CoDE 2010–2011 Mayo Clinic Center for Innovation · • CoDE 2010-2011 • Mayo Clinic Center for Innovation • 3 • exceptional success.” CoDE 2010-2011 Projects from the Mayo

CoDE 2010–2011 Mayo Clinic Center for Innovation

• 2 • CoDE 2010-2011 • Mayo Clinic Center for Innovation •

FPOCONNECT DESIGN ENABLE

• CoDE 2010-2011 • Mayo Clinic Center for Innovation • 3 •

exceptional success.”

CoDE 2010-2011 Projects from the Mayo Clinic Center for Innovation

Collaboration, co-creation, and innovation

Mayo Clinic Center for InnovationThe Center for Innovation (CFI), officially launched in June 2008, continues to help Mayo Clinic achieve

its mission to transform the experience and delivery of health care. CFI’s unique approach fuses design

thinking with scientific methods in the primary objective of connecting, designing and enabling ideas

that can transform the delivery and experience of health care for patients everywhere.

CFI connects people inside and outside Mayo Clinic in ways that have never been attempted before,

identifies opportunities and realizes solutions that will transform care delivery and experience, and

facilitates and accelerates the pace of innovation across Mayo Clinic by making the invisible visible.

CoDE Innovation FundsThe idea of Connect Design Enable (CoDE) Innovation Funds originated from CPI-IO Innovation grants,

and grew into a program that has gained enterprise-wide attention. The program offers internal funding

opportunities to all employees of Mayo Clinic. Administered through CFI, CoDE projects are reviewed

by many, ensuring they are in alignment with institutional goals and strategy. The approval process is

swift as is the project’s progress. Fund recipients have one year to complete what they propose. CFI

staff provides fund recipients with help

as needed to inspire and enable them throughout the year.

“At the Center for Innovation, we know that innovation requires collaboration and partnership. CoDE Funds were created to accelerate the process of design-thinking and ultimately, a fast proof of concept”, says Nicholas LaRusso, M.D., medical director. “So far, we have had

Nicholas F. LaRusso, M.D. Barbara Spurrier, M.H.A.

Gianrico Farrugia, M.D.

CoDE 2010-2011 • Projects from the Mayo Clinic Center for Innovation

FPO

The Path to Recovery – Individualized

Unless you’ve watched “Terminator” a few too many times, you know that

humans are not robots. Humans are unique: Our DNA proves it. By the same

token, there is merit in the notion of our being “the same on the inside.”

Despite our diversity, many of us are the same —

predictable, even — underneath the skin. When

David J. Cook, M.D., Anesthesiology, saw that heart

surgery patients could benefit from a standardized

care system, he got an idea.

In late 2008, Mayo saw the need to deliver cardiac

surgical care more efficiently. The cost of cardiac

surgery was higher than Medicare could reimburse.

Mayo leadership had known for some time that the

workflow before, during and after surgery needed to

be reworked, so they looked to a broad partnership

to help create a solution. Dr. Cook and Thoralf

Sundt, M.D., Cardiac Surgery, led the effort, along

with nursing and administrative partners.

Hundreds of hours of meetings with caregivers

throughout cardiac surgery revealed consistent

themes: lack of standardized care approaches,

poorly defined expectations, and ambiguous

communication — all leading to “overcare.”

Because of unclear expectations in advancing

recovery, Dr. Cook states, “there was too much

care for too long.” Patients were on ventilators

and antibiotics longer than needed, or had bladder

catheters for longer than what was indicated. In a

hospital environment, more care is often not

better care.

Project Title: Electronic Pathway

Proponent: David J. Cook, M.D.

Department: Anesthesiology

Opportunity in Brief:

+ Cardiac surgery patients were at a higher risk for overcare, because

clear communication of clinical expectations or individualized paths

for patients’ progress did not exist.

+ The Electronic Pathway was created to communicate a patient’s

status to the care provider, allowing advances to be patient-specific

and continually monitored.

+ The Electronic Pathway communication has created clearer patient-

physician communication, — to provide the appropriate amount of

care in a timely manner.




Connect

Allowing patients

to understand

their pathway to

a successful recovery

through their

physician’s model

for progress.

Design

The electronic pathway

monitors a patient’s

progress, allowing

physicians to allot the

needed amount of care

based on the patient’s

progress.

Enable

Monitoring a patient’s

progress via the

electronic pathway

opens communication

between patient and

physician, while not

over-delivering or

under-delivering

the needed care.

“We analyzed the use of operating rooms, ICUs and every major care process step that patients move through on their path to recovery.”

— David J. Cook, M.D.

Dr. Cook and his colleagues, with the help of the

Department of Systems & Procedures, spent at

least a year analyzing the practice and talking with

all patient care stakeholders. “We analyzed the

use of operating rooms, ICUs and every major care

process step that patients move through on their

path to recovery,” says Dr. Cook.

Cardiac surgery is dramatic. Watch any medical

TV show and, most likely, the defining moment of

life or death is on the operating table, often with

open heart surgery. Each patient is unique, but

the care process can be uniform. Dr. Cook and his

colleagues saw the need to standardize the steps

in cardiac surgery, as appropriate — what needed

to be done every time. So they began assessing

time stamps and the normal recovery sequence for

every step in the recovery process.

Patients who are “outliers” — have a catheter in

for extra time, for example — cost more money

and are at increased risk of complications. To

reduce overcare and advance the process of

each care step, Dr. Cook and his colleagues

created a standard practice model — an electronic

pathway — to support patient care from the OR to

discharge.

Each Step on the Pathway

The team created protocols and guidelines for

each step in the care plan. They then bundled

those steps into groups of related orders and

protocols called “metaorders” that are designed to

support the patient as well as meet clinical criteria

to advance the patient to the next care step.

To stay on the pathway, patients had to meet

criteria for safe progress at every step. If they

didn’t, they stayed at that level until clinically ready

to advance. This model empowered everyone from

the patient to the bedside provider to make the

decisions that moved the patient along in the

process to receive the best care, in the shortest

time for the least money.

This was a huge departure in the way care was

organized. Until then, communication was a

big issue. “The care was organized as a series

of starts and stops,” says Dr. Cook, “where a

provider would have to be called to advance

each care step.” The new model simplified the

communication of clinical expectations and

allowed the patient to advance more rapidly.

Better Outcomes with Each Step

Nationally, about 75 percent of patients who

have coronary artery bypass grafting (CABG)

stay in the ICU more than a day after surgery.

Before the pathway was in place at Mayo,

close to 55 percent of CABG patients stayed in

the ICU for that long. In 2010, that percentage

was cut in half thanks to innovations in care

by Dr. Cook and his colleagues. How did they

find a solution? “You have to get outside the

current frames of reference,” he says. “You

have to have intellectual freedom and support

from leadership to tackle change.” How did

they effectively implement the solution? They

started very conservatively and persevered.

Knowing what needed to be done was easier

than making changes, especially in a successful

practice. After all, states Dr. Cook, “You need to

have imaginative range, determination and the

blessing to tackle change in health care.”


FPO



+ The Anxiety Coach app resulted from the

convergence of two elements: a project in

which OCD patients used the iPod touch to

record symptoms and a practical treatment

manual dealing with exposure-based therapy.

+ The app’s library of “fear ladders” gives

users ongoing access, with personalized

steps towards conquering their fears,

which are tracked by a therapist.

+ Each patient’s app generates a ‘to-do’ list

of exercises leading toward conquering

fears and/or increasing compliance

to work with a health professional.

Project Title: Anxiety App: Exposure-Based Therapy

Proponent: Stephen Whiteside, Ph.D., L.P.

Department: Psychology

Stephen Whiteside, Ph.D., L.P., works with children who have

anxiety disorder. “Many children and also adults do not receive

treatment or do not receive good treatment,” says Dr. Whiteside.

“Exposure-based therapy, which helps patients with anxiety

disorder identify and respond to challenging situations, is the

most effective treatment for many anxiety disorder conditions.

There just aren’t enough therapists who specialize in treating

anxiety disorder, especially in children, to meet the demand.”

With its 2010 CoDE innovation award funding, Dr. Whiteside’s

project team is developing a technology-based tool to address

the need for effective treatment: An iPod Touch and iPhone

application (app) that allows people with anxiety disorder to

record their symptoms and prompts them to complete therapy

exercises that help them address and alleviate their fears. “The

tool, called Mayo Clinic Anxiety Coach, helps both patients and

therapists by providing mobile, ongoing access to a structured,

personalized treatment program,” says Dr. Whiteside. “Children,

especially, don’t love pen and paper. Wireless technology is

integrated into their lives so completely that the Anxiety Coach is

logical and user-friendly for them. Therapists can also track their

patients’ progress via the app.”

The project team’s first version of Anxiety Coach was basic and

rated only anxiety levels. The current version includes a self-

test with questions about fears and worries. Based on each

individual’s answers, the app generates more-detailed questions

and, ultimately, a score that reflects the nature and severity of the

person’s fears. “The most innovative element of this version of

Development of a Mobile Tool for Exposure-Based Therapy of

Anxiety Disorders

Anxiety disorder — a problem with fear and worry that causes distress

or interferes with daily life — is one of the most common mental health

problems. It comprises conditions such as social anxiety disorder, panic

disorder, chronic worry, obsessive-compulsive disorder (OCD), separation

anxiety disorder and specific fears.



Connect

Providing patients with

anxiety disorders an

Anxiety Coach app that

can help them track

their symptoms, while

primary care providers

can access a structured

treatment plan based

on the patient’s needs.

Design

The user-friendly

Anxiety Coach app

allows persons with

anxiety disorders

to help themselves

through a series

of steps toward

conquering their fears.

Enable

Persons with anxiety

can learn how to

help themselves, set

goals, and seek the

help of primary care

physicians, who can

also use the app to

tailor and track their

patients progress.

“The app generates more-detailed questions and, ultimately, a score that reflects the nature and severity of the person’s fears.”

—Stephen Whiteside, Ph.D., L.P.

Anxiety Coach is that it helps people make a

list of steps to take to face their fears,” notes

Dr. Whiteside. The app includes a large library

of fear ladders (descriptions of increasingly

challenging steps to conquering one’s fears) that

helps people create a to-do list that matches

their fears. Finally, the app helps them set up their

exposures to the fears they need to face.

No physician required

Anxiety Coach addresses the needs of three

primary user groups: people with anxiety disorder,

primary care physicians and mental health

professionals. It allows people with anxiety

disorder, and especially those who are reluctant to

seek treatment, to use the app as a self-help tool.

And primary care providers have access to a

structured treatment plan that requires minimal

resources. Anxiety Coach can help mental health

professionals by increasing patient compliance

and allowing them to track patients’ progress in

therapy. Because the project team hopes to market

the app to help treatment-adverse people, a primary

goal is to develop a practical tool that does not

require a physician’s presence for use. “It’s akin to

a self-help book,” notes Dr. Whiteside. “Someone

with anxieties and worries can purchase it and use

it independently, but it also provides that user with

an introduction to how to seek more traditional

treatment, should they need it.”

2012 pilot studies will evaluate upgraded app

This CoDE project, like many others, was not fully

completed in one year. A pilot group comprised

of three patients with OCD tested a precursor of

Anxiety Coach before the team received its CoDE

award. The app helped children and their families

keep track of symptoms and treatment-related

exercises. With CoDE funding and additional

support from CFI, the team created a more

extensive app that included psychoeducation, a

self-test, and treatment instructions. The project

team conducted an initial focus group. “We

learned that although we had worked hard to

simplify the content, we had included too much

information and too many steps. We went back

to drawing board,” says Dr. Whiteside.

In a pilot scheduled for early 2012, several

of Dr. Whiteside’s current patients will use

the upgraded version of the app and provide

feedback. To test the app, the project team

plans to recruit people interested in trying a

self-help program for their anxiety disorder.

Additional studies of whether and how the

app can be integrated into therapy and the

primary care setting will be considered, based

on results of these pilots. “The project team’s

short-term goal is to develop a workable app

and pilot its use with anxiety patients receiving

therapy,” says Dr. Whiteside. “Our long-term

goal — to make the tool widely available

through mobile application distribution

mechanisms — will provide an unprecedented

ability to evaluate the effectiveness of

technology-based therapy across a wide range

of patient and community groups.”

Anxiety App was a result of the convergence

of two other projects

• TheDepartmentofPsychiatryand

Psychology’s five-day intensive treatment

program for children with obsessive-

compulsive behavior.

• Publicationofapracticaltreatmentmanual

for therapists for implementing exposure

therapy, called “Exposure Therapy for

Anxiety: Principles and Practice,” by

Jonathan S. Abramowitz, Ph.D., Brett Jason

Deacon, Ph.D., and Stephen P. Whiteside,

Ph.D., L.P.


FPO

An app for Mayo Clinic Patients

How often have we said, “I wish I could just press a button and get <something>.”?

In the second decade of the 21st century, making this magic button a reality

might not be that difficult. The answer, of course, could lie in creating an app.

Working with this thought, a group of Mayo Clinic allied health staff began

thinking about how to use this popular new technology to meet the needs

of Mayo Clinic patients. What if, by simply pushing a button on a cell phone,

patients could get information about their medical appointments or

transportation or hotel reservations or any of the many needs they have

identified as personally important?

“We focused much of our discussion on how a mobile app could improve

patients’ interaction with Mayo,” says team member Francesca Dickson,

a specialist in the Department of Public Affairs. “And, we asked ourselves

how it could contribute to the unparalleled experience Mayo Clinic wants

for its patients.”

As an answer to these questions, the concept for an app was born. After

brainstorming about the viability of this proposal, a team led by Mark

Henderson, division chair, Information Technology (IT), and John Murphy,

also a specialist in the Department of Public Affairs, submitted

an application to Mayo Clinic’s Center for Innovation for a

CoDE fund that could support their efforts in

researching the potential for the app and finding a

way to build it.

“When we received the good news that our application had

been accepted, we learned we would have funding and CFI

resources to help us through the process,” says Henderson.

“The team was awarded $40,000 to pursue their goal, and so

the journey began.”

Researching the need

The group conducted phone interviews with Volunteer

Services to determine the general questions patients ask

most frequently. The top requests were for Social Services,

International Services and Business Services. The group

Project Title: Mayo Clinic Patient app: eConcierge Services

Proponents: Mark Henderson and John Murphy

Departments: Information Technology and Public Affairs



+ The intent of the eConcierge app is to create a

simple stream of updates and useful resources

to the patient, allowing patients to relax with

everything they need at their fingertips.

+ The app would update itself, preventing worry and time

wasted for the patient — enabling a more enjoyable visit.

+ The app answers visitors’ basic questions and connects

visitors to resources and eConcierge services.



Connect

Creating a mobile app

containing services

that are attuned to the

needs of and available

resources for patients

during their visit.

Design

The app reflects the

resources needed by

every patient and also

the specific itinerary,

maps and limited

record information

needed for a patient’s

visit.

Enable

Providing guidance and

resources for a patient

during a visit, available

through information

kiosks and on May 15

released publicly

through the Apple App

Store.

“In less than a year, we’ve built an app that Mayo Clinic can be proud of and will be available to the public in May 2012.”

—Mark Henderson, Division Chair, Workstation Support Services

further examined the questions asked at various

Information Desks. They found a broad range of

queries that include personal needs such as where

to eat, park their car, find a hotel, get a patient

shuttle, find a campus tour or locate restrooms.

Clinical needs included requests for directions to

specific desks and the locations of the hearing aid

store, patient library, Patient Services and Social

Services.

Brainstorming with CFI staff

With this information in hand, the group then met

with CFI support staff to map out potential paths

to success. This included visioning — what the

real answer could be — and scoping — where to

start and how to search for answers. Based on

these discussions and the questions typically

asked by patients, the team tightened the scope

of the project and selected the preliminary tools

to include in the proof of concept app:

• Wayfinding

• Appointments

• HealthRecommendations

• ProviderInformation

• Messages

• HelpSection

• PatientMedicalRecords

Moving from ideas to reality

With a vision of what the app could become, the

first step was to develop a proof of concept that

spelled out the specifics of the app. The team had

a good idea of what patients wanted, and they had

narrowed the scope of the project, so creating a

beta app became the focus. They worked with

a team from Information Technology (IT) to develop

a partially functional version of the app based on

the iPad™ technology.

The team agreed that the app’s content should be

limited, based on the funding available and time

allocated, and that it should be centered on needs

patients have during a visit. Six categories were

created:

• AboutMayoClinic

• AboutRochester

• Communication

• MyHealth

• MyVisit

• Transportation

It was also determined that patients wanted

an electronic itinerary that included information

about preparing for appointments, patient

education about tests and procedures, maps

and directions to desks and procedure areas,

and access to the patient portal. Then, the team

engaged an external developer to move the

idea from the whiteboard to a working prototype.

“This has been an exciting project,” says

Murphy. “The entire team learned far more

than just how to build an app. We had the

experience of collaborating with colleagues

from across Mayo Clinic as well as working

with an outside developer. We came to see

technology as an enabler to the patient

experience here, and we realized there are

other places this app can reside, such as

informational kiosks that would give access

to patients who don’t have mobile technology.”

Henderson, chair of Workstation Support

Services, says, “The team did a great job of

pulling together many pieces to create what

became this prototype app. Information

Technology is now working on the production

app, in collaboration with Global Products and

Services. The app was released to Mayo Clinic

employees in April 2012 for further testing,

quickly followed by the publication of it in the

Apple App store for public availability on May

15, 2012.”


FPO

Project Title: Pediatric Phlebotomy Chair

Proponent: Aida Lteif, M.D.

Department: Pediatrics

Children Experience Greater Fear

While most adults can usually cope with a medical appointment that

involves needles, they would probably say the activity is not

exactly their favorite. Situations such as these can be especially

troublesome for children who need blood work several times

a year. But now, thanks to a $50,000 CoDE fund from the

Mayo Clinic Center for Innovation, Mayo’s Pediatric Center

is working to make those experiences more pleasant

by designing an innovative new phlebotomy chair that

features built-in distractions to help take children’s

minds off what’s happening to them.

Aida Lteif, M.D., a pediatric endocrinologist on Mayo’s

Rochester campus, and others on her team are working

on designing the new chair. Dr. Lteif says the need

was identified as she and her team were working

on a Mayo Service Excellence Collaborative

project intended to help improve the laboratory

experience for children. During this process, Dr.

Lteif says, she and her team quickly realized that

phlebotomy chairs were not meeting the needs

of their patients nor their phlebotomists. That

needed to be changed. “Most kids are fearful of

blood draws,” Dr. Lteif says. “And for those of us

who have seen children squirm, cry and faint while

sitting in a phlebotomy chair, it was made quite

clear that we needed to do something to make that

experience more tolerable.”

The ‘Just Right’ Chair

Based on the group’s initial design ideas, they

ordered a new salon-style chair that Mayo Clinic

Facilities & Support Services staff then helped

modify by adding an additional foot release pedal

to allow phlebotomists to raise and lower the chair

from either side. Hand-operated releases were


+ Pediatric Phlebotomy chair prototypes have

created a way to distract patients from the

fear or anticipated pain of the needle.

+ The goal of the chair is to create ways for the patient’s

attention to be redirected and pain scores to be lowered.

+ Phlebotomists are continuing to seek chair improvements

that enhance the kid-friendly design and distraction

that will lead to a better patient experience.




Connect

Developing a chair with

helpful distractions

that redirect the

patient’s attention,

allowing care providers

to draw blood or

deliver vaccines more

efficiently.

Design

The chair and built-in

distractions under

development create

an environment that

redirect the patient’s

focus, thus lowering

their anxiety and pain

scores.

Enable

Creating a sense of

calm and engagement,

distracting the patient

away from the fear or

anticipated pain during

the delivery of vaccines

or drawing blood.

“For those of us who have seen children squirm, cry and faint while sitting in a phlebotomy chair, it was made quite clear that we needed to do something to make that experience more tolerable.”

—Aida Lteif, M.D., Pediatric Endocrinologist

also added to the chair so that phlebotomists can

help the children recline, if need be. “A lot of kids

and teenagers faint during blood draws, and the

old chair couldn’t really recline well,” Dr. Lteif says.

“With the new chair, when someone starts fainting,

our phlebotomists can click a button to make the

chair recline, which will then make the patient’s

legs go up in the air so that it’s safer for them.”

Before work began on the new chair, the team

already had one distraction device in place called

“The Buzzy,” which Dr. Lteif says looks like a

bumblebee. “People use it more for vaccines,”

she says. “It vibrates and has a cold patch so

when we put it on a child’s arm and we move it,

the kids don’t feel anything because it numbs the

skin. But we can’t put anything cold on the kids’

skin when we’re drawing blood because that

constricts the veins.”

Still, Dr. Lteif says, when kids held “The Buzzy”

in their hand during their procedures, the

distraction was enough to take their minds off

what was happening to them. Survey results also

showed that the device helped lower pain scores.

“That’s why we decided that we wanted to offer

more distractions to the kids,” Dr. Lteif says. “And

that we wanted to have games and distractions

for all age groups — from 1-year-olds to 15-year-

olds.” Dr. Lteif says the new phlebotomy chair’s

built-in distractions include a monitor that can

play music, along with a series of short video clips

that originate from an Apple iPod and iPad. “It’s

a friendly environment here, but the only thing

that’s unfriendly is that kids have to come in and

get poked and there’s really nothing to distract

them from that now,” she says. “We know that

distraction works, so the idea is for kids to come

in and sit in the chair and rather than focus on the

blood draw, they’ll focus on what the chair has to

offer them.”

With a prototype chair in place, Dr. Lteif and

her team have tested how kids respond to the

new chair and impact during blood draws. She

says early results have all been positive.

“We’ve prototyped the new chair and we know

that the iPad works great, the iPod works

great, and the projector screen works great,”

she says. “All of the feedback we’ve gotten

is that the kids really love the distractions.”

And while the project seems a likely answer

to the problem, Dr. Lteif says the prototype

chair needs more work. “It’s not yet that

magical chair,” she says.

With one new chair already in place, the

team has ordered a second chair that’s

being designed and modified by a company

outside of Mayo Clinic to eventually give Dr.

Lteif and her team of phlebotomists two kid-

friendly options. Dr. Lteif says the Center for

Innovation has been invaluable in helping to

create the concept and advance the project.

“They’ve really been helping us every step of

the way,” she says.



+ Obstructed sleep apnea, or repeated obstructions of the

upper airway, can lead the body to respond slowly or not

at all to such episodes — possibly leading to death.

+ Pulse oximetry reads oxygenation levels in the

blood, with peripheral nerve stimulation sending

oxygen when breathing stops — creating a

model of consistent monitoring and care

+ The proposed Oxistimulator would be a small, noninvasive,

portable device that allows nurses to monitor patients’

blood oxygen saturation levels via wireless transmission.

CoDE 2010-2011 Projects from the Mayo Clinic Center for Innovation

Project Title: Oxistimulator

Proponent: Joan Kilger, R.N., C.R.N.A.

Department: Anesthesiology

Sleep Can be Deadly for Some

Hollywood actor John Candy. Television pitchman Billy Mays. On the surface,

these two men may not have seemed to have much in common. But doctors

say both died in their sleep from obstructive sleep apnea.

Obstructive sleep apnea is a condition characterized by repeated episodes

(often five or more) of a partial or complete obstruction of a person’s

upper airway that occurs while they sleep. Muscles that support the

upper airway relax, resulting in a blood oxygen saturation loss of

up to 4 percent, or more. Under normal sleeping conditions, a

person’s central nervous system would self-activate a series of

arousal mechanisms in response to these decreasing blood

oxygen levels, waking the individual and ending the airway

obstruction. But these arousal mechanisms often are not

sufficient for patients who have obstructive sleep apnea.

Joan Kilger, R.N., C.R.N.A., a nurse anesthetist on Mayo

Clinic’s Rochester campus, first encountered this condition

seven years ago while caring for a patient in his mid-40s following

a routine surgery. Kilger says the man, who was generally very

healthy, had no problems or complications throughout his surgical

procedure and no problems in the recovery room. Later that night,

however, the man began feeling pain. But it was “an appropriate

level of pain for having just had surgery,” Kilger says. The man was

given an appropriate level of narcotics for that pain and, at the time,

all seemed well. However, the next time that nurses checked on the

man, he was brain dead.

“He had stopped breathing,” Kilger says. “After trying to revive him,

the care team had to finally let him pass away. And after his death,

postmortem tests determined that he died from undiagnosed

obstructive sleep apnea. That, of course, was quite striking

to learn.”



Connect

Coupling two Mayo

technologies, pulse

oximetry and peripheral

nerve stimulation, to

monitor oxygenated

blood through a device,

currently in clinical trials.

Design

The device would allow

for the monitoring and

tracking of patients’

oxygenated blood

levels, as well as notify

nurses if the patient

needs additional

care, via wireless

transmission.

Enable

Developing the device

for clinical trials with the

main goal of providing

the patient and care

team with an effective

means of delivering and

monitoring their patient’s

oxygenated blood

levels.

“This device is, without a doubt, one of the most patient-centered innovations I’ve ever seen.”

—Richard Hinds, Respiratory Therapist

Idea into Action

So striking that the experience motivated Kilger to

dedicate the next seven years of her life to finding

a way to prevent these sudden, unexpected

deaths. And that research has led to efforts by her

and others in her work area to develop a device

called an Oxistimulator. The project has been

assisted by a CoDE fund from the Mayo Clinic

Center for Innovation.

Richard Hinds, a respiratory therapist on Mayo’s

Rochester campus, is one of those helping

Kilger develop the Oxistimulator. He says the

device is really a coupling of the two well-known

technologies.

“The first one is pulse oximetry, which gives you

the ability to read the oxygenation level in the

blood,” he says. “The second is peripheral nerve

stimulation, which is something that’s already

used in our operating rooms here at Mayo.”

Kilger says that to protect patients from prolonged

episodes of sleep apnea, the most common

system includes the use of pulse oximetry

integrated with an alarm system that alerts nurses,

who then go and wake the patient. And while pulse

oximetry is considered to be a highly sensitive,

reliable and cost-effective way to monitor

respiratory depression on the nursing floor, Kilger

says relying entirely on nurses to intervene during

the multiple episodes of apnea that occur every

day could potentially lead to those nurses being

taken away from other important tasks or needs on

the floor.

“Basically, what this device does is what the

human body normally does on its own,” she says.

“It monitors the amount of oxygen in the blood

and when that amount drops and the body fails to

effectively stimulate on its own, the device picks

up and handles the stimulation as a bridge.”

Kilger says the device’s design calls for a

“safe, immediate, nonpainful, yet effective,”

stimulus that is delivered to a patient’s wrist

by a portable pulse oximeter connected to a

small probe on the patient’s finger. The device

is tethered to a small laptop computer so that

nurses and clinicians can monitor the patient’s

information. The stimulus is delivered directly

to the ventral surface of the patient’s wrist in

response to a preselected oxygen desaturation

point and lasts for approximately two seconds.

The device is designed to be capable of

notifying nurses via wireless transmission if

a patient’s blood oxygen saturation fails to

recover after a stimulus has been delivered.

“The whole idea is to provide something that

works within a reasonable scenario of our

clinical practice,” she says.

Kilger says the team has a prototype device

that’s being developed by staff in Mayo’s

Department of Engineering. Once that work is

completed, the next step is to test the device’s

effectiveness in a clinical trial. Hinds says he’s

confident the device will pass the test.

“This device is, without a doubt, one of the

most patient-centered innovations I’ve ever

seen,” he says. “It has the potential to greatly

and positively influence our clinical practice.”


FPO

Project Title: TransFuse

Proponent: Mark Ereth, M.D.

Department: Anesthiesiology

His new method to get the word out is a game-like

iPad app.

Mayo Clinic’s TransFuse Application for iPad

includes information on appropriate transfusions

and 16 clinical scenarios where users earn points

for proper treatment decisions.

A CoDE innovation fund — along with the creative

juices of software developers and Mayo medical

illustrators — made the app a reality. “The first

time I touched an iPad, I knew it was going to be

an amazing tool for health care in general and for

blood management in particular,” says Dr. Ereth.

“Working with the Center for Innovation design

team, the whole concept crystallized.”

The free app has been offered at the online Apple

app store since September 2011. While it’s

designed for health care providers, patients

can view it, too.

A longtime proponent of more prudent use of

blood transfusions, Dr. Ereth co-founded a

multidisciplinary group of Mayo Clinic clinical

investigators who focused on blood function,

transfusions and cardiopulmonary bypass. They

advanced safer techniques for Mayo Clinic heart

surgery patients. Three years ago, he founded

and now directs Mayo’s comprehensive blood

management program. The work of this group

Implications of Blood Transfusions

Mark Ereth, M.D., says it’s time to curtail the number of blood transfusions —

and he’s talking big numbers. While blood transfusions save lives, they also

increase the risk of stroke, heart attack, kidney failure and death.


+ Blood transfusions, although lifesaving in critical conditions,

carry risk and can harm a patient if delivered unnecessarily.

+ The “TransFuse” gaming application allows users to explore the dangers

of unnecessary blood transfusions, engaging users in clinical scenarios

and enhancing their knowledge of better blood management practices.

+ The TransFuse 2.0 app’s ability to survey other transfusion results

allows users to understand possible scenarios and gain more

meaningful consensus in blood management practices.




Connect

Marrying software

development and blood

transfusion knowledge

to leverage a greater

awareness of the risks

of blood transfusions

— through an iPad

application.

Design

The “TransFuse”

gaming application

allows users to virtually

walk through clinical

scenarios. They earn

points for making

proper treatment

decisions.

Enable

Interacting with

the app, users are

encouraged to think

about the potential

consequences of

unnecessary blood

transfusions, while

preparing them to

make more informed

decisions in real time.

“About 20 percent of blood transfusions are unnecessary, and another 20 are inappropriate.”

—Mark Ereth, M.D., Cardiothoracic Anesthesiologist

has led to a 50 percent reduction in blood

transfusions at Mayo Clinic and an estimated

cost savings in excess of $10 million.

Much more education remains to be done.

“Nationwide, many of the day-to-day clinical

decisions on transfusions are 10 years behind

the science,” he says.

That’s where the iPad app comes in. Unlike many

medical iPad apps, TransFuse is more than a

textbook turned electronic. Users work through

clinical scenarios to better understand the risks

and benefits of transfusion. Animations show

how the body reacts to transfusion. The second

version, TranFuse 2.0, released in January 2012,

adds another dimension — the ability to build

regional practice consensus.

Consensus-Driven Decisions

Dr. Ereth explains that blood management

practices vary by region, and rightly so. Population

differences, how surgeries are performed and even

a patient’s diet affect the transfusion decision.

TranFuse 2.0 acknowledges these differences.

Users record how low they would let hemoglobin

levels drop for each scenario before transfusing.

“This approach will challenge the status quo,”

says Dr. Ereth. Typically, clinical consensus is

developed by a group of physicians meeting in a

conference room to formulate general consensus.

“The result is something like, ‘exercise more,’ or

for blood management, ‘transfuse less.’ Many

guidelines are so vague that there’s very little

benefit. We need specific guidelines or consensus

for more specific clinical scenarios.”

TransFuse 2.0 has the potential to build more

meaningful consensus. “Clinicians provide the

input,” he says. “By clicking on map, you can

compare your results to others and ask, ‘Why

are they different?’”

Dr. Ereth has a passion for better blood

transfusion management, but the iPad

technology is taking him in new directions.

“When we set out to do this, we had a bigger

vision than blood transfusion,” he says. “Our

app designers built an application platform

that can be easily adapted to other topics.”

Mayo Clinic apps on anesthesiology, general

surgery and tropical diseases are under

development. Dr. Ereth also is talking with

other health care institutions about applications.

“At Mayo, it’s part of our mission to share

best practices,” he says.

Communication is Changing

Dr. Ereth believes that much of that sharing will

be via iPad. “Ten years ago, a cellphone was

just a communication device,” he says. “Now,

it does everything.” He predicts the same

path for the iPad. “iPads will be instrumental in

education and the delivery of health care. Within

five years, it’s likely that the majority of health

care providers will use iPads or similar tablets

in all aspects of their practices.”


FPO


Project Title: Patient Travel Assistance

Proponent: Phillip Burton

Department: Capital Contracting

In the past, patients coming to Mayo Clinic’s

Rochester campus had access to the services of an

on-campus Northwest Airlines Service Center to help

them get back home. After the events of Sept. 11,

2001, however, Northwest Airlines closed most of

its service centers, including the one on Mayo’s

Rochester campus. Mayo Clinic then partnered with

another travel agency to supplement the services

that were lost when the Northwest Service Center

closed. This arrangement, however, ended in 2006

after Mayo Clinic consolidated five of its travel agency

relationships into a single contract with Carlson

Wagonlit Travel.

Since 2006, Mayo Clinic has continued to work with

Carlson Wagonlit Travel to offer travel services to

patients. But the cost of providing these services

has been greater than the revenue they produce, so

Mayo Clinic has continued to make up the difference.

But now, with the help of a CoDE fund from the

Mayo Clinic Center for Innovation, a new patient

travel services pilot project is working to improve,

streamline and ultimately self-fund the travel services

that Mayo Clinic offers to patients.

Phillip Burton, manager of Capital Equipment and

Lab Contracting for Mayo Clinic and a proponent

of the patient travel services pilot, says the goal of

the project is to consolidate and simultaneously

coordinate the scheduling of all patient appointments

and travel requirements when a patient makes the

choice to come to Mayo Clinic.

For those patients traveling to Mayo Clinic’s Rochester campus from out of

state or out of the country, trying to figure out and finalize travel arrangements

that will get them to Mayo Clinic in time for their appointments can often add

a new layer of stress to an already stressful situation.


+ Patients’ trip planning has traditionally involved

coordinating with multiple venues: travel, hotel and

hospital — which is time intensive and can be stressful.

+ A pilot patient travel services program is under way, attempting

to streamline a patient’s itinerary as soon as the decision

is made to visit — housing all information in one place.

+ The program shows promise as a way to seamlessly schedule

a patient’s travel and visit, avoiding unnecessary costs to

Mayo Clinic and allowing a more enjoyable patient stay.



Connect

Coordinating patients’

travel, appointment

and concierge service

needs through a single

touch-point, improving

patients’ travel and

visit.

Design

The service provided

makes Mayo a “one-

stop-shop,” outlining

patients’ travel,

arrangements and

appointments —

eliminating stress to

visitors and the cost

incurred from patient

“no shows.”

Enable

Ensuring that patients

get the most from their

visit, spending less time

making arrangements

and ensuring the

utilization of the

resources and services

Mayo provides.

“The cost of a patient ‘no show’ can range anywhere from $2,900 to almost $7,000. But, more than that, these situations can cause frustration and stress for patients.”

—Phillip Burton, Manager, Contracting

“There are at least three areas of Mayo that

we want to tie together to this,” he says. “First,

we want to be able to make all of the patient’s

arrangements for them as soon as they decide

that they want to come to Mayo Clinic. But we

also want to incorporate the services that our

existing appointment desk and patient concierge

desk offer, as well.”

Burton says the ultimate goal of the project is to

give patients and visitors to Mayo Clinic a “one-

stop shop” of sorts for all their travel needs to and

from Mayo Clinic, as well as somewhere to go

when changes need to be made.

“We want to give them one number to call,” Burton

says. “And if there’s a disruption or change to

their travel, we want to be able to say, ‘Let us

take care of rescheduling your appointment, let

us take care of rebooking your travel … we’ll

arrange everything.’ And then we’ll work with our

appointment desk so that those appointment

slots that open up can be given to other patients.”

Because some international and domestic patients

often travel significant distances to come to Mayo

Clinic, Burton says unforeseen interruptions or

changes in their travel itineraries due to weather

or personal circumstances can sometimes

cause those patients to be “no shows” for their

appointments. That causes problems for the

patients and for Mayo Clinic, Burton says.

“The cost of a ‘no-show’ patient for Mayo Clinic

can range anywhere from $2,900 to almost

$7,000,” he says. “But, more than that, these

situations also cause frustration and stress for

our patients as well.”

That’s why, if Mayo’s new travel office pilot

project is successful, Burton says it has the

ability to decrease these patient ‘no shows’

and unfilled appointment slots while increasing

patient satisfaction along the way.

“We want to be able to provide this service free

to our patients so that we can help ease their

minds and take the burden of traveling away

from them,” he says. “The funding we’ve gotten

from the Center for Innovation is going to go a

long way toward allowing us to do that. And, in

the long run, that’s going to help our patients

and it’s going to help Mayo Clinic at the same

time.”


FPO


Project Title: Stroke Telemedicine for Arizona Rural Residents and

Mayo Clinic Florida Regional Stroke Initiative

Proponent: Bart Demaerschalk, M.D. (Ariz.) and David Miller, M.D. (Fla.)

Department: Neurology (Ariz.) and Radiology (Fla.)

In 2009, project teams at Mayo Clinic in Arizona and Florida submitted separate CoDE fund requests

to support telestroke services. The teams hadn’t worked together and were at different stages of

implementation. They were awarded $75,000 to share collaboratively.

Mayo Clinic in Arizona “had three years of research under our belts and a comprehensive five-year plan

ready to go,” says Bart M. Demaerschalk, M.D., with the Department of Neurology. The project team

sought CoDE dollars to bring telestroke services to 35 rural hospitals in Arizona.

At Mayo Clinic in Florida, the project team sought CoDE funding to begin telestroke services with Parrish

Medical Center in Titusville, about 120 miles away. “Telestroke services wouldn’t have happened in

Florida without CoDE support. We lacked vital infrastructure and funding,” says David A. Miller, M.D.,

with the Departments of Neurosurgery and Radiology.

Telemedicine in Arizona 2012

More than 1,000 patients have been assessed, diagnosed, and treated through telestroke services

at Mayo Clinic in Arizona, a certified primary stroke center. Hospitals in ten communities currently

participate in the telestroke network.

“Statistics have confirmed the network’s safety, reliability and cost effectiveness,” says Dr.

Demaerschalk. “The median response time, after a hospital in the network contacts Mayo, is 1 minute.

Diagnoses and treatment decisions are accurate more than 96 percent of the time. There has been a

10-fold increase in use of emergency stroke treatments such as tissue plasminogen activator (tPA) in

network hospitals.”

In June 2011, Mayo Clinic in Arizona announced that all hospitals in the telestroke network had

transitioned to a subscription-based Mayo Clinic Telestroke Service, which plans to introduce five

additional hospitals to its network in 2012.

On the Horizon

The telemedicine program at Mayo Clinic in Arizona now offers 15 specialized services through

telestroke, teleneurohospitalists and tele-epilepsy (tele-EEG) networks. There is growing interest in a

teleconcussion network, too, notes Dr. Demaerschalk, in part because Arizona law mandates evaluation

and clearance of concussed athletes by trained healthcare providers.

“Updates on Stories from CoDE 2009–2010”



The Department of Neurology in Arizona recently completed an evaluation of the use of smart phones for

teleradiology and an evaluation of the Facetime video conferencing smart phone application (app) for

clinical stroke assessments. Both apps were successful when compared with face-to-face examination.

Mobile devices will likely become preferred vehicles for physicians of the future,” says Dr. Demaerschalk,

“because they afford complete site independence and rapid emergency response solutions.”

The department also volunteered to pilot econsult across every neurological subspecialty.

Telemedicine in Florida 2012

Because it benefitted from knowledge of Arizona’s experience, the project team at Mayo Clinic in

Florida was able to determine the best telestroke technology, streamline the physician-credentialing

process, and participate in building a national telestroke program far more quickly than anticipated.

Because of its participation in Mayo’s telestroke services program, Parrish Medical Center was

recertified as a primary stroke center. “Our relationship with Parrish has grown,” says Dr. Miller.

“Nearly 250 patients have been seen by telestroke consultants. The utilization rate for intravenous

tPA in Parrish was zero we began the partnership. Now it’s 21 percent.” The team also monitors the

time from when the call is made until a Mayo consultant responds: The average is 2.6 minutes.

The telestroke services team didn’t use some of the imaging services available originally, but has

since worked to integrate quality images that Mayo consultants can see in real time. Informally, the

team is also testing the use of smart phone technology.

“Patients are very receptive to telemedicine interaction,” says Dr. Miller. “They’re intrigued by the

technology, comfortable with the quality of interaction and reassured by access to a high level of

expertise.”

On the Horizon

As of March 1, 2012, Satilla Regional Medical Center in Waycross, Ga., became Mayo Clinic Health

System in Waycross. Plans are in place for Satilla to become a member of the telestroke network.

“There’s no question teleservices will continue to play a larger role in medicine,” says Dr. Miller.

“Telemedicine services are a logical way to reach more people in communities with small hospitals

that may not have specialists available.”


FPO


Project Title: Teledermatology: Outreach to State-wide PCPs & Dermatologists

Proponent: James Yiannias, M.D. (Ariz.)

Department: Dermatology

“Innovation is the process of taking ideas into manufacturable and marketable form.”

– Watts Humphrey

Mobile teledermatology as proposed by James Yiannias, M.D., the current Dermatology Department of

Mayo Clinic Arizona, continues to gain traction with Arizona State University’s student clinic adapting the

technology.

Increasing efficiency and patient care satisfaction the mobile teledermascope allows patients to

take a picture of their skin abnormality, which is sent to a physician. Dr. Yiannias sees the mobile

teledermascope as a way to provide almost instant and effective access to teledermatology specialists.

Patients have reaped the benefits of the product and process, feeling as though they have direct access

to their physician and can be provided triaged care if a suspicious skin abnormality is verified.

The mobile teledermascope and teledermatology process is increasing privacy and reliability as moves

the concept throughout the enterprise, with hopes for eventual commercialization.

Project Title: YES – A Patient Locator Board/Dashboard

Proponents: Vernon Smith, M.D. and Andy Boggust, M.D.

Department: Hospital Internal Medicine and Emergency Department

In 2009, Vernon Smith, M.D., and Andy Boggust, M.D., were not only granted CoDE funding for their

YES project but were also provided the conditions for innovation to occur. The YES board/dashboard,

Dr. Smith says, is “innovative in the sense of integration” operating as a transparent technology for staff

needing important data, in real time and at a glance.

In keeping with the CoDE innovation award, the YES board has continually evolved to provide more

innovative solutions to serve a larger audience, gaining attention both inside and outside of Mayo Clinic.

Microsoft’s Amalga, a health care data aggregator, has recently acquired the YES board technology,

providing real-time data delivered to care teams with a simple interface.

One key function of the YES board provides a visual and intuitive interface that has already deciphered

through data detailing the most relevant and real-time information about a patient to a member of his/

her care team. A key success factor of the YES board is not the technology or product itself, but the



YES team’s efforts toward continually improving the product and serving more people. Drs. Smith

and Boggust agree that the aim of YES is to allow workflow to drive the software, ensuring workflow

efficiency and better patient outcomes.

The YES board has increased Emergency Department efficiency by eliminating the need for finding a

number and paging the service needed to attend to a patient’s needs and ensuring the proper care or

service was delivered. The YES board allows the service to be requested with a click of a button, and

all services are recorded and made visible on the board with icons allowing the physician to ensure

the proper care was delivered.

Besides integrating the workflow with the data updates for routine tasks, YES has also played a

crucial role in numerous critical scenarios. On one occasion, the YES board accurately detected

and alerted physicians of a patient who was being discharged, but who was actually experiencing a

heart attack. The YES alert system allows a patient to be monitored in real time but also is crucial in

mapping his/her progression or improvements. Many patients have been positively impacted by the

information that YES provides physicians and continually allows them to forecast and act effectively

in critical scenarios.

Drs. Smith and Boggust agree that the initial funding from Mayo Clinic’s Center for Innovation

allowed for an ‘institutional buy-in’ which has brought the YES board attention within the enterprise

and traction outside of Mayo, as well.

The YES team understands that change is constant, and for innovation to occur, solutions that adapt

to change need to be readily available and flexible. In keeping with its goal to save critical thinking

for critical situtations, the team is continually adding to YES’s capabilities, updating its functions to

better serve its users.

Project Title: Pressure Ulcer Prevention Bed

Proponents: Jeff Bell

Department: Illustration and Design

“Be not afraid of going slowly, be only afraid of standing still.”

— Chinese proverb

The pressure ulcer bed continues to make progress in small chunks. The bed is back at Benchmark

Electronics undergoing a safety study to make sure it won’t pinch, electrocute or otherwise cause harm

during the clinical trial. If everything goes well, a proof of concept trial will take place in spring 2012.

“The road to success is always under construction.”

— Arnold Palmer



Project Title: Electronic Outreach for Dementia Behavior Management

Proponents: Glenn Smith, Ph.D.

Department: Psychology

In 2009 Glenn Smith, Ph.D., L.P., sought CoDE funding to respond to create a resource for dementia

patients, their family, physician, care facilitators and the Dementia Behavior Assessment Response Team

(DBART) to prevent future hospitalizations and disruptive behavioral occurrences.

Insights gained through working with Mayo’s Center for Innovation, created a model in which computers

could be shipped to care facilities, and Skype telecommunication technology could be used to

communicate. “Hindsight is 20/20, and what makes perfect sense now wasn’t as clear when we

proposed the plan,” Dr. Smith notes.

The incorporation of Skype not only cut the budget in half, but also provided a platform that was easy to

use. Dr. Smith sees not only the improved ability to provide care more efficiently, but also to provide care

that alleviates the concerns of families, health care providers and care facilities.

Maximizing efficiency and shortening proximity, the telecommunication approach provided a benefit to

those organizing the sessions, facilities requesting the Skype sessions, and peace of mind to the DBART

team facilitating the sessions.

Jane Smith, administrative assistant, has planned the DBART sessions for the past few years, from

planning the travel of the DBART team to shipping the computers with Skype capabilities. She notes the

difference the incorporation of telecommunication has had. “The technology cuts the time between a

sessions request and the actual session, preventing hospitalizations that may have occurred during the

previous waiting period,” she says.

About 50 miles away, an hour’s drive each way, St. Brigid’s at Hi Park in Red Wing can now request

Skype sessions with the DBART team with significantly less wait time. Lisa Oelkers, director of Social

Services and Family Communication leader at St. Brigid’s, notes that the DBART team provides excellent

care and, through Skype technology, has significantly lessened the wait time for an appointment.

Dementia behavior management is a topic of increased interest as the aging population continues

to grow in size, as is the need for more care facilities to deal with the influx. The DBART team and

telecommunication model has created an avenue for behavioral issues to be resolved and patient care to

be delivered successfully.



The success of this endeavor was made possible by:

Center for Innovation

2010 Culture and Competency of Innovation CoDE team

Terri Vrtiska, M.D., Physician Lead

Kim Savolainen, Project Manager

Beth Kreofsky, Associate Project Manager

Rose Anderson, Design Researcher

Dana Ragouzeos, Design Researcher

Jeri Neumann, Administrative Assistant

Theresa Lewis, Administrative Assistant

Center for Innovation leadership

Nicholas LaRusso, M.D., Medical Director

Barbara Spurrier, Administrative Director

Gianrico Farrugia, M.D., Associate Medical Director

Donny Dreyer, Operations Manager

Lorna Ross, Design Manager

CoDE Application Reviewers

Center for Innovation Staff

David Hayes, M.D., Mayo Clinic Management Team

Jan Jasperson, Systems and Procedures

Michael Rock, M.D., Chair, Hospital Practice Subcommittee

Jessica Grosset, Chair, Information Technology - Rochester

Brian Nass, Global Products and Services

Alfred Anderson III, Information Technology

Bill Bertschinger, Finance

Francesca Dickson, Public Affairs Consultant

CoDE 2010-2011 Awardees

Aida Lteif, M.D., Department of Pediatrics

Mark Ereth, M.D., Department of Anesthesiology

Acknowledgments for 2010-2011 CoDE Innovation Funds

Phillip Burton, Supply Chain Management

John Murphy, Public Affairs

Stephen Whiteside, Ph.D., L.P., Department of

Psychology and Psychiatry

David J. Cook, M.D., Department of

Anesthesiology

Joan Kilger, Department of Anesthesiology

Awardee Collaborators

Richard Hines, Andrew Higgins, Lance Trewhella,

Jeffrey Thompson, Sharon Prinsen, Katherine

Poduslo, Macaila Eick, Julie Host, Cheryl

Beacom, Lorena Nimke, Kris Mueller, Maggie

Kruser, Erin Fischer, Jodi Muenkel, Wade Kreun,

Ann Nelson, Lacey Gagnon, Tammy Olney,

Christopher Lopez Kohler, Lisa Mundy, Penny

Messner, Erin Peper, Mark Henderson, Timothy

Faber, Sherry Bergeson, Alysa Himle, Linda

Balgeman, Jennifer Dusso, Tia Meyer, Tom Besch

Kathy Shepel, Sharon Erdman, Steve Jurrens,

and James Christensen

Department Chairs and Administrators

who provided feedback and support for the

awardees

Brad Narr, M.D., Scott Eising, Kelly Krajnik, Amy

Davis

MC6295-73rev0512

Documents

CoDE 2010–2011 Mayo Clinic Center for Innovation · • CoDE 2010-2011 • Mayo Clinic Center for Innovation • 3 • exceptional success.” CoDE 2010-2011 Projects from the Mayo