As the healthcare industry embraces technology to improve patient care and reduce costs, integrating disparate systems is critical to maximize performance. Something as simple as a common basis for timekeeping can make a difference in records accuracy, device and system interoperability, security, regulatory compliance, and overall efficiency of operations. Because technology implementations are network-centric, timekeeping in software and hardware can be easily synchronized to the official worldwide time standard.
It’s only a matter of time before one of these happens to you …
- A new quality initiative or pay-for-performance policy requires documentation of times of diagnosis and treatment, but you cannot comprehend records that indicate which patients have received care before being admitted.
- Worse, your legal department and compliance officer have raised serious doubts about the accuracy of your records — just as the family of a patient files a lawsuit claiming that the patient did not receive timely care.
- Your new health information technology network has been hacked and no one can understand the extent of the intrusion.
- Your new access control security system has locked out your staff or prevented you from accessing critical documents.
- One of your systems isn’t interoperable with another, resulting in data crashes, conflicts and scheduling problems.
- Staff is late for meetings, there are problems with shift changes, confusion twice a year due to the daylight saving time change.
The list of problems goes on and on. Yet all of these issues can be traced to a single, critical factor: Time. Time affects every aspect of the health care organization:
Nurses and Doctors rely on time to maintain accurate schedules and records, such as determining when the last patient’s procedure or test was performed, or medication administered, and when the next will be.
Facility and engineering staff work to make sure the hospital infrastructure is accurate, trouble-free and properly maintained. Accurate time must be set and maintained for everything from wall clocks and medical devices to closed-circuit TV monitors and access control systems.
Information Systems staff need a time reference to support accurate time stamps and log files for their software systems and hardware, including firewalls, routers, servers and workstations. This is necessary for records accuracy and interoperability, to detect and correlate the effects of network intrusion and to support the latest encryption and authentication standards. Time initiates processes such as backups, reconciles database transactions and is used for troubleshooting.
At the executive level, accurate time is important to ensure compliance to regulations, improve the use of resources through coordinated schedules and reduce the risks of liability, because records are used as legal evidence. Accurately time-stamped records are used for everything from insurance investigations to the reconstruction of emergency events, sometimes in conjunction with outside agencies (such as EMS and 911).
Finally, billing and insurance providers need accurate records of procedures, admittances and discharges and to verify times of birth and death.
In the past, when time was different among the various areas of the health care facility, disparate time was merely an inconvenience. But as systems have become increasingly interconnected, synchronized time throughout the health care enterprise becomes critical for regulatory compliance, to reduce legal liability, increase efficiency, and to improve care.
Time: Vital for Patient Care
When accurate time matters, clocks need to be synchronized to each other. Members of law enforcement or a military squad compare and reset watches to synchronize operations as a matter of life and death. Similarly in healthcare, synchronized clocks are an enabling tool to improve the quality of healthcare to save more lives.
Nowhere is this more important than in emergency medicine. For example, the treatment of heart attack victims is a race against time. Cardiologists know that “time is muscle.” The sooner that blood flow can be restored in patients with blocked arteries, the more likely the heart can be saved.
Quality management principles apply to any improvement program, including reducing the time of diagnosis and treatment. However, you cannot improve what you can’t measure. Variance in clocks results in variance in performance, even before any other variable is taken into account. That’s why the patient advocacy group, the Society of Cardiovascular Patient Care, looks for synchronized clocks in their accreditation process. According to former Executive Director Robert Weisenburger Lipetz, “Reducing time to treat heart attack victims is critical to successful patient outcomes. Accurate coordination of times among EMS, the emergency room, the cardiology department, and the catheterization lab, is essential for facilities to accurately measure and thus control the related processes for the care of ACS⎯acute coronary syndrome.”
Time-based benchmarks set the standards for quality care. For treatment of blood vessel obstruction as the cause of ACS, the current benchmark for the time from hospital arrival until the blockage is relieved (“door to balloon”) is about 90 minutes. With the multitude of processes involved in diagnosing and treating chest pain, every minute counts. Without synchronized time in the facility, it is impossible to accurately document performance or reconstruct events for process improvement. New pay-for-performance scenarios can impact financial performance if facilities cannot document time-based improvements in metrics such as door to balloon.
Time in the Electronic Health Record
Technology efficiencies in the health care industry are made possible by interoperable devices and systems that share data in real time. Electronic health records (EHR) are one result of a data-sharing network that is used throughout the health care system. Although the potential benefits and efficiencies of EHRs are well-known, the industry is still working to understand and overcome the challenges of “wiring” operations. Significant issues include compliance with industry regulations, data security, patient privacy, records accuracy and interoperability of systems, networks, devices, operating systems, and applications.
A time-synchronized network, in which all computer clocks are generating accurate and identical time stamps, plays an important role in addressing all these challenges. Without time synchronization, the reliability of every record can be questioned. For example, a valid and legal medical entry must address the following questions:
Who did it? An authentication system is required to identify the user of the system. Authentication standards require time synchronization between clients and servers for many implementations, because time-based “tickets” are used to thwart replay attacks that are attempts to gain unauthorized access to the system.
When did they do it? Accurate time stamps traceable to worldwide time standards tell us when an event truly occurred.
What was done on the system, and did anyone tamper with it? Accurate time stamps and log files are used to perform audits to detect suspicious activity and assess its scope.
Best practices and industry regulations, including HIPAA, Medicaid/Medicare and the Joint Commission, require accurate time-based computer records. Over the past several years, organizations and initiatives such as Health Level Seven (HL7), Integrating the Healthcare Enterprise (IHE), the Certification Commission for Health Information Technology (CCHIT), and others recognize time synchronization as a critical compliance component for EHR interoperability and security. As an example, the IHE has developed the Consistent Time profile as an integral requirement for healthcare network deployments. Consistent Time ensures that system clocks and time stamps of all the computers in the network are well-synchronized with a median error of less than one second.
Synchronization to Legally Traceable Time
One of the subtleties of time synchronization is the need for accuracy traceable to official time vs. uniformity between just a few clocks. Time is one of the seven legally-defined units of measure. Since the Treaty of the Meter of 1875, time has been coordinated worldwide. Today, official time known as Coordinated Universal Time (UTC) is measured by vibrations of the cesium atom, an extremely accurate time constant. (UTC replaced Greenwich Mean Time [GMT] in 1972.) UTC is kept by and synchronized between national metrology institutes like the National Institute of Standards and Technology (NIST) in Boulder, Colorado.