Boaz Carmeli

Simulation-based models of emergency departments:: Operational, tactical, and strategic staffing

The Emergency Department (ED) of a modern hospital is a highly complex system that gives rise to numerous managerial challenges. It spans the full spectrum of operational, clinical, and financial perspectives, over varying horizons: operational—a few hours or days ahead; tactical—weeks or a few months ahead; and strategic, which involves planning on monthly and yearly scales. Simulation offers a natural framework within which to address these challenges, as realistic ED models are typically intractable analytically. We apply a general and flexible ED simulator to address several significant problems that arose in a large Israeli hospital. The article focuses mainly, but not exclusively, on workforce staffing problems over these time horizons. First, we demonstrate that our simulation model can support real-time control, which enables short-term prediction and operational planning (physician and nurse staffing) for several hours or days ahead. To this end, we present a novel simulation-based technique that implements the concept of offered-load and discover that it performs better than a common alternative. Then we evaluate ED staff scheduling that adjusts for midterm changes (tactical horizon, several weeks or months ahead). Finally, we analyze the design and staffing problems that arose from physical relocation of the ED (strategic yearly horizon). Application of the simulation-based approach led to the implementation of our design and staffing recommendations.

Control of Patient Flow in Emergency Departments, or Multiclass Queues with Deadlines and Feedback

We consider the control of patient flow through physicians in emergency departments (EDs). The physicians must choose between catering to patients right after triage, who are yet to be checked, and those who are in process (IP) and are occasionally returning to be checked. Physician capacity is thus modeled as a queueing system with multiclass customers, where some of the classes face deadline constraints on their time-till-first-service, whereas the other classes feedback through service while incurring congestion costs. We consider two types of such costs: first, costs that are incurred at queue-dependent rates and second, costs that are functions of IP sojourn time. The former is our base model, which paves the way for the latter (perhaps more ED realistic). In both cases, we propose and analyze scheduling policies that, asymptotically in conventional heavy traffic, minimize congestion costs while adhering to all deadline constraints. Our policies have two parts: the first chooses between triage and IP...

High throughput reliable message dissemination

We consider applications that require high rate, reliable message dissemination in a many-to-many environment. Examples of such applications include stock market centers and synchronized server clusters. As network capacity increases, the achievable throughput of messaging applications becomes bounded by processing times rather than communication speed. To reduce processing times we suggest the use of message aggregation. We consider performing message aggregation at either the sender, a message-server, or a network switch. The performance of each of these methods in terms of throughput and delay is analytically evaluated and compared against that of a naive implementation that does not perform message aggregation. We show that in typical real-world messaging applications, performing message aggregation can increase throughput by order of magnitude.We base our results on experiments that have been conducted using various operating systems running on different hardware platforms. Our results indicate that the achievable throughput of messaging applications is determined by the number of packets-per-second, rather than bytes-per-second, a receiver or a transmitter should handle.

Toward simulation-based real-time decision-support systems for emergency departments

Emergency Departments (EDs) require advanced support systems for monitoring and controlling their processes: clinical, operational, and financial. A prerequisite for such a system is comprehensive operational information (e.g. queueing times, busy resources,…), reliably portraying and predicting ED status as it evolves in time. To this end, simulation comes to the rescue, through a two-step procedure that is hereby proposed for supporting real-time ED control. In the first step, an ED manager infers the EDs current state, based on historical data and simulation: data is fed into the simulator (e.g. via location-tracking systems, such as RFID tags), and the simulator then completes unobservable state-components. In the second step, and based on the inferred present state, simulation supports control by predicting future ED scenarios. To this end, we estimate time-varying resource requirements via a novel simulation-based technique that utilizes the notion of offered-load.

Information technology for healthcare transformation

Rising costs, decreasing quality of care, diminishing productivity, and increasing complexity have all contributed to the present state of the healthcare industry. The interactions between payers (e.g., insurance companies and health plans) and providers (e.g., hospitals and laboratories) are growing and are becoming more complicated. The constant upsurge in and enhanced complexity of diagnostic and treatment information has made the clinical decision-making process more difficult. Medical transaction charges are greater than ever. Population-specific financial requirements are increasing the economic burden on the entire system. Medical insurance and identity theft frauds are on the rise. The current lack of comparative cost analytics hampers systematic efficiency. Redundant and unnecessary interventions add to medical expenditures that add no value. Contemporary payment models are antithetic to outcome-driven medicine. The rate of medical errors and mistakes is high. Slow inefficient processes and the lack of best practice support for care delivery do not create productive settings. Information technology has an important role to play in approaching these problems. This paper describes IBM Researchs approach to helping address these issues, i.e., the evidence-based healthcare platform.

Masking Gateway for Enterprises

Todays business world revolves around the need to share data. On the other hand, the leakage of sensitive data is becoming one of our main security threats. Organizations are becoming more aware of the need to control the information that flows out of their boundaries and must more strictly monitor this flow in order to comply with government regulations. This paper presents an SOA-based solution called Masking Gateway for Enterprises (MAGEN), which allows the sharing of data while safeguarding sensitive business data. The major novelty lies in architecting a single system that handles a wide range of scenarios in a centralized and unified manner.

Lessons learned in deploying a wireless, intranet application on mobile devices

Wireless mobile applications provide a new set of design challenges for application designers. While many programmers are familiar with creating traditional desktop applications, they are not familiar with the challenges of the wireless mobile domain. Instead of having keyboards, mice, and high-resolution screens, the mobile application designer is constantly reminded that the handheld, mobile application is a very different (not deprived) input/output device. We describe our attempt to use these devices in creating a wireless corporate information application. The paper can be broken into several key efforts. First, we examine the hardware/networking requirements of the problem. Second, we examine our development environment for application coding and testing. Finally, we describe design issues encountered while developing applications for this environment.

Dynamic masking of application displays using OCR technologies

Industry coalitions are developing regulations to govern information sharing and to protect sensitive business data and the privacy of individuals. In many cases, these regulations make it impossible to outsource business operations, unless the companies have effective technologies to protect sensitive information. This paper addresses scenarios in which data servers and applications are owned and maintained on the premises of a company, and the service providers remotely access the data and the applications. We present a unique solution called Masking Gateway for Enterprises (MAGEN) that masks sensitive information appearing on application displays, without any interference with the applications that generate those screens. The major novelty lies in the utilization of optical character recognition (OCR) for analyzing and understanding application screens. Together with a comprehensive rule language, this approach makes it possible to characterize fields containing sensitive information and mask them according to predefined rules. The rule language is very flexible, abstract, and intuitive and is designed to cope with a vast set of policies and security needs. We describe the major challenges in implementing MAGEN and the results of experimenting with it in situations that occur in actual business settings. We outline techniques that optimize the OCR process to minimize latency and ensure robust operation.

Public health affinity domain: a standards-based surveillance system solution

The negative impact of infectious disease on contemporary society has the potential to be considerably greater than in decades past due to the growing interdependence among nations of the world. In the absence of worldwide public health standards-based networks, the ability to monitor and respond quickly to such outbreaks is limited. In order to tackle such threats, IBM Haifa Research Lab and IBM Almaden Research Lab developed a PHAD implementation which consists of an information technology infrastructure for the public health community leveraging the Integrating the Healthcare Enterprise (IHE) initiative and important standards. This system enables sharing of data generated at clinical and public health institutions across proprietary systems and political borders. The ability to share public health data electronically paves the way for sophisticated and advanced analysis tools to visualize the population health, detect outbreaks, determine the effectiveness of policy, and perform forecast modeling.

Towards health 2.0: mashups to the rescue

Over the past few years, we have witnessed a rise in the use of the web for health purposes. Patients have begun to manage their own health data online, use health-related services, search for information, and share it with others. The cooperation of healthcare constituents towards making collaboration platforms available is known today as Health 2.0. The significance of Health 2.0 lies in the transformation of the patient from a healthcare consumer to an active participant in a new environment. We analyze the trend and propose mashups as a leading technology for the integration of relevant data, services, and applications. We present Medic-kIT, a mashup-based patient-centric Extended Personal Health Record system, which adheres to web 2.0 standards. We conclude by highlighting unique aspects that will have to be addressed to enable the development of such systems in the future.