May 22, 2020: On today’s episode, we discuss healthcare communications with Dr. Ben Kanter, a pulmonologist by training and CMIO for Vocera communications. As Ben mentions in our conversation, healthcare practitioners are working in a time when it’s dangerous to even pick up a hospital phone. While patients, nurses, and doctors need to minimize their exposure to infection, communication has never been so important. How can doctors communicate with their patients and with each other while avoiding contact and wearing PPE? Ben answers questions like this while addressing other communication challenges faced in the healthcare industry. He also details some of the innovative communication solutions that are being implemented in hospitals. But, as Ben reveals, increasing the means in which healthcare workers can communicate often leads to an interruption in healthcare services. Ben discusses how integrated and monitored communication systems and policies are as important as new hand-free methods of communicating. Finally, Ben shares his communications best-practices along with his predictions about the future of healthcare communications. Don’t miss this episode — after this pandemic, healthcare communication will never be the same again!
Key Points From This Episode:
COVID Series: Communication with Dr. Ben Kanter CMIO of Vocera
Episode 253: Transcript – May 22, 2020
This transcription is provided by artificial intelligence. We believe in technology but understand that even the smartest robots can sometimes get speech recognition wrong.
[0:00:04.5] BR: Welcome to This Week in Health IT where we amplify great thinking to propel healthcare forward. My name is Bill Russell, healthcare CIO, coach, and creator of This Week in Health IT, a set of podcasts, videos, and collaboration events dedicated to developing the next generation of health leaders.
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[0:01:14.1] BR: All right, this morning we’re joined by Dr. Ben Kanter, a pulmonologist by training and CMIO for Vocera communications. Good morning Ben and welcome to the show.
[0:01:23.9] BK: Morning Bill, thanks for having me.
[0:01:25.7] BR: We have that delay going, we’re getting used to this world of Zoom that we’re all living in. I’m looking forward to this conversation — communication is extremely important, normally, within a hospital, within the health community but during a pandemic, that is really magnified. So let’s go ahead and dive right in. How have systems been utilizing technologies for communication?
[0:01:49.7] BK: Yeah, you’re absolutely right Bill, they need to keep their staff safe, they need to keep the patient safe, as really accentuated the complications of communicating, particularly if you’re wearing PPE. That was and has been an ongoing challenge and it’s not unique if you think about healthcare. First responders, let’s say firemen, they need to be able to communicate with the rest of their team. Folks that are on a battlefield, soldiers, they need to be able to communicate and you certainly wouldn’t expect your soldiers to have to stop what they’re doing and take off their protective equipment in order to communicate. The same thing holds for our first-line folks in healthcare, the physicians and nurses who are taking care of patients really shouldn’t have to dock their PPE if they’re going to have communication.
[0:02:45.5] BR: Yeah, so what have the solutions looked like? I saw in one of your blog articles – Caregivers Shouldn’t Risk Contamination for Communication. How do we get around that? How do we give them the opportunity to communicate with patients and with each other without taking that protective equipment on and off?
[0:03:06.0] BK: Yeah, let me just highlight the difficulty of taking off your PPE correctly — it’s hard to do. It takes time. You have to be really vigilant and physicians and nurses, in the last big study that I looked at, showed that roughly 40% make errors when removing their PPE. That significantly increases the risk of self-contamination. If you self-contaminate, not only are you at obvious risk, but you become this unwitting vector for ongoing infection within your organization.
The key then is to minimize first of all, the need to put on your PPE in the first place. How can you enable two way communication with a patient, even if they’re not in a traditional patient bed, right? In this pandemic, we’ve got patients that are in ‘pop-up beds,’ if you will, temporary beds that may not have a standard nurse on call.
How do you enable two-way communications so that the nurse or the physician can talk with the patient without having to put on PPE in the first place to get into that room? Secondly, if I’m in the room, what I really want to be able to do is communicate in some manner externally without having to take off my PPE and so for that, with Vocera, we have our traditional badge that I’m wearing and we have our smart badge which is right next to it. These can be worn underneath PPE, and underneath PPE, they still give you the full access to all the communication channels so whether you’re calling one person, calling a group, calling your command center, need to reach the COVID intubation team, you can do all of that from one of these devices underneath the PPE.
[0:04:56.1] BR: That’s interesting. Has — I mean, obviously, the risk for contamination being what it is — but my question is, has the communication changed fundamentally as a result of the pandemic? Or is it just changed the way we’re doing it because of the need for PPE throughout the entire system?
[0:05:19.7] BK: I think it’s more of the latter, it’s really changed the manner in which we can do it safely. Before the pandemic, leaving a room and picking up a phone would not be thought of as a dangerous thing to do. But it’s dangerous now. It’s dangerous. Minimizing the need to use multi-use devices where people are sharing devices is important. I think it’s more of the latter.
[0:05:44.9] BR: You know —
[0:05:45.4] BK: Communication in this setting is as important as ever because you’ve got to deal, not just with the patient and the care team, but how do you move the patient efficiently through your hospital, how do you handle the surges and you can’t manage a surge. You can’t manage throughout without communication.
[0:06:05.4] BR: Yeah, normally, when we’re doing this kind of thing and we’re rethinking this, we spend a lot of time on policies and procedures leading up to this. Now, obviously, we did an awful lot of work in a very short period of time and I’ve heard some really creative, almost MacGyver-like solutions that people pull together to do some amazing things. Will we now go back and update our policies and procedures and are we going to see that happen — and do you think coming out of this that people will rethink their communication platforms?
[0:06:38.9] BK: I do. You’re right, there’s nobody more creative than the frontline nurse who is stifled from doing his or her job. They will figure out a way to get something done. Whether it’s through the use of things like baby monitors or other off-the-shelf solutions. If you think about PPE — gloves, masks, face shields, technologies have been around a long time but gloves started out as sheep intestine. We don’t use ship intestines anymore, right? The masks that we use are not just simple cloth, they’re polyester N95s. Technology has evolved and I think that we’re going to see communications technologies and hands-free technologies become really an integral part of PPE moving forward. That’s one major shift.
[0:07:35.6] BR: Do you think there will be a lot of policy work that has to be done in how we think about it? What I hear you saying also is that hands-free communication will probably become the norm. There’s no reason for it not to be the norm through the entire health system?
[0:08:03.2] BK: Right. I do believe that things have started moving that way. There’s a time and a place to have access to your hands, where you have access to a smartphone, there’s a time and a place where you need to be hands-free, whether that’s in an isolation room under PPE or it’s in the O.R, or you’re doing a procedure. Hands-free and using the voice interface is the way that we become used to in our commercial devices over the past couple of years is really the future. Voice driven actions are going to be key.
As far as policies and procedures, it’s an interesting question because over the — as smartphones have come into use in hospitals, there are now more and more ways to reach people. Whether it’s by text, voice, SMS, video, et cetera. Each of these modes of communication brings with it advantages and disadvantages. For example, if I’m trying to communicate with you and it’s a large volume of very highly contextual information, it’s probably best that we have that discussion like we’re doing today. Some kind of synchronous communication. If it’s a small short message that’s not very intricate, perhaps a text message is appropriate.
Some of these messages, modalities are more interruptive than others. It’s actually made the communication environment more complicated, not simpler. In the old days, I either walked up to you or I called you. You do need policies today, you need policies that guide what are the appropriate uses of certain technologies and inappropriate — I’ll also give you one other important example. In health systems, there’s a policy that defines the electronic health record as your gold standard place for all patient documentation. There’s probably 150 different options for secure texting. I mean, I could literally build a secure text solution if that’s all I want to do, build an isolated secure texting solution, I can build that in my garage in days, literally, I’ve done that. You need to have a top down solution that says look, for enterprise communication and collaboration. Here is the system that we will all be on because, if you have your doctors on one system, your nurses on another, your administration on another, respiratory care on another, they’re not truly communicating and they can’t collaborate. Policies regarding communication in general are going to be very important.
[0:10:29.8] BR: You know, it’s interesting. I’m asking the question and you’ve been great in not doing a sales pitch. But I’m going to ask the question because it’s been a while for me, it’s been about four years since I was CIO. We had Vocera in a couple of locations and you almost just described what we had. So we had 16 hospitals, I think, three of the hospitals were using Vocera but each individual nursing community or care community does decide what communication platform they were going to use and it did, from an IT perspective, create all sorts of challenges. From our perspective, it also created challenges — from their perspective, they were constantly coming back to me saying, “Hey can we integrate with this, can we do this, can we do that?” So give me an update on Vocera. I assume you are talking more like a platform for communication across the entire hospital today as opposed to a point solution which is what I was dealing with, maybe four or five years, you know?
[0:11:29.6] BK: That is exactly right. We have become a full fledged platform. We are the communication collaboration hub for the organization. So if I were to describe our system, at our central, the centerpiece of the Vocera offering, our secret sauce if you will, is our ability to first of all integrate with up to roughly 150 different hospital systems, aggregate that information in our system and we can bring this print data from different systems together. Write rules around this so we can take information from example, from the ADT system, from your alarm system, from your tally system, from your lab, from RAD, from whatever — bring all of those pieces of information together, write rules around it and then act so we could then escalate those messages. And we don’t care what the end-point is, whether it is our device or whether it is a smartphone using Android or IOS or a tablet or a desktop.
We then can message that out if it is not accepted, we can escalate those messages to one or more people, essentially an unlimited ability to do that with tremendous flexibility and then all of the audit and reporting is on that same platform. So we become a hub for all of the voice, all of the text, all of the alarms, the alerts, all of that close to our system and then since we are agnostic as to the end-user device, we don’t care whether the nurse or physician are using a BYOD, whether they are using a badge, or whether they are switching between the devices. It doesn’t make any difference. From there, in our directory, we not only can show who is acting now, we have all the present information and so you can tell at a glance for example, if I am a physician, I can look up a patient on my app and I can see in real-time who are the nurses who are caring for this patient right now — who is available and immediately reach them. It is very simple things like that that gives a lot of power to the end-user.
[0:13:39.0] BR: You know one of the things that we have been talking about and we’ve had some CFO’s on, talking about the financial challenges that health systems are going to be facing, at least for the foreseeable in the next year or two years coming out of this. So we talked a lot about platforms in IT and I think one of the things about it is the ability to automate, right? So we take a bunch of touch points out of things. That is one of the things a platform should do. And they also put the security layer around the whole thing so I don’t have to think through security on this one, security on this one, security on passing information. Talk a little bit about the automation that is available under your platform?
[0:14:20.8] BK: So I want to go back to something you just said a second ago and that is, with a platform like ours, one of the goals of communications inside healthcare is to try to minimize delays or drops in communications, right? Communication and efficiency is a problem for the hospitals and it is a major cause of sentinel events. Virtually, every system you place in a hospital today has an ability to send alerts and alarms directly to someone. So, with the best of intentions, a lot of those alarms now route directly to the nurse carrying a smartphone and I just call it a perfect storm of good intentions. You now have all of these various systems that can ping the poor nurse and so the nurse ends up spending his or her shift handling issues that are coming to her directly on the phone. When in the past that didn’t used to happen. Many of those calls went for example to the clerk on the floor who would then do the triaging and route those.
So nurses were getting interrupted a lot before we ever put a phone in their hands. So you have to be really, really careful about how you automate these processes — and there is, I think, a really good intent to minimize the delays and communication and route things to the staff but there is a limited amount of bandwidth that people have. And they’ve got to be able to have time to do patient care without getting interrupted. So everybody is familiar with alarm fatigue. We really talk about interruption fatigue. How do we orchestrate? How do we mediate the need to reach that same person with different information? And it is getting more complicated over time. It is not getting easier. So just putting a smart phone in the hands of your staff does not make things better for them. It can paradoxically make things actually more difficult. It is how you orchestrate those calls on the backend. That is really key and that is what we do. We are a workflow orchestration platform.
[0:16:22.3] BR: So my last question coming out of this is, are there best practices around doing that to avoid alert fatigue or, I don’t know, transition fatigue between priorities and those kinds of things so people are constantly changing their focus?
[0:16:38.1] BK: Yeah, I think there are. So, for example, and if you are going to automate an alarm that is going directly to your staff, I think it is incumbent on the IT department to set up those alarms ahead of time and then monitor them. Sort of mirror them before bringing them live. How many alarms, how many interruptions per nurse you know and you can set up metrics for example, alarms per patient per shift. How many are coming in and monitor that before you ever turn it on.
There is nothing worse than saying, “Okay we are going to set”, for example, let us say we decide that we are putting in a tele system and I want to pass all of my H defibrillation alarms directly to the staff. We know that the false positive for telemetry alarms is in the 90s. The vast majority of telemetry alarms are not actionable. You will absolutely destroy your nurses with interruptions if you do that or the same thing with oximetry alarms — basic unedited oximetry alarms. Just passing them all to the nursing staff is a road to disaster. So you need to turn on these systems ahead of time, monitor them. So that is one important part. The second best practice is to have a clinician be the mediator between, for example, your nursing staff and the IT department. You want to trust in a nurse leader, a nurse informaticist ideally, who is that go-between who can work with the nursing staff to adjust the alarm threshold parameters. The enunciation delays and other things so that again, by the time the nurse gets an alarm or a message, it is highly likely to be true. The passive predictive values can be high. I think a third is to integrate your communications platform, particularly if you are going to be passing alarms and interruptions with your alarm management committee. It is a great role to have your multi-disciplinary alarm management committee take ownership of a lot of these policies and practices.
[0:18:41.9] BR: I want to close with one last question and this is mostly that you are a pulmonologist by training and what do you think just personally, what do you think the most lasting impact of the work that we have done in healthcare will be coming out of this crisis?
[0:18:59.9] BK: So, my analogy is if you’re alive long enough to remember, when the guy was poisoning the Tylenol bottles, before that you could open up any jar of food and you had immediate access to the food. None of these safety layers were there or you might have to peel off that paper after you unscrew the lid. That has become the norm. What today is the exception becomes tomorrow’s norm. So the way we are using PPE, this requirement for communication, that is going to change.
I think we are going to accelerate. Obviously we have already accelerated our move to Telemedicine. You probably did five years of telemedicine evolution in five weeks. It will never go back. Telemedicine is here to stay and here to stay in a much wider swathe of medical practice than ever it would have been envisioned. So that’s not going to change. I think the recognition of the dangers that our staff go through when caring with patients with infectious disease is something that is like normalization of deviance. We all recognized that it was there when I worked in a highly resistant, multi-resistant TB clinic. There is no treatment for the disease as we were treating. If we had been contaminated, it would have been really life-threatening. We just accepted that. I think there is now a better recognition that we need to protect our healthcare workers to the utmost. I don’t think that is going away.
[0:20:43.0] BR: You know I remember that Tylenol scare and that was really scary and they responded very quickly to that.
[0:20:50.9] BK: Bill I lost your audio.
[0:20:52.7] BR: Oh you did? Sorry about that. I could still hear you great. I really appreciate the analogy around the Tylenol. The exception from yesterday will be the norm moving forward. I think that is what we are going to see. You know that’s all for this week. I really appreciate the time, Dr. Kanter. Thanks for coming on and talking about communication during a pandemic.
[0:21:15.2] BK: My pleasure Bill, I appreciate it. I am to do this again in the future, thank you.
[0:21:20.7] BR: That is all for this week. Special thanks to our sponsors, VMware, StarBridge Advisors, Galen Healthcare, Health Lyrics, Sirius Healthcare and Pro Talent Advisors for choosing to invest in developing the next generation of health leaders. If you want to support the fastest growing podcast in the health IT space, the best way to do that is to share it with a peer. Send them an email, let them know that you value and you’re getting value out of the show and also, don’t forget to subscribe to our YouTube channel while you’re at it.
Please check back often as we continue to drop shows until we get through this pandemic together. Thanks for listening. That is all for now.