By Dave Pearson
Advances In Computerized Maintenance Management Systems
Advances in computerized maintenance management systems (CMMS) have enabled clinical engineering (CE) to expand its capacity for organizing its work around ever-shifting mountains of medical equipment. And the gains have gone beyond improving response times and data capture on discrete work orders. From regulatory compliance and inventory control to systems integration and asset management, healthcare CMMS facilitates contributions that serve the CE profession as well as the hospital.
Despite the undeniable utility of the newest software, some familiar device management problems linger. Not least among the persistent headaches are competing approaches to nomenclature (one department’s “large infusion pump” is another’s “pump, infusion, high volume”) and, too often, disagreements over preventive maintenance scheduling options (risk-adjusted vs. regularly scheduled).
What’s more, not only is there more medical equipment to manage than ever before—between 600 and 700 different device types, and growing—but just about every medical appliance that touches a patient is networked, too.
CMMS can only go so far in equipping clinical engineers to manage such disparate cans of worms.
“CMMS is basically a database, and any database is only going to be as good as the people entering the information,” says Thomas Pasquariello, a clinical engineering supervisor at Mayo Clinic Arizona. “We’re the ones who are data-entering that information, and a hard part within our own staff is managing the data going in.” Mayo Arizona presently has 23 people on staff and approximately 14,000 items in its inventory.
“You get out of CMMS what you put into it,” adds David Pesavento, Mayo Arizona’s level-3 BMET. “If it’s kept accurate and it’s kept up to date, it will help you maintain very good reporting on inventory, productivity and even parts. But it does take work to keep it accurate and up to date.”
Incidentally, Mayo Arizona is preparing to change its CMMS to a new vendor’s offering. Pasquariello and Pesavento stress that the new solution, like their current one, will only be one element of the group’s medical device management strategy.
But, they say, it will be one very important element.
“Having a solid program to capture every piece of equipment that comes into the institution—making sure it’s captured, getting that evaluation, doing the risk assessment, deciding whether or not it’s going to be included in the program—all of this is essential to managing the inventory,” says Pasquariello.
Bottom line for Mayo Arizona, as for most hospital-based clinical engineering programs around the U.S.: CMMS is nothing less than indispensable. Best to forgive its minor shortcomings and make the most of its major attributes.
CMMS might be thought of as an EMR for medical equipment. When a medical device gets “admitted” to the hospital, clinical engineering examines it, diagnoses its ailments (or, more often with new equipment, gives it a clean bill of health) and assigns it to a room or a holding bay until a room becomes available. All of this is entered into the electronic record, as is every contact it will have with CE—and with other hospital departments with clinical or administrative interests—for the remainder of its stay.
This analogy can only be taken so far, of course. Kaiser Permanente Clinical Engineer Ilir Kullolli summarized the database’s versatile functionality in more down-to-earth terms in Biomedical Instrumentation & Technology in 2008. “A CMMS is much more than just a way to schedule preventive maintenance,” he wrote. “By using a CMMS, you can create equipment logs to record events associated with a piece of equipment; create work orders automatically according to a schedule or manually from service requests; record authorized uses of equipment; and track scheduled services or PMs, training, maintenance history, employee time, downtime of a device, parts inventory, purchase orders, and much more.”
A lot has happened in three years. By now, there’s even more “much more” to healthcare CMMS. But the software hasn’t come so far that its latest bells and whistles add up to the makings of a complete solution right out of the box. Not for everyone, anyway.
“I have worked on CMMS for more than 30 years, since before the IBM PC was born, and I still don’t think there’s an ideal system out there,” says Ted Cohen, MS, manager of clinical engineering at the University of California (UC) Davis Health System. “In my mind, the biggest problem is cost-related. You need to know your costs and track them, and nobody, or almost nobody, is able to do all service, maintenance and repairs themselves.”
He’s referring to work orders that must be filled by original equipment manufacturers (OEMs) or ISOs rather than the in-house CE department. “We need to make it easier to get accurate and complete vendor parts-and-service data, or service reports and cost data, into our CMMS.” Currently, the CE clerical staff enters vendor data, he explains, but there’s not always a reliable prompt for that step since the hospital pays upfront for many vendor services via service contracts.
Knowing what he knows, Cohen can’t help but view the present through the lens of the past.
“In the early days, we were just trying to keep a decently accurate inventory of equipment,” he recalls. “As computer database applications grew, we began to use them for more friendly and robust CMMS, including a system that I co-developed as a custom [solution] for our use.”
UC Davis used that homemade system for about 20 years, as it was “very robust,” according to Cohen. His team built in extensive billing and cost-management tools for vendor service as well as in-house labor and parts, and added other features that made it a hard habit to break. By 2010, the problem was its age—and Cohen’s.
“I think the powers-that-be started getting concerned that I was going to leave and it would become unsupportable,” he says with a chuckle. It didn’t help that the program, which ran on a Unix operating system, had become isolated as a stovepipe system within the institution. The IT group had no role in setting it up or supporting it.
With the pressure on, Cohen and his team started looking for a CMMS package. (Again, the IT department stayed away. “Their choice,” says Cohen. “We’re on their network, we use general-purpose computers that they provide, but they stay away from the software side of what the CMMS does.”) After an extensive evaluation, UC Davis’ clinical engineers decided that no commercial system met all their needs. So they picked one that came close enough and commissioned its maker to extensively customize it with special functionality for billing, purchasing and invoicing.
“This is not just my own experience with this cost-management, vendor cost [divide],” says Cohen. “Other large organizations have this same issue where they may well have a robust computer system to do cost accounting, and they may have a custom-built CMMS for a huge number of devices, but they’re not integrated.”
After an extended period of customization, development, testing and data conversion, “we have been live on this new system for about 18 months,” says Cohen. “It is finally starting to meet our needs.”
Hospitals have needs too. Take, for example, compliance and accreditation. Medical device management plays a major role in meeting these institutional needs, and CMMS plays a major role in medical device management.
Both seem to be holding up their end of the bargain.
“Our standards that relate to medical equipment are EC 020401 and EC 020403, and compliance with those two standards by clinical engineers is very high,” says George Mills, senior engineer for the Joint Commission’s Standards Interpretation Group. “We don’t see a lot of problems, so the industry is managing its clinical equipment very well.” The commission also bases that conclusion on its national survey results, he adds.
Mills says proper management of medical devices begins with the fundamentals: an up-to-date inventory that produces appropriate preventive-maintenance schedules.
Here’s where things can get contentious.
One might think it goes without saying that, when it comes to scheduling preventive maintenance across the inventory, higher-risk equipment takes priority over lower-risk equipment always and everywhere. One would be wrong to think that. In many ways, CEs have, through little fault of their own, been stuck in the early 1970s on this point. That was when clinical engineers arrived en masse to safeguard patients against basic electric shocks from medical machinery. The thinking was: Test everything with an electrical current according to regularly scheduled preventive maintenance, regardless of the difference in risk between one device and the next.
This should have ceased being the norm a long time ago, says Malcolm G. Ridgway, PhD, senior vice president of MasterPlan, the international ISO based in Chatsworth, Calif. “There are three levels of risk that you can look at,” he says. “One, can the device cause a life-threatening injury? Two, can the device cause an injury, but not a life-threatening one? And three, can the device not cause an injury, but cause a delay in treatment or diagnosis?”
Ridgway stands among a large contingent of industry veterans who have spent decades lobbying for the standardization of risk-based, evidence-based preventive maintenance scheduling. So far, the efforts have been influential but not decisive.
“It’s been debated long enough, unnecessary preventive maintenance versus evidence-based maintenance,” says Ridgway. “It’s time to fish or cut bait. We clinical engineers should lend our weight to focus hospitals on safety by keeping our attention on higher-risk devices.”
What’s In A Name?
Ridgway identifies two other problems that continue to vex medical device management despite the capabilities afforded by CMMS—and despite the best thinking of the clinical engineering brain trust: connectivity and nomenclature.
On connectivity: “There’s been a lot of talk about IT and about how we should know more about networking in order to help solve those problems, but the aspect of when networks connected to high-risk devices fail, as opposed to the devices themselves—there hasn’t really been a simple, dedicated effort to isolate those failure modes,” Ridgway says. “And that’s something that needs to be put on the agenda.”
On nomenclature: “We’ve never been able to agree on a common terminology for medical devices,” says Ridgway. “You encounter this when you switch from one CMMS to another; in fact, it’s a basic fly in the ointment with any kind of inventorying system. Some people have advocated using the ECRI Institute nomenclature, and I think that’s as close as we’ve got to a solution, but it’s not ideal. The ECRI nomenclature organizes things in a nice way for listing, but it’s not what people call things in the real world.”
James P. Keller, Jr., vice president of health technology evaluation and safety with the ECRI Institute, the nonprofit based in Plymouth Meeting, Pa., points out that people can quickly find popular names for every entry with just a click in ECRI’s industry-standard Universal Medical Device Nomenclature System (UMDNS). “ For example,” says Keller, “the common names Bovie and ESU are linked in UMDNS to their standard term, electrosurgical units.”
Of course, they’re both right. In the UMDNS, each entry even comes with a product definition to ward off confusion over devices that are similar in description and appearance. But, to Ridgway’s point, given that several CMMS vendors incorporate the UMDNS into their software, why has none produced a similarly comprehensive database that leads with the vernacular—and then marketed the retooled system to clinical engineers?
In any case, the encyclopedic organization of the UMDNS is surely one of the characteristics that make it such a reliable source of safety alerts and product recalls.
At the end of the day, these services are—like the endeavor of medical device management itself—all about cost effectively minimizing the chances that patients will get hurt by devices designed to help them.
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From Healthcare Technology Management Magazine