UCSF Medical Center is part of the University of California, San Francisco, one of the 10 campuses of the University of California. The 560-bed facility has the only nationally designated Comprehensive Cancer Center and the only Center of Excellence in Women’s Health in Northern California. In April of 2007, USCF Perioperative Services launched the Retained Item Initiative as part of an ongoing effort to reduce the number of foreign bodies left in patients; since implementing a cutting-edge bar coded sponge management system, no incidents have been reported. Recently, HCI Associate Editor Kate Huvane Gamble had an opportunity to speak with CMIO Michael Blum, M.D., about this initiative, as well as future plans for UCSF.
KG: UCSF Medical Center is one of only a handful of healthcare organizations in the country that has implemented bar coded sponge management in order to prevent foreign bodies being left in patients. Is this issue a big priority at UCSF?
MB: We’ve been working on the concept for years to try to reduce anything left behind. I think it’s unacceptable to unintentionally leave anything behind. That’s been the philosophy over the last two years. We’ve put more focus and attention on it, and we’ve really started looking at technologies we could bring to bear. Obviously there’s more attention focused on it now as it’s a ‘never event’ for CMS. So it’s been one just of the elements of our overall patient safety and reduction campaigns for several years.
In addition to the bar coding aspect for sponges, there’s also the RFID approach that’s evolving that we looked as well but it wasn’t quite as far along, and we needed to implement some technology in this space. So we ended up going with the bar coding approach as a first pass at it.
KG: What method was being utilized before the sponge tracking system was put in? Was it a manual process involving white boards?
MB: Yes, that’s what we were doing.
KG: So you decided to see if bar-coding could help improve accuracy?
MB: Our general philosophy is that you need to use the technology where it replaces activities that human beings can’t do particularly well, as counting is one of the things that machines can do much better than people do. Computers can count much better and much more reliably; tracking things better and more reliably. So taking tasks that need to be automated and repeated and don’t have cognitive function as part of them, but just have counting or automation — we try to move as much as possible to technology in those spaces to really minimize the risk. You can’t expect people to do things at 100 percent, no matter how many times they do it. No matter how well-trained they are, no matter how much they focus on it, human beings just don’t operate that way. So in those spaces, we either back them up with technology or we replace the task with technology.
This was a pretty obvious opportunity to deploy that as we can. Now having said that, you still have to make sure that the workflow you develop around it makes it so that the technology is appropriately utilized. For instance, the benefit of this technology is that it counts really well and it recognizes things really well, but it doesn’t do a lot of other pieces, and so people can find workarounds, which can foil the technology if you’re not careful with how you implement it. If you implement it so that it takes a lot of extra time or it’s a barrier to clinical care, people will figure out ways to defeat it. So just as important as choosing the technology, the choosing the vendor and choosing which piece you like best is making sure that it meets the workflow needs so that fits and integrates well. Either you redo the workflow, or it fits into the existing workflow, one or the other.
KG: Who was the driver in this project, and what was your role?
MB: This was driven by perioperative. The perioperative space is somewhat self-contained; there’s a separate medical director. In this particular patient safety example, they really ran and were responsible for most of the clinical buy-in and cultural change. But on a general level in a hospital or medical center, that would be one of my responsibilities; in addition to evaluating the technology and evaluating the appropriateness of it, it would be my responsibility to evaluate it in the context of the clinical environment and the workflow. And then once we decided we thought it would work and we thought we could benefit from it, and once we started gearing up and doing the project management and developed a project around it and as we started doing the implementation, my responsibility would be to bring it to the clinicians and explain to them the rationale for doing it, what’s going to change, what the benefits are going to be, how it’s going to impact their lives, what’s in it for them, what’s in it for the patients, all of that, and getting people on board to make the changes that are going to necessarily.
Usually this is squarely on my plate, but in this case we had other people who carried it.
KG: Is the bar-coding system isolated to the perioperative department or are there interfaces in place — or at least plans to interface with supply chain or other departments?
MB: I’m not sure if there’s any intention to interface the sponge tracking to inventory systems.
I think that as we start looking at these tracking technologies in general, they will absolutely be integrated. This is one small example of tracking technologies, whether we use RFID to track where the patients are in our facility, or where our IV pumps are and so on, or whether we’re talking about bar coding of specimens. We bar code the blood draws and bar code the patient, and then we bar code the vile that the blood goes into to make sure it’s all matched up. Then that gets bar coded and scanned once it gets down into the lab, so that automates the integration into lab. So there’s already of a lot integration of bar coding and eventually RFID in other systems in the organization.
KG: Where is the blood vile bar coding live right now?
MB: It’s on the floors and in the laboratory, and we’re expanding that as we implement our new medical record to really even facilitate workflow and the matching of patients and specimens and easing the burden down in the laboratory. So that will get expanded even further.
KG: What is the new medical record you’re using, and what’s the status?
MB: We’re in the middle of implementing. We use GE Centricity Enterprise EMR and we’ve got most of it in place. Over the next year, we’re rolling out provider order entry, a new pharmacy system and clinical decision support. As part of doing that, we’re going to expand some of the other technologies at the same time. We use CareFusion’s specimen collection and bar code management in that space, and we’ll be rolling that out along with some additional patient tracking functionality.
KG: Where are you with RFID right now? Where is it live?
MB: We have RFID already in place for a lot equipment tracking, and a lot of that in the OR is already in place. We track over 1,000 devices, and that’s getting rolled out into much of the medical center.
KG: Of all the tracking you’re doing, sponge tracking seems like it is definitely the most cutting-edge technology being used.
MB: Foreign body left behind is a very high-profile issue and this is a very discreet application of the technology. But positive identification and tracking issue is a much broader issue that has not only safety implications but also operations implications, cost savings and efficiency in addition to the very high profile and highly important quality implications.
It comes back to the fact that we have to deploy the technology to do things that people don’t do particularly well, or that the top technology can do much more efficiently. These are perfect things for technology.
KG: So it’s fair to say that UCSF doesn’t shy away from cutting-edge technologies?
MB: Right. Gartner has a break-down; there are the early adopters, there are the mainstream people, and there the laggers in technology adoption. And we’re not on the bleeding edge of early adopters; we definitely wait to make sure others have validated that this stuff really works. But we’re pretty early; we’ve got an evolving history of being early adopters. We did the joint development with Motion Computing and Intel around the C5 clinician platform that was first launched here. And we’re the development partner with GE on Centricity EMR and we’re developing their first generation integrated ICU information system. So we pretty aggressively adopt technology, but we still avoid being on the bleeding edge of it.
KG: That seems like a pretty sound approach. But as CMIO, does that tendency to adopt on the early side and partner with vendors make the job more challenging?
MB: It certainly makes my job more interesting. I’m almost schizophrenic about it. One day I’m pushing to adopt a technology that’s pretty early on and not completely proven, and the next day, when someone wants to bring in another technology, I’ll say, ‘it’s too early, it’s not proven enough yet’.
I have a pretty strong technology background and obviously I’m a clinician, so one of my jobs is to assess which of these technologies is really appropriate. And I’m in the position to have one of the better perspectives on, is this really going to bring us benefit for the patient’s perspectives? Or is this something that just seems cool that’s going to kind of be a flash in the pan and then go away. That’s one of the challenges.
KG: We hear a lot about that – with so many technologies coming out all the time, it seems like one of the biggest challenges is deciding which ones have staying power. I imagine that can’t be an easy task, with all the technologies that come across your plate.
MB: Oh yeah, on a daily basis. And some of them get really expensive too. The new rage is convergence in communications. And everyone and their brother has a new antenna system now that they’re trying to tell us is going to make it so that everyone can communicate seamlessly and everything will work. And these things are really expensive; we’re talking multi-million dollar installations, and it’s very disruptive to put them in. Then if it turns out it wasn’t a good choice, you’re really in a bad place.
KG: I think that’s how a lot of people still feel about RFID.
MB: Right, the vendors will approach us and they’ll say, ‘we’ll be able to track anything — we’ll be able to track a gnat down to one-meter resolution. And then when they get there, they can’t even tell you which room they’re in. And then some of the companies get gobbled up, or they go out of business. So it’s important to really be careful with these investments.