand-alone lines to form a coherent system of transportation, marking a quantum leap in organized urban transit.

Much like passengers in 1800s London, clinicians have recently been capable of accessing productivity-enhancing technology but also left to negotiate a collection of uncoordinated, stand-alone apps. Like the London Underground, AirStrip ONE unifies all diverse strands, making patient data easier to access anytime and anywhere, thus supporting faster and more informed patient care decisions.

THE HISTORY OF AIRSTRIP IN OBSTETRICS A 2003 coffee shop meeting between an obstetrician and application developer led to the creation of AirStrip, leveraging mobile technology in order to provide anywhere, anytime access to maternal/fetal waveforms and other essential data elements from the perinatal information system.

ENCOURAGING COHERENCE IN HEALTHCARE TECHNOLOGY

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Such access meant that whenever a nurse, intern, resident or physician called another provider with a concern, the consulting provider would be able to see data from the perinatal information system on his or her mobile device. Clinicians and their supervisors were able to view the strip live, as well as several hours of history, from wherever they might be.

AirStrip for labor and delivery was first deployed in Texas in 2006. In those pre-iPhone days, clinicians used Windows mobile devices and operating systems to monitor patients in labor and delivery by viewing the live electronic fetal monitoring waveform (the uterine contractions of the mother and heart rate of the fetus) in near real time. At the time this was cutting-edge technology widely hailed by clinicians as beneficial. However, the technological impediments in these ‘pre-app’ days were significant: complex compression algorithms to support efficient digital signal processing; evolving national wireless communications infrastructure; spotty cellular network coverage; short cellphone battery life; diverse ‘bring your own device’ (BYOD) hospital policies; and stringent HIPAA security requirements.

Even with those early challenges, AirStrip uniquely addressed the systemic causes of preventable medical injury by:

1. Enabling providers to expedite diagnosis and treatment

2. Reducing the probability of confusion inherent in verbal descriptions of clinical data

3. Enhancing clarity and speed in care team communication

4. Reducing the likelihood of misinterpretation of Electronic Fetal Monitoring (EFM) data

Over time and across hundreds of hospitals, obstetricians, nurses and anesthesiologists have reported improvements in patient safety, clinical efficiency, teamwork and communication as a result of having mobile access to live labor and delivery patient data. At this writing, AirStrip in OB is used to support an estimated one out of every six births in the U.S.

In fact, AirStrip has been used in the safe delivery of 3.5 million babies since its inception and is used to manage more than 615,000 births annually.

AirStrip ONE introduces a coherent system: a single point of access that ensures data integrity and enables clinicians to seamlessly access the appropriate data for a given task. Furthermore, AirStrip ONE is vendor- and data-source agnostic, capable of uniting a wide array of patient data in a single application.

MITIGATING CHALLENGES IN LABOR AND DELIVERY REMAINS A CRITICAL OBJECTIVE There are roughly four million births in the U.S. per year.1 One in five pregnancies (800,000) is considered high-risk. About 12.5 percent, or 500,000 infants, are born prematurely before the full gestation period of 40 weeks.2

Most adverse events and near misses in obstetrics, according to patient safety research, occur during the perinatal period, from 20 weeks of pregnancy to 28 days of life.3 Fully 70 percent of these situations, it was determined, were preventable.4 64 percent of the preventable errors in meritorious perinatal malpractice cases are attributed to one or more of the following:5,6

1. Failures or delays in the diagnosis and treatment of fetal distress

2. Miscommunication among providers related to patient status

3. Misinterpretation of EFM data

It should be noted that while research provides little evidence to suggest that EFM improves neonatal outcomes or prevents pre-term birth, it is nonetheless common practice. Continuous cardiotocography, a form of fetal monitoring, is the most commonly performed obstetric procedure, used in at least 85 percent of all U.S. births.7

It is not that EFM technology yields no benefit; it is self-evident that more information is preferable to less. Rather, it is that EFM technology is merely a tool and its

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effectiveness is a function of how that tool is used. Healthcare entails sophisticated processes, and tools such as EFM become increasingly effective when used to support coordination among team members in the care of a patient.8

Skilled medical personnel, adhering to sound processes, are enabled by technology to deliver superior care. That simple observation is profound in light of the reasons identified above as the causes of preventable medical injury. Delayed diagnoses, poor communication, and misinterpretation of EFM data imply that preventable injuries spring from systemic breakdowns.9 Reducing and mitigating medical injury therefore depends upon strengthening systems and processes.10 Indeed, that is what researchers have concluded.11 AirStrip ONE directly enables providers, as well as facilitates and strengthens the processes.

Consider a quarterback in the NFL who enjoys the benefit of being able to hear the coach via a transmitter in his helmet (the current model). The quarterback communicates to his teammates in the huddle so that everyone knows his role on the next play. It is merely left to execute.

The scenario in OB care, absent mHealth, is considerably more challenging. The team, which might consist of the delivering attending physician, the resident, the laborist, the registered nurse, the charge nurse, and the OB anesthesiologist need to be ‘in the huddle’ even if they are not in the same building. It is not unusual to have to ‘hand-off’ care at various points.

To convey a cardiotocograph verbally requires a qualitative and quantitative description of uterine contractions, baseline fetal heart rate, variability, presence of accelerations, periodic or episodic decelerations, and changes or trends in patterns over time.12 No surprise then that the National Institute of Child Health Development (NICHD) asserts that visual assessment is required for accurate interpretation.13

Beyond this, providers need visibility into the care continuum. AirStrip ONE provides secure anytime,

anywhere access to relevant data, including live waveforms, and thereby facilitates precise communication among team members; a provider on a different floor or in a different building can see the same data that the team members at the bedside can see. Being able to see the same data in near real time precludes having to allocate time for verbal descriptions and reduces the probability of misinterpretation and disagreement, the inevitable result of vagueness or incomplete understanding. Being able to see critical lab and test results, antenatal care notes, ultrasounds and other studies expands the provider’s ability to make informed data-driven decisions.

Such enhanced efficiency and clarity is no small matter with respect to patient safety. For example, in the case of an emergency cesarean section, time is critical. The accepted goal with respect to the procedure is 30 minutes or less from ‘decision-to-incision.’14,15 Time squandered coming to an informed decision for want of access to the data or confusion among team members may be costly both in terms of patient health and the ensuing inquiry if such a delay results in a preventable injury. Put another way, AirStrip ONE can enhance the process of care that includes collaborative, multidisciplinary assessments of patient data. Immediate access to the data can help avoid the sort of systemic breakdowns that lead to preventable injury illustrated in the following case studies.

CASE STUDIES An HCA study of 189 perinatal claims closed between 2000 and 2005 at a cost of $168 million found the following:

• 70 percent of all obstetric claims involved substandard care that was causally related to the injury.

• These 70 percent of cases accounted for 79 percent of all costs associated with the 189 claims.

• Payments were most prevalent in cases involving fetal monitoring in cases of vaginal birth after cesarean (VBAC), maternal injury, and shoulder dystocia.

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• In each of these cases, delayed physician evaluation of a non-reassuring fetal heart rate tracing and delayed delivery was the primary issue associated with the adverse outcome and resulting litigation.10

At Wayne State University, the failure to monitor the fetus in accordance with the accepted OB clinical pathway was the most frequent departure from compliance. This failure resulted in a nearly six-fold increase in the probability of a malpractice claim.16

Among Harvard hospitals, a failure to diagnose or delay in diagnosis and treatment when fetal distress was present was a factor in up to 31 percent of the obstetrical medical malpractice cases. The misinterpretation of fetal monitoring data was a factor in 20 percent of meritorious cases, and most frequently involved clinical judgment failures involving the lack of or inadequate assessment and patient monitoring.3, 5, 6

Strengthening systems and processes is the key to reducing many preventable medical injuries and claims in obstetrics. Systems and processes consist of people, enabled by technology, executing their respective roles. First, clinical deterioration has to be recognized and addressed in a timely manner. Second, members of a care team have to communicate and share concerns before they become critical. Third, fear and embarrassment both as it relates to the hesitation an inexperienced team member might have in sharing a concern or in asking for help must be overcome.3 AirStrip ONE directly addresses the first two components and indirectly impacts the third component - more of an intangible or ‘soft’ skill - by encouraging a culture of team cohesion in a way that can enhance patient safety.

LIVE DIGITAL DATA OPENS THE DOOR FOR CLINICAL DECISION SUPPORT The AirStrip ONE mobile interoperability platform pulls real-time EMR and continuous monitoring waveform data from multiple systems and then translates and normalizes this information in a single user interface.

For OB providers, the digitized waveform, along with prenatal medical record data, ultrasounds, and historical Amniotic Fluid Index (AFI) measurements, exam status and the like are compiled into a single pane that allows providers to efficiently access and view this data within the necessary context for optimal patient management. Streaming all of this digital data in near real time also presents an opportunity to provide clinical decision support to bedside caregivers.

Algorithms can be applied to such data, and leveraged to cue clinicians monitoring patients. When trended analysis reveals a potential problem, clinicians can be alerted. This level of automated support can provide a necessary and valuable backup or early warning system that can support the immediate synthesis of evolving evidence-based practice guidelines,17 reduce observer interpretive variability,18 and strengthen patient safety.19

mHealth also presents a way to engage and connect maternity patients more fully with their clinical providers as active participants in their prenatal care. Timely communication and messaging, video conferencing, and live consultation by specialists can all be expedited with mHealth.

LEVERAGING AIRSTRIP ALONG THE OBSTETRICS CONTINUUM OF CARE In the case of the English rail system, as villages and cities grew, rail lines were extended outward from London and eventually across the country. Similarly, AirStrip ONE facilitates a broader deployment of mHealth solutions pertaining to the obstetrics service line to include all points along the continuum of care. The start of care, enabled by mHealth, can begin earlier. Such an extension of the continuum of care should be viewed as a means to avert, or at least manage, high-risk pregnancies and protect against the long-run costs they may yield. Efficiency-enhancing technology is an investment. Integrating mHealth yields a return.

For example, a high risk pregnancy can be monitored remotely with AirStrip Sense4Baby™ - a non-invasive, wireless electronic maternal and fetal monitoring system

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that utilizes wireless technology and a smart device to transmit data to a HIPAA-compliant, cloud-based data storage system - providing intermittent non-stress tests (NST) long before the onset of labor. The historical data then would be available to provide background in a decision support context that might occur at a later point in care. Integration with the antenatal electronic medical record can provide a level of insight to delivering providers not previously available. AirStrip ONE, then, not only facilitates the transition from point-to-point along the continuum, encouraging communication and mutual understanding at any given point, it can also be employed at low cost to support care along the continuum.

The readiness of the market to adopt patient management approaches including home monitoring vary from low in the U.S. - where technology infrastructure, the medico-legal climate, and reimbursement incentives are misaligned - to high in countries where access to specialists and antenatal services are physically and financially challenging. Indeed, “remote maternal-fetal monitoring is feasible in resource-constrained environments and can improve maternal compliance for monitoring sessions.”20

THE PHYSICIAN EXPERIENCE A review of satisfaction data supports the claims made above with respect to the use of AirStrip ONE. Obstetrician mean overall satisfaction scores are up to 11 percent higher at AirStrip hospitals than their regional and national peer group counterparts. And, physician satisfaction levels not only increased at AirStrip hospitals but were also sustained over three years, compared to results from the three years prior to AirStrip deployment.

These data were compiled before enhancements to AirStrip ONE. These enhancements were the result of ongoing monitoring of the user experience, consistent with AirStrip’s culture of continuous improvement, that yielded fresh insights and ultimately the development of a system that makes myriad data sources more accessible, including the EMR and body sensors in order to relieve ‘app overload.’

If AirStrip ONE did nothing beyond enhancement of physician satisfaction, then it would still be noteworthy due to the high costs and overall value connected to physician recruitment and retention.

• The average OB-GYN yields revenue of nearly $1.44 million annually.21

• The average physician turnover rate is 6.8 percent.22

• The average OB-GYN vacancy rate ranges from 4.5 percent (urban teaching hospitals) to 37 percent (rural service areas).23

• It takes, on average, 14.9 months to fill an OB-GYN vacancy.23

• The average interview cost per vacancy is $31,000.24

• Combining the cost of having a vacancy with the cost of recruitment can yield a total cost of nearly $1.5 million.

• Physicians’ perceptions of quality of care and remote access to electronic health records are important determinants of physician professional satisfaction.25

AirStrip ONE provides clinical workflow support along the obstetrics continuum of care. This improves the clinician experience of care, and enables greater cost control and revenue potential for hospitals.

SUMMARY Like the connectivity afforded by the rail and subway systems of London, AirStrip ONE fulfills the need for mobile, interoperable, automated and actionable analytics in healthcare. It puts this data into the hands of the clinicians who need it, when they need it, and with the necessary patient context.

AirStrip ONE can be used to address the systemic causes of preventable medical injury, primarily by expediting and adding clarity and breadth to communication among the

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care team. It has also improved the physician experience of care.

During pregnancy, AirStrip ONE can be used to connect the care team to patient status along the antenatal continuum of care. In labor and delivery, it is intended to enhance the collaborative and multidisciplinary assessments of patient data at critical junctures. It can be used to connect new mothers to care providers after discharge by bringing even the most geographically dispersed care team together almost instantaneously.

In addition, the ability to leverage streaming, live digital data for clinical decision support along the obstetrics care continuum represents a revolutionary opportunity for transforming the ways maternity care has traditionally been delivered.

© 2015. AirStrip Technologies. All rights reserved.

Trademarks not belonging to AirStrip Technologies are the property of their respective companies. iPhone and iPad are registered trademarks of Apple Inc.

AUTHORS: Nancy Hudecek R.N., B.S.N., M.S. Martin D. Kennedy, Ph.D. Tom H. Karson, M.D. Eric Venn-Watson M.D., M.B.A. Matt Patterson, M.D. Chris Lato

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REFERENCES 1 Martin JA, Hamilton BE, Osterman JK, et al. Births: Final data for

2012. National vital statistics reports; vol 62 no 9. Hyattsville, MD: National Center for Health Statistics. 2013.

2 Maternal-Fetal Medicine. High-Risk Pregnancy Care, Research, and Education for Over 35 Years. Society for Maternal-Fetal Medicine and Society for Maternal-Fetal Medicine Foundation. Retrieved October 15, 2014 from https://old.smfm.org/attachedfiles/smfmmonograph3.1.pdf

3 Groff, H. Understanding CRICO's Perinatal Claims. FORUM. March 2001. Volume 21. No. 1. Pp. 1-3.

4 JCAHO. Preventing infant death and injury during delivery. Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Sentinel Event Alert, Issue 30, July 21, 2004.

5 Gardner, R. Obstetrics-related Claims. FORUM. February 2006. Volume 24. No. 1. Pp. 10-11; 18

6 Lavalley, D., Hoffman, J. Obstetrics-related Claims 1997-2007. FORUM. September 2007. Volume 25. No. 3. Pp. 2-5.

7 Martin JA, Hamilton BE, Sutton PD, et al. Births: final data for 2002. Natl Vital Stat Rep.2003;52(10):1-113.

8 Simpson KR, James DC, Knox GE. 2006. Nurse-physician communication during labor and birth: implications for patient safety. J Obset Gynol Neonatal Nurs. 2006;35:547-556.

9 Simpson KR, Knox GE. Common areas of litigation related to care during labor and birth: Recommendations to promote patient safety and decrease risk exposure. J Perinat Neonat Nurs. 2003;17:110-125.

10 Clark, S., Belfort, M., Dildy, G., Myers, J. 2008. Reducing Obstetric Litigation Through Alterations in Practice Patterns. American Journal of Obstetrics and Gynecology Vol. 112, No. 6, December 2008. pp 1279-83.

11 Simpson KR, James DC, Knox GE. 2006. Nurse-physician communication during labor and birth: implications for patient safety. J Obset Gynol Neonatal Nurs. 2006;35:547-556.

12 Robinson, B., Nelson, L. A Review of the Proceedings from the 2008 NICHD Workshop on Standardized Nomenclature for Cardiotocography. Update on Definitions, Interpretative Systems With Management Strategies, and Research Priorities in Relation to Intrapartum Electronic Fetal Monitoring. Rev Obstet Gynecol. 2008;1(4):186-192. 2008 MedReviews®, LLC.

13 Macones GA, Hankins GD, Spong CY, et al. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring: update on definitions, interpretation, and research guidelines. Obstet Gynecol. 2008;112:661-666.

14 American College of Obstetricians and Gynecologists. Standards for Obstetric Services. Sixth Ed. The College, Washington, DC; 1988

15 American Academy of Pediatrics and American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. Second ed. The College, Washington, DC; 1988

16 Ransom, S., Studdert, D., Dombrowski, M., Mello, M., Brennan, T. Reduced Medicolegal Risk by Compliance With Obstetric Clinical Pathways: A Case–Control Study American Journal of Obstetrics and Gynecology VOL. 101, NO. 4, APRIL 2003.

17 Coletta J, Murphy E, Rubeo Z, et academia. Am J Obstet Gynecol

2012;206:226.e1-5.

18 Parer JT, Hamilton EF. Comparison of 5 experts and computer analysis in rule-based fetal heart rate interpretation. Am J Obstet Gynecol 2010;203:451.e1-7.

19 Clark SL, Meyers JA, Frye DK, et al. Recognition and response to electronic fetal heart rate patterns: impact on newborn outcomes and primary cesarean delivery rate in women undergoing induction of labor. Am J Obstet Gynecol 2014; Nov 22. pii: S0002-9378(14)02249-2. doi: 10.1016/j.ajog.2014.11.019. [Epub ahead of print]

20 Roberto Tapia-Conyer, Shelley Lyford, Rodrigo Saucedo, et al., “Improving Perinatal Care in the Rural Regions Worldwide by Wireless Enabled Antepartum Fetal Monitoring: A Demonstration Project,” International Journal of Telemedicine and Applications, vol. 2015, Article ID 794180, 10 pages, 2015. doi:10.1155/2015/794180

21 Merritt Hawkins. 2013 Physician Inpatient/ Outpatient Revenue Survey. Last accessed online April 1, 2015 at http://www.merritthawkins.com/uploadedFiles/MerrittHawkings/Clients/mha2013revsurveyPreview.pdf

22 Cejka Search and American Medical Group Association (AMGA). 2013 Physician Retention Survey. American Medical Group Association. Alexandria, VA

23 Howell, J., Sum, A. September 2009. Massachusetts Medical Society Physician Workforce Study. Waltham, MA.

24 Cejka Search and American Medical Group Association (AMGA). 2011 Physician Retention Survey. American Medical Group Association. Alexandria, VA

25 Freidberg, M., et al, Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy, RAND Corporation, Oct, 2013

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