Oh, how times have changed… or have they?

Posted by Michelle Grate, RN MSN CPHIMS on Sep 19, 2014 @ 09:00 AM

chart_ring_binder_cart_rack_carstens_first_healthcareI stumbled upon an interesting statement recently, "The immediate availability of a patient's chart record means greater convenience to the nurse, the attending physician, the intern and the hospital administrator. Not only is there a marked saving in time, but greater accuracy is secured in clinical records when the chart and chart holder are easily accessible." Sounds like many of the conversations we hear today about electronic documentation. But the source of this statement may surprise you: it is from a series of articles in The Modern Hospital, circa October, 19221! Looks like the theme of immediate availability of a patient's record has been around for a long time and for the same reasons.

This has put me in a bit of a nostalgic mood. Recently I was doing some work at a hospital and I glanced fondly at the good ol' chart rack. It has always been an integral piece in our arsenal of nursing tools. Although they may be a little different from one hospital to another – some are square, some are round, some have wheels, and some sit on a desk – they are all basically the same. Even today with all the electronic documentation and EHRs, they can still be seen doing their humble job on the nursing units, albeit a little thinner than they used to be. I have many memories of pulling up the chart rack to my spot at the nursing desk and doing my documentation for the day, hour, shift or whenever I got the chance.

But I digress, so back to the subject of immediate availability. If you have been a reader of our blog posts, you are already aware that we are advocates of immediate availability of patient's vital signs in the electronic record. Our goal is to help make that possible for any med/surg environment.   We can help you collect vitals directly from most spot check monitors and transmit them along with additional documentation to the electronic record in near real time. This isn't future availability, it is available now. And apparently it still helps with the age old theme of "immediate availability of a patient's chart record".

Does your facility still have chart racks?
What is in them?
Do you think they will ever go completely away?

 

[1] The Modern Hospital (Vol. XIX, p. Adv. 105). (1922). Chicago: The Modern Hospital Publishing.

 

Image credits: Franklin Mills Co.

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Tags: Nurses, Clinical Documentation, ThrowBack

The Documentation Paradox in Med-Surg

Posted by Susan Niemeier, RN BSN MHA on Sep 17, 2014 @ 11:44 AM

The med-surg unit is an operationally intense care environment with typically two out of three hospitalized patients residing in this area. The acuity of patients in this setting is escalating, along with rising co-morbidities and patient age. In parallel, the hospital's patient population is shifting more toward outpatient care, increasing the number of short-stay patients. Short-stay patients are those who stay in the hospital for approximately 23 hours or less and are then discharged to go home. Often, these patients are placed in med-surg units and require a heightened level of observation to assess for subtle changes in their condition. As acuity increases, so do the number of devices at the bedside, along with the requirements for entering data into a patient's record.

Despite these conditions the nurse-to-patient ratio in med-surg units has not changed. This results in more work and immeasurable stress. Add to that the regulatory, legal and hospital compliance efforts for higher degrees of documentation, as well as pressure to discharge patients as soon as possible, and you can see that there is a "perfect storm" of increased workflow requirements that could lead to errors putting patients at risk.  

The environment wherein med-surg nurses work has become incredibly complex and demanding. The result is that they must provide increased effort, energy, and attention just to perform their normal, daily activities. Many are close to the breaking point; they simply cannot take on any more work or responsibility without significantly impacting patient care.

One responsibility that steals substantial time from patient care is documentation. The increasing complexity of patients seen in the med-surg unit means that nurses are constantly moving (between one and five miles during a typical 10-hour shift), making decisions on the fly, and multitasking, all of which takes a high toll on performance and work processes.1 Given all this, nurses view documentation as a lower priority item on their list, choosing to document in batch mode when they have a few minutes rather than in the real time.

In fact, studies find that it takes between two to twelve hours after collecting data from patients' monitors before nurses enter it into medical record. The manual entry of data leads to error rates as high as 17%.2 Yet documentation is taking up an increasing amount of nursing time, with studies finding that 35% of a nurse's time is spent on documentation (147 minutes in a 10-hour shift), while less than 20% is spent on patient care and education, and just 7% on assessment and surveillance.3

The focus on quality in today's healthcare environment means the EMR must be fully integrated into clinical care and decision making. Among the benefits when used properly, for instance, are better decisions and better coordinated care. With physician order entry, physicians need an ‘information rich' record with real-time data. Ancillary departments such as respiratory, physical, occupational and speech therapy also require access to an up-to-date medical record so they may immediately know a patient's state. Such information is equally important for pharmacy, infection control and discharge planning.

However, while EMRs can bring numerous benefits to the hospital environment and improve patient care, they are impractical and even dangerous if the data is not accurate, timely, and complete. So, therein lies the paradox: much of the data entered into an EMR is on the shoulders of med-surg nurses. Yet med-surg nurses are forced to place this task towards the bottom of their list because of their patient care priorities.

The current system relies on the nurse to function as a "human bridge" between medical devices and the EMR. The med-surg unit is no exception. Med-surg nurses capture patient data throughout the day from a number of devices, manually writing the data on a clipboard, sticky pads, paper towels or even alcohol wipes. At a later time during the shift, they key the data into each of their patients' electronic record. The danger of this approach is the increased likelihood of errors and potential for omissions. Moreover, valuable time slips by - time during which critical decisions are made based on data that could be hours old. Just as important, all of this activity of capturing data from various bedside devices and manually keying it into a record takes the clinicians away from direct patient care and surveillance, which can affect outcomes. Very simply, under the current system, clinicians doing both clinical documentation and patient assessment simultaneously is ... well ... incompatible, to put it lightly.  

There are solutions to this "human bridge" problem that can remove the nurse as the "middleman". There is increased focus on the automation of clinical documentation, that is:  the electronic transfer of data from a medical device to the EMR, and other clinical systems. The integration of data in med-surg is even more critical as the patient acuity rises along with the number of number of bedside devices to assist in monitoring. Due to the fundamental nature of vital signs, devices that take these measurements are typically among the first to be targeted for automation. Integration, however, is not limited to devices measuring vital signs. Other types of devices that can be integrated in med-surg include (but not limited to) scales, smart beds, infusion pumps, etc. By not having to record and transcribe information into the EMR, a considerable amount of time can be saved. And, automating the collection of data ensures that all desired information is accurately collected. This eliminates the possibility of accidentally omitting essential data during documentation. Recording patient data at a higher frequency allows for catching subtle changes in a patient status much sooner. 

In an environment where information is recorded automatically into the patient's record, there is no need for a physician and the interdisciplinary team to wait on the med-surg nurse to complete rounds and transcribe the data.

In the end, bringing a flexible, documentation automation system into med-surg can help reinvest nursing time to direct patient-care activities, improve nursing productivity and satisfaction, enhance the completeness of the medical record, and ultimately, improve the delivery of safe, high quality care.

My question to you is, why do hospitals choose not to automate device documentation in med-surg when the evidence is clear?

 

References

1) Potter P, Boxerman S, Wolf L, et al. Mapping the nursing process. J Nurs Adm. 2004; 34(2):101-109

2) Wager KA, et al. Comparison of the Quality and Timeliness of Vital Signs Data During a Multi-Phase EHR Implementation Computers in Nursing. CIN: Computers, Informatics, Nursing. 2010; 38(4):205-212

3) Hendrich A, Chow M, Skierczynski B, Zhenqiang L. A 36 hospital time and motion study: How do medical-surgical nurses spend their time? The Permanente Journal. 2008;12(3):25-34

 

Originally posted on ADVANCE Healthcare POV Blog.

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Tags: Medical Device Connectivity, Patient Care, Medical Device Integration, Nurses, Clinical Documentation, Med-Surg, Low Acuity

Time. It’s What Med-Surg Nurses Need Most to Care for Patients

Posted by Cyndi Coyne, RN on Aug 27, 2014 @ 11:01 AM

Join-MDI-in-MedSurg-webinarI read an article a few weeks ago that truly blew me away. It first caught my attention in Becker’s Hospital Review, but I have since seen it appear in other publications, such as the Wall Street Journal. It was about bringing nurses back to the bedside. You may be thinking “Isn’t that where they are already?” But here’s the big surprise. The article was about Novant Health in North Carolina and their initiative to free-up nurses so they can spend more time doing what they do best: taking care of patients.

It all began when hospital leaders wanted to know how much time nurses actually spent in patient rooms during a 12 hour shift. What they found was shocking to me, at first. It was only 2 ½-3 hours! They weren’t alone; other healthcare organizations had similar findings. Still, that really floored me! But then I recalled when I was a bedside nurse and I have to admit, considering the nurse/patient ratios and all the activities involved in caring for the average med-surg patient, 2 ½-3 hours sounds about right. I often commented that although it may have taken me five minutes to complete a task, it took more than twice as long to gather the supplies … sometimes having to call or even go to another department … then round up a co-worker to provide an extra set of hands, and afterwards, of course, document it all. With shorter patient stays, quicker patient turnover, and older, sicker patients, med-surg nurses are really squeezed.

Novant decided to do something about it and set an ambitious goal—70% of nurses’ time (or 8.5 hours of a 12 hour shift) spent in patient rooms. To develop a plan to accomplish this, they gathered a group of 40 nurses from across their healthcare system. Wisely, they engaged their own experienced nurses to brainstorm solutions instead of hiring an outside consulting group to swoop in, do a big study, and then dictate a plan of action. The nurses studied process flow and discovered the top activities that pulled them away from the bedside: hunting for supplies, tracking down medications, filling out paperwork, and looking for test results.

The battle plan they developed involved implementing a care team approach that called for LPNs, CNAs, pharmacy techs, and other support staff, to rally around the RN to ensure all of a patient’s needs would be addressed. This included some adjustments in each person’s role so that each team member functions to the full extent of their training and licensing.

In addition, they relocated supplies either in or closer to patient rooms; brought medications to the point-of-care; and implemented an EMR with physician order entry, along with a computer workstation in each patient room. This was all aimed at reducing the required steps in caring for the patient along with documenting that care. Bringing everything the patient needs to the point of care—what a revolutionary idea!

Integral to this strategy was automating the capture of medical device data, which freed-up the clinician from the manual process of entering data into the patient record; not to mention increasing the accuracy of the data, as well. It’s an essential tool that allows nurses more time to focus on the most important part of their job—the patient.

Research proves the more time nurses spend at the bedside, the fewer patient falls, the fewer medication errors, the higher the patient satisfaction rates, and the lower the infection rates. Furthermore, nursing satisfaction also increases, leading to lower nurse turnover. Med-surg units are the backbone of any hospital. Easing the workload of this vital group can only lead to good things.

Oh, and by the way, Novant reached their goal. Nurses are now spending 72% of their time in patients’ rooms allowing them to not only care for their patients, but also keep patients and their families better informed regarding post-hospital care, ways to improve their health, and the prevention of subsequent hospitalizations. Very impressive Novant! Bravo!

How much time do you think nurses at your hospital are engaged in direct patient care?
What measures have been instituted in your organization to increase nurses’ time at the bedside?

We're Discussing MDI in Med-Surg Today at 2:00pm EDT!

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Tags: Medical Device Connectivity, Medical Device Integration, Nurses, Medical Device Information System, Med-Surg

Med-surg and device integration: Why not?

Posted by Susan Niemeier, RN BSN MHA on Aug 21, 2014 @ 03:11 PM

Webinar

  • Med-surg is a demanding, operationally intense care environment. The majority of a hospital’s patients are located in med-surg and generally, the unit provides most of its revenue. In fact, med-surg is described as the hospital’s “backbone”, and it can be argued that it is the most important department in an acute care facility.

  • Med-surg nursing units have the highest nursing turnover rate (>24%) compared to other nursing departments. Without intervention, med-surg will turn over their nursing staff every four years. The cost of turnover is two times the annual salary for this position, averaging around $100,000 per nurse. This has a profound impact on hospitals’ margins.

  • Med-surg units drive patient satisfaction opinions. Nurses cite work pressure and loss of control as the most common predictor of organizational work dissatisfaction. Med-surg nursing units are the last area in which patient’s reside and often the area that has the greatest impact on their perception of care. Consider the impact on measuring patient satisfaction through HCAHPS, which enables comparisons to be made across hospitals.

 

So, why talk med-surg and device integration? The frontline clinicians who work on the med-surg unit represent an essential and costly resource. Maximizing their effectiveness and efficiency is critical to hospital operations and the promotion of safe patient care, which is precisely what medical device integration is designed to do. I hope the data points above express the importance of supporting med-surg clinicians with the tools they need to do their job.

 

Register To Learn More

Expanding Medical Device Integration to Med-Surg 

Wednesday August 27, 2014, @ 2pm - 3pm ET 

Susan Niemeier MHA, RN, Chief Nursing Officer at Capsule

Register Here.

 

 

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Tags: Medical Device Connectivity, Medical Device Integration, Medical Device Information System, Med-Surg

Safety First - Are You Automating Your Medical Device Data?

Posted by Halley Cooksey, RN on Aug 13, 2014 @ 12:59 PM

ID-100247920When I grew up, safety equipment like bike helmets and seat belts were few and far between. Some of the best memories from my childhood are of sitting in the back of my parent’s station wagon with my sisters untethered to either our seats… or to electronic devices. We passed the time by playing license plate bingo and trying to get truck drivers to beep their horns.

Fast forward 20 years, and the thought of allowing a child into a car without a seat belt, let alone in the “wayback” of a station wagon... err, a SUV... would land a parent on a DFACS (Department of Family and Child Services) watch list. The impetus behind these changes was research. Research found that when children are placed in the backseat of a car, and securely fastened, their chances of survival are greatly improved if they are involved in a car accident.

Nursing practice has followed suit. As a nurse, it is our duty to ensure that we provide the safest care to the patients we serve. Clinical, nursing-driven research has laid the foundation for what is considered to be “best practices” to support us in achieving that goal. But, what if those best practices aren’t enough?

I read an article last week that stated that in 2013, an estimated 440,000 patients died due to medical errors. That’s four times the population of my hometown! As nurses, what can we do to help decrease those errors? How can we be the driving force that saves one of those lives?

Sending data automatically from medical devices at a patient’s bedside into the medical record and other information systems, like clinical decision support, is a good first step in supporting the reduction of those errors.

Have you conducted any studies at your facility that have shown improvement in patient care when documentation is automated?

Let me know your thoughts! Share your story!

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Tags: Medical Device Connectivity, Medical Device Integration, Patient Safety, Nurses, Medical Device Information System, Medical Device Data

Timing is Everything - Especially with Vital Signs!

Posted by Michelle Grate, RN MSN CPHIMS on Aug 08, 2014 @ 12:25 PM

ID-10044848The age old saying, “timing is everything,” still rings true today with Clinical Decision Support (CDS). The most effective time to present a CDS alert is immediately at the point-of-care. But how effective is an alert if the data triggering it is entered hours after the actual event?

To achieve the greatest benefit from CDS, data needs to be entered in near real-time. This is why automated documentation of vital signs is essential, even with periodic vitals collection.

We have long tried to achieve the ideal scenario of real-time bedside documentation, but incorporating the necessary workflow is difficult. While many facilities have deployed auto documentation for continuous monitoring in the ICU or the OR, the med/surg environment, or any location where periodic vital signs collection is performed, is often overlooked or not evaluated for automating documentation.

But why? This is an important environment that can benefit by enhancing CDS with automated periodic vital signs collection.

For example, early detection of a patient’s declining condition in the med/surg environment can lead to early intervention and prevent untoward events. CDS is an essential element in early detection and vital signs are a key component of many CDS rules. When vital signs are not entered into the electronic record for minutes or even hours after they are taken, the opportunity to maximize the benefits of early detection is lost.

It is as simple as this: the sooner data is entered, the sooner the CDS rule can trigger an alert and the sooner the patient can benefit. All of this will help lead to better outcomes.

The med/surg environment should be the patient's next stop in a hospital before going home, not back to the ICU or to another critical care area. Maximize the benefits of CDS with automated vital signs documentation at the point-of-care. Capsule's SmartLinx Chart Xpress™ works with a variety of spot check monitors and sends validated vital signs to information systems in near real-time.

 

Do you have automated vital signs documentation with your periodic monitoring locations?
What are some other benefits you see to automating this workflow?
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Tags: Medical Device Integration, Alarms and Alerts, Medical Device Information System, Medical Device Data, Med-Surg, Low Acuity

The Right Technology at the Right Time

Posted by Susan Niemeier, RN BSN MHA on Jul 28, 2014 @ 10:46 AM

I find myself spending large amounts of time in airports, arriving early to get through strict security, or passing time in terminals due to weather or mechanical delays. During those periods, I seek refuge at a quiet boarding gate that has a high concentration of power outlets or Internet access. Finding these spots is often a challenge, as I peer under seats, circle support columns and poke around vending machines. Occasionally, if I'm lucky, I run across a re-charging station to at least take care of my power needs.

These recharging stations are becoming more and more popular as business travelers flock to them to charge a plethora of devices. There you can find the latest "must have" or "cool" device / gadget on the market. But as I glance at the array of devices, I wonder, "Is cool always smart?" As a nurse, what really matters to me is the impact a device has on workflow or how I do my job, not necessarily its "coolness."

By many estimates, the typical nurse spends approximately 2 hours a shift simply keeping numbers current in patient medical records. By the time the doctors and multidisciplinary care team actually receive the information, it's often already outdated. To me, "smart" gadgets should help me decrease the time I spend inputting data and increase the time I spend directly caring for my patients.

Mobile devices, such as tablets and smart phones, may be the latest technology, and what many hospitals are considering incorporating into every part of nursing workflow. But I'm not so sure these devices will help a nurse achieve what he/she intends. In my experience, adding to nurses' tool belts (which can include as many as 15 other devices) can sometimes weigh us down rather than increase the time directly interacting with patients. We should be "hands on" with our patients, not with another device.

As nurses, our focus should always be on delivering safe, competent, and compassionate care. We should take caution with becoming the first to use an innovative new technology. So, before moving ahead with the introduction of the latest and greatest mobile technologies, perhaps a hospital should consider the following items:

  • Is it easy to use? Has it been thoroughly tested in the care environment?

  • How many steps must the nurse complete in order to get data to its end location? Is it intuitive? Simple? Fast?

  • Does it need to be put down for best data input? Where do we put the device if the patient needs our immediate attention? Then what about the transmission of infectious properties as we go from room to room?

As with any technology purchase, good research and asking the right questions are musts to help assure the tools acquired are more than "cool," but actually useful. When it comes to nursing and patient care, that usefulness equates to quality care, so we must be aware of the shiny new gadget and be confident that we are implementing the right technology, for the right people, at the right point in time.

(Originally posted on www.advanceweb.com)

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Tags: Nurses, Healthcare Technology

Batched Vitals

Posted by Halley Cooksey, RN on Jul 16, 2014 @ 09:00 AM

doctor-stethoscope-patientNursing school…

Just hearing those words can make many of us cringe and flood us with a multitude of memories, whether it was studying the Krebs Cycle until 3 a.m. only to have to show up for clinicals at 7 a.m., or being convinced that you were going to be diagnosed with whatever disease process you were currently learning. All fond memories aside, nursing school was just that: school.

It gave me a foundation, but it didn’t give me the experience I was going to need to survive in the real world. We all talk about real world vs. textbook nursing. But it isn’t until you are on the floor – by yourself – that you really learn what being a nurse is all about and how to manage your time.

Time management is a critical component for any nurse to master. We must figure out how to be in six to eight patient rooms at nearly the same time and ensure we are providing personal, high quality, safe care. So, to “clone” ourselves, we learn to create shortcuts. Some of them are OK, but they often go against established hospital policy. One of the shortcuts I developed was “batched vitals”.

Batched vitals is a process I used when I would have a patient return from a procedure or who would require frequent vital signs monitoring. Knowing that I could not be in the room every 15 minutes, I would program the vitals machine to take measurements according to the doctor’s order and would promise myself to return and check on the patient, peek at the vitals, and then go on my way and repeat the process. Once I could steal away 15 uninterrupted minutes, I would wheel my computer in and manually enter the vitals in to the flow sheet from the vitals machine.

Is this shortcut safe? Have you ever “batched” your vitals?

I ask because I am truly curious as to what other nurses are doing. What is their real world practice as compared to textbook nursing? As a vendor who is out in the field, I get a lot of feedback from nurses and I have found that batched vitals seem to be a general practice. I am not saying that it is right or wrong (although I’m slightly comforted that I am not on an island of my own). But what I am asking is do we need to look at what the impact is on patient care by following this process?

I have read a few studies, but nothing says in bright red letters: “you must be at the bedside every 15 minutes”. But, if this is the case, does technology need to support real nursing practice and allow for sending validated batches of vitals? Or, should we continue with business as usual and embrace the adage of “we’ve always done it this way”?

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Tags: Medical Device Connectivity, Patient Care, Medical Device Integration, Patient Safety, Nurses, Nursing Stories, Vital Signs

Multitasking Nightmares? Tame Them with A MDIS

Posted by Karen Lund, RN BSN on Jul 10, 2014 @ 12:00 PM

ID-10083882Rising patient acuity and dramatically shortened hospital stays are threatening nurses’ ability to meet the needs of their patients. We are constantly on the move, switching from activity to activity, too often finding it difficult to spend enough time with our patients.

How many times have you had to tap your super-power multitasking abilities? Daily? Take, for example, the following all too common scenario. Patient #1 is coming back from surgery. The blood bank calls to say the packed red blood cells are ready for patient #2. You’re waiting for labs in order to give medications to patient #3. Your nurse aide has just informed you that your confused patient #4 has just fallen out of bed and requires immediate help. And patient #5 is waiting for you to complete brand new procedures for discharge paperwork so he can leave the hospital. Sound eerily familiar?

Nurses have adapted to the endless demands for our attention in order to meet both patient needs and their facility’s goals. Distractions may come in many forms on top of patient care, such as new equipment, increased education for new procedures, documentation requirements, and orienting new staff. Krichbaum (2007) reported 40% or more of a nurse’s workday is outside of direct patient care. So what happens when nurses feel like they’re no longer helping the patient and that they’re overwhelmed with non-value tasks? Burn out?

A Medical Device Information System (MDIS) can help nurses gain back more time by helping improve the efficiency of patient documentation. It automatically integrates your medical device data into your hospital’s information system(s), which can save documentation time, increase communication, all while improving accuracy and timeliness. Moreover, in addition to providing connectivity with the EMR, an MDIS delivers monitoring, management and analysis of real-time patient data, enabling nurses to recognize signs of a patient’s physiological deterioration.

Why is this important? An MDIS is one of the few IT solutions that can take some of the pressure off those who give care to our loved ones, while offering real enhancements to the quality of care we are so committed to deliver.

If your facility has already deployed medical device integration capabilities, what kind of impact has it had on your daily activities? And if you haven’t, what’s holding you back?

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Tags: Patient Care, Workflow, Medical Device Information System, Clinical, Clinical Documentation

Maximizing the Benefits of Your Medical Device Integration Strategy

Posted by Michelle Grate, RN MSN CPHIMS on Jul 01, 2014 @ 10:00 AM

ID-10061774A successful strategy is crucial to helping guide decisions throughout an organization, making it critical that it be in alignment with the organizational goals that it is designed to support.  If the strategy is developed without a clear understanding of those goals, then resources, effort, and money can easily be misappropriated. 

When it comes to information technology, a strategy would not be complete without a thorough architecture covering all aspects of an enterprise. However, one of the challenges for developing that strategy is to look into the future and make plans for current infrastructures as well as potential emerging technologies.  A good enterprise architecture will assist in keeping the focus on growth and the necessary predecessors to get there.

With respect to integrating medical device data with the electronic health record (EHR), the strategy needs to look at the current and long term needs of the organization in order to maximize the investment of the medical device information system (MDIS).  Gone are the days when the ICU is considered the only location for integration of medical devices. 

The vast amount of patient data that can be collected and analyzed for real-time clinical decision support can lead to better outcomes. The more medical devices that are connected to the EHR and other information systems, the greater the amount of patient data that can be evaluated for clinical decisions.  Developing a MDIS strategy will help guide the organization's goals and plans over a long term period and keep the organization focused on their patients as they pursue expanding their use of medical device data.

 

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Tags: Medical Device Connectivity, Medical Device Integration, implementation, Medical Device Information System, CONNECT, Medical Device Infrastructure

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