Nurses are at the frontline of healthcare, often being the first point of contact to provide patients with the care required and like any other role in the healthcare profession, they are often time-crunched and have a myriad of tasks to accomplish on the ground. Technologies such as analytics and monitoring tools can help nurses improve their work and decision making processes, but these must be seamlessly integrated into their existing workflows and most importantly, not cause additional burden or take more time to execute.

Experienced professionals in the area of nursing informatics from Singapore recently shared their lessons learnt at the Hillrom Dialogue Series. In addition, an IT staff who works in the long-term care setting of a nursing home presented some of the unique technical challenges of integrating medical devices into the EMR. 

Improving clinical decision making and enhancing workflows

“Through the use of machine automation/analytics by scoring the vital signs and the basic physiology parameters, it removes subjectivity from the patient assessment and give healthcare professionals, especially new nurses, the confidence in seeking advice on how best to manage the changes in a patient’s condition,” said Mr Khoo Kian Boon, Informatics Nurse Clinician, Sengkang General Hospital. 

Mr Khoo was explaining some of the key differences between manual and machine analytics in the collection of patients’ vitals data, and the advantages the latter provides. With machine analytics, escalation protocols and care interventions are also built-in, hence reducing ambiguity in the decision-making process by nurses or doctors. Finally, compliance rates improve significantly with machine automation when compared to manual processes, as it minimises disruption to the nursing workflow. 

Working in one of the newest public hospitals in Singapore, Mr Khoo gave the example of how his organisation adopted and modified the National Early Warning Score (NEWS) to suit the local needs of predicting in-hospital mortality. NEWS is a rescue strategy to aid early identification of patients who are deteriorating clinically and intervene promptly to prevent further deterioration. This is done through a score system to assist with prompt recognition and rapid response.

At Sengkang General Hospital, the NEWS is integrated into Welch Allyn medical devices so there are no additional devices introduced to the nurses and they do not have perform additional documentation or extra tasks to get the required information. The devices also interface with the EMR system and the NEWS aggregate information so the nurses and doctors can intervene or react according to set protocols. 

“Clinical judgment is still paramount for assessing the condition of a patient – the NEWS serves as a guide to inform the nurse about the next step of intervention that is required,” concluded Mr Khoo.

Seeing her role as the bridge between the clinical and IT sides, Ms Jennifer Soo from the Nursing Informatics Department of KK’s Women’s & Children’s Hospital (KKH) shared on how the integration of clinical guidelines with medical devices helped with improving clinical decision and intervention. Prior to 2016, KKH, like majority of hospitals at that time, clinical charting was done manually on pen and paper by nurses on the ground. In 2016, the medical device integration (MDI) process was launched so that the patients’ vital signs and other clinical/medical parameters can interface with the hospital EMR system. 

Subsequently in 2017, KKH’s early warning system, also known as KKH Early Warning Score (KEWS) was adopted. Previously, the nurses would record the patients’ vital signs and other clinical parameters and based on their individual clinical judgment and experience, they would then decide whether to update the clinicians at various intervals. The process is similar for doctors who would decide what diagnostic orders to prescribe and if any medications are necessary based on their specialty and experience. 

KKH’s combination of MDI and KEWS was a method to reduce ambiguity and subjectivity in intervention and treatment pathways for patients, as well as reduce manual transcription errors and time taken in the manual entry of patients’ vitals. At KKH, all in-patient BP machines and EMR had been integrated with the KEWS system. The system calculates the KEWS score based on patients’ vital signs and will prompt for actions if the score is out of the normal range. 

Lessons from a long-term care environment setting

In Singapore, acute care settings in public hospitals operated by the Ministry of Health Holdings are equipped with comprehensive EMR systems, advanced software modules and generally have a high level adoption of technologies such as automated systems and robotics. By contrast, long-term care settings, for instance, nursing homes are operated by voluntary welfare organisations (VWOs) with basic EMR systems (e.g. NHELP, INGOT), basic software applications and adoption of technologies are comparatively lower.

Mr Tan Kok Hua, who is Deputy Director at Kwong Wai Shiu Hospital, a 600-bed nursing home facility in Singapore, shared a case study of a consortium of six nursing homes run by VWOs and their collective objective of enhancing patient safety and reducing workloads of nurses through a streamlined process of patients’ vital signs data collection with transmission of data to the EMR. Previously, it would take nurses at least two minutes (per patient) to manually take their vital signs and then manually enter the information into the EMR. 

“Harmonisation – having six nursing homes coming together to agree on the process is very important. If it is a single process, it means a single collective effort to establish a single set of configurations. This also means a single set of test scripts, a single set of training material and resources/costs can be shared,” Mr Tan elaborated. 

The case study also presented some key challenges – notably the varying levels of IT maturity levels across each of the six nursing homes, the financial constraints of enhancing patient safety vs maintaining reasonable operating costs and a lean workforce which has to deal with daily operations yet set aside time for running projects. 

Mr Tan also emphasised that the commitment and participation of users, in this case, nurses, as one of the key success factors: “Nurses are the key drivers, not IT. This is very important and we often neglect this point. It is thus very important to get the right user champion and IT’s role is to help shoulder the technical aspects of the project implementation.” 

Security concerns

Addressing a security-related question on the lack of an internet separation policy* in nursing homes, Mr Tan replied that it is done differently in their case. For instance, if the staff does not need to use the clinical system, there is no way they can even assess the cloud network. When it comes to cloud for clinical staff, they are not allowed Internet access but they get ‘whitelisted’ to use the cloud. For smaller nursing homes, it makes more economic sense to leverage on cloud storage because they cannot afford the high overall costs of on-premises solutions. Necessary due diligence is carried out to ensure proper Internet segregation practices in the context of a nursing home.

Cybersecurity – medical device security is top of mind

Mr Poruri Ramakrishna, Product Manager, Asia Pacific, Patient Monitoring & Diagnostic Cardiology, Hillrom, explained that one of the top cybersecurity concerns amongst both manufacturers and healthcare providers is medical device security. Poor medical device security could lead to potential unauthorised access to personal health information (PHI) and in 2015, a hospital in the US was fined $850,000 for Health Insurance Portability and Accountability Act (HIPAA) violations relating to failure to protect PHI on a medical device.

In terms of network security for healthcare providers, the two points of impact are (medical) device security and data security. The key challenges in maintaining device security are authentication, unauthorised use of devices, advanced network settings and patient validation. Hillrom addresses these challenges in their devices through bi-directional authentication, an Active Directory which is based on the hospital’s IP infrastructure, password-protected advanced devices settings and patient identification via ADT. 

The key challenges in maintaining data security are the types and layers of encryption available, and possible malicious intrusion in the form of malware, ransomware, phishing, DoS attacks, etc. Hillrom’s Welsh-Allyn medical devices have built-in server authentication and multi-layered encryption such as AES 128-bit encryption over network to Welch Allyn Connex CS software (CSM) and WPA2 Enterprise wireless encryption. They are also FIPS 140-2 certified and utilise the Risk Management Framework (RMF), a United States federal government policy (Department of Defense) and standards to help secure information systems from cyberattacks.

“You need to constantly educate yourself on cybersecurity so you can know where the threats are coming from. As device manufacturers, Hillrom and Welsh-Allyn spend large amounts of money to improve their cybersecurity. Mostly importantly, we need regular feedback from our customers,” concluded Mr Ramakrishna.

*Public healthcare organisations in Singapore have an internet separation policy in place after the SingHealth cyberattack in 2018.