Tomorrow's operating room to harness Net, RFID

SAN FRANCISCO--It's hard to do most jobs without talking to your peers, but in the operating room, poor communication can cost a life.

In the operating room of the future, however, telling a doctor he or she is making a mistake could be as easy as pointing to a computer screen or "wall of knowledge"--a thoroughgoing summary of background data, vital signs and strategic information designed to prevent mistakes during surgery.

To best understand this so-called operating room of the future, which experts discussed at the "OR of the future" medical conference here on Monday, imagine a football video game. It would show players' backgrounds, injuries, vital statistics, real-time video, milestones and progress logs. It would keep track of the players, the coaches and give the gamers options for play calling.

In surgery, the "wall of knowledge" presents a similar "team huddle," translating the big picture, minute by minute, of the patient and surgical events from various data. That's a big change for nurses, doctors, assistants, surgeons and anesthesiologists who are typically so focused on their specific tasks and specialized computer feeds that they might sometimes miss the patient's overall health.

"We see the acceleration of technology coming into the OR and nurses are having to keep up with the 'data burden,'" said Dr. Warren Sandberg of the center for Integration of Medicine and Innovative Technology at Massachusetts General Hospital in Boston. "We think there's room to convert all that information into knowledge...With this system, anybody can see a snapshot of everything that's happening."

Giving doctors and other medical staff that big picture can be important, because human error and poor communication are the most common reasons one in 25 patients experience avoidable injury under the knife, according to the National Institutes of Health.

Of course, Sandberg has a stake in this particular future. He's part of a pilot "OR of the Future" (ORF) at Massachusetts General that has been using advanced technology for the last three years. He demonstrated ORF technology here at the one-day conference.

The ORF computer system is an integration system with a single, secure Web interface for many different data sources. With technology from LiveData, based in Cambridge, Mass., the ORF takes high-speed data streams from hospital databases and various networks, synchronizes them and then time-stamps them for display onto a Web portal, which can be transmitted on an Internet-connected PC in the room.

Vital stats displayed
The digital display includes the patient's name, weight, age, gender and the procedure he or she is undergoing. It includes a detailed list of medical staff on duty and where they are according to RFID tags they're wearing. It lists critical information such as allergies, precautions and special needs, followed by charts on the patient's heart rate, ventilation, fluids, body temperature and so on. That information is documented before, during and after the surgery.

In most hospitals, that information would be held on clip boards and white boards, and within the computer systems and minds of medical staff. In most cases, it's hard to get all of that in one spot.

"As you sit in the OR you get bits of information from different places. Rarely does the group have the big picture on the individual," said Michael Leonard, the physician leader for patient safety at Kaiser Permanente and former director of anesthesia at Colorado Permanente Medical Group.

One of the most progressive--and controversial--elements of the system involves location tracking technology for medical staff and patients. Doctors and nurses wear radio frequency identification (RFID) tags, similar to key chains, which are synchronized

to the system and track their whereabouts. The OR display will show a complete list of staff expected for a surgery, and when a doctor or nurse enters the room the name will become brightly lit. That way, unfamiliar faces can be met with assurance.

Sandberg said that in the ORF at Massachusetts General, doctors were reluctant to use the RFID tags, but have grown accustomed to the system and find it valuable.

There's been much to overcome to provide this sort of bird's eye view. Individual technology providers such as General Electric, Siemens and Philips have yet to develop industry-wide standards for their medical gear. LiveData stepped in about five years ago and created a unified interface and system for the disparate gear.

Hospitals reluctant
Still, hospitals are reluctant to adopt this technology for numerous reasons.

For one, if the system goes down, a nurse or doctor would need an information technology specialist to help. During surgery, that won't do. The system could also add fuel to the litigiousness of patients, providing detailed, archived data on surgery and doctors' whereabouts when something went wrong. During the workshop, at least one physician also expressed concern about the learning curve of hospital staff as it adapted to the new system and its impact on old-fashioned communication.

"There's a natural tendency to rely on technology, but you have to be mindful of human interaction," Leonard said.

Doctors and LiveData have already learned that people in the OR move around a lot in order to see different computer screens and check vital signs. Having one point that brings all that information together saves time.

Sandberg said that they also plan to create alarm settings so the system can alert medical staff to take necessary actions in the operating room. For example, if a patient is not getting ventilation and his or her heart rate is rising, the system could send a warning.

LiveData's CEO said the company is talking informally with lawyers and the Food and Drug Administration about integrating alarms into the system. Such capability, although extremely helpful, could add liability to the company.

Other ideas for improvements include combining RFID tag capabilities with automatic sign-ons to the computer system. The system recognizes a physician with an RFID tag within 30 seconds, but the doctor still must log on to other data systems when in the room, which can take two minutes or more, according to executives.

Aileen Killen, the director of nursing in perioperative services at the Memorial Sloan-Kettering Cancer Center, showed pictures of her hospital's "wall of knowledge" on Monday to illustrate a design for a safer OR. It consists of four large computer screens with much of the same data from LiveData, with audio and video feeds, and pathology reports. "We wanted everything off the floor," Killen said.

At Massachusetts General, the ORF is a standard clinical care environment, and no data is collected personally for use in the research. The ORF takes up to 20 cases a week, and according to Sandberg, the efficiency of the system lets the staff care for more people in a day but spend the same amount of time with each patient.

"We're not replacing people, we're adding a layer of decision support," Sandberg said. "We're way out there on the cutting edge."