Patent Application
20240112802
Any and all applications, if any, for which a foreign or domestic priority claim is identified in the Application Data Sheet of the present application are hereby incorporated by reference under 37 CFR 1.57.
Hospitals, nursing homes, and other patient care facilities typically include patient monitoring devices at one or more bedsides in the facility. Patient monitoring devices generally include sensors, processing equipment, and displays for obtaining and analyzing a medical patient's physiological parameters. Physiological parameters include, for example, respiratory rate, SpO2 level, pulse, and blood pressure, among others. Clinicians, including doctors, nurses, and certain other medical personnel use the physiological parameters obtained from the medical patient to diagnose illnesses and to prescribe treatments. Clinicians also use the physiological parameters to monitor a patient during various clinical situations to determine whether to increase the level of medical care given to the patient.
Patient monitors capable of measuring pulse oximetry parameters, such as SpO2 and pulse rate in addition to advanced parameters, such as HbCO, HbMet and total hemoglobin (Hbt) and corresponding multiple wavelength optical sensors are described in at least U.S. patent application Ser. No. 11/367,013, filed Mar. 1, 2006 and entitled Multiple Wavelength Sensor Emitters and U.S. patent application Ser. No. 11/366,208, filed Mar. 1, 2006 and entitled Noninvasive Multi-Parameter Patient Monitor, both assigned to Masimo Laboratories, Irvine, CA (Masimo Labs) and both incorporated by reference herein. Further, noninvasive blood parameter monitors and corresponding multiple wavelength optical sensors, such as Rainbow™ adhesive and reusable sensors and RAD-57™ and Radical-7™ monitors for measuring SpO2, pulse rate, perfusion index, signal quality, HbCO and HbMet among other parameters are also available from Masimo Corporation, Irvine, CA (Masimo).
Advanced physiological monitoring systems may incorporate pulse oximetry in addition to advanced features for the calculation and display of other blood parameters, such as carboxyhemoglobin (HbCO), methemoglobin (HbMet) and total hemoglobin (Hbt or SpHb), as a few examples. Advanced physiological monitors and corresponding multiple wavelength optical sensors capable of measuring parameters in addition to SpO2, such as HbCO, HbMet and Hbt are described in at least U.S. patent application Ser. No. 11/367,013, filed Mar. 1, 2006, titled Multiple Wavelength Sensor Emitters and U.S. patent application Ser. No. 11/366,208, filed Mar. 1, 2006, titled Noninvasive Multi-Parameter Patient Monitor, incorporated by reference herein. Further, noninvasive blood parameter monitors and corresponding multiple wavelength optical sensors, such as Rainbow™ adhesive and reusable sensors and RAD-57™ and Radical-7 ™ monitors for measuring SpO2, pulse rate, perfusion index (PI), signal quality (SiQ), pulse variability index (PVI), HbCO and HbMet among other parameters are also available from Masimo.
For purposes of summarizing the disclosure, certain aspects, advantages and novel features of several embodiments have been described herein. It is to be understood that not necessarily all such advantages can be achieved in accordance with any particular embodiment of the embodiments disclosed herein. Thus, the embodiments disclosed herein can be embodied or carried out in a manner that achieves or optimizes one advantage or group of advantages as taught herein without necessarily achieving other advantages as can be taught or suggested herein.
This disclosure describes embodiments of a medical network service that can replace or supplement some or all of an expensive internally staffed clinical facility network with a cloud-based networking service. The medical network service in certain embodiments can provide networking services via software as a service (SaaS) technologies, platform as a service (PaaS) technologies, and/or infrastructure as a service (IaaS) technologies. The medical network service can provide these services to large existing clinical facilities such as metropolitan hospitals as well as to smaller clinical facilities such as specialized surgical centers. The networking services provided by the medical network service can replace and/or supplement existing IT networks in hospitals and other clinical facilities and can therefore reduce costs and increase security and reliability of those networks. In addition, the medical network service can provide synergistic benefits that can improve patient outcomes and patient care.
In certain embodiments, a method of providing patient monitoring data over a network may include, by a medical edge router having one or more hardware processors, receiving input packets with the medical edge router, where the input packets include information related to patient monitoring data, analyzing the input packets to identify any patient monitoring alarms in the input packets, transmitting first ones of the input packets that do not correspond to a patient alarm over a first communications channel, and in response to detecting a patient monitoring alarm in second ones of the input packets, transmitting the second packets over multiple second communications channels.
In certain embodiments, a system for providing patient monitoring data over a network can include a medical edge router having one or more hardware processors. The medical edge router can include a traffic inspector that can receive input packets including information related to patient monitoring data and to analyze the input packets to identify any patient monitoring alarms in the input packets. Further, the medical edge router can include a routing module that can transmit first ones of the input packets that do not correspond to a patient alarm over a first communications channel and transmit second ones of the input packets over multiple second communications channels in response to detecting a patient monitoring alarm in the second input packets.
In certain embodiments, a method of providing patient monitoring data over a network can include, by a medical edge router having one or more hardware processors, receiving input data with the medical edge router. The input data can include information related to patient monitoring data. The method may also include attempting to transmit the input data over a first communications channel. Further, the method may include, in response to determining that the first communications channel is unavailable, attempting to transmit the input data over a second communications channel. Moreover, the method may include, in response to determining that the second communications channel is unavailable, transmitting a reduced form of the input data over a third communications channel.
In certain embodiments, a method of configuring a patient profile in a patient monitoring device can include, by a medical network service including one or more hardware processors, determining whether a patient admitted to a clinical facility is associated with an existing alarm settings profile stored with the medical network service. The method may also include, in response to determining that the patient is associated with the existing alarm settings profile, assigning the existing alarm settings profile to a monitoring device associated with the patient. Further, the method may also include, in response to determining that the patient is not associated with an existing alarm settings profile: identifying a matching alarm profile template that matches one or more attributes of the patient, and assigning the matching alarm profile template to the monitoring device.
The method of the preceding paragraph may include any combination of the following features. For instance, the method may further include obtaining the one or more attributes of the patient when the patient is admitted to the clinical facility. The one or more attributes of the patient can include one or more of the following attributes: age, gender, health condition, and medication associated with the patient. The identifying of the matching alarm profile template can include selecting a neonate alarm template in response to determining that the age of the patient corresponds to a neonate. The neonate alarm template can have different alarm settings than an adult alarm template. Further, the method may also include presenting the matching alarm profile template to a clinician for approval prior to assigning the matching alarm profile template to the monitoring device. The method may also include presenting the matching alarm profile template to a clinician for customization prior to assigning the matching alarm profile template to the monitoring device. The existing alarm settings profile may be generated at a second clinical facility different from the clinical facility and stored in computer storage for subsequent access.
In certain embodiments, a system for configuring a patient profile in a patient monitoring device can include a medical network service having one or more hardware processors. The medical network service can determine whether a patient admitted to a clinical facility is associated with an existing alarm settings profile stored with the medical network service. In response to determining that the patient is associated with the existing alarm settings profile, the medical network service can also assign the existing alarm settings profile to a monitoring device associated with the patient. In response to determining that the patient is not associated with an existing alarm settings profile, the medical network service can also identify a matching alarm profile template that matches one or more attributes of the patient and associating the matching alarm profile template with the patient.
The system of the preceding paragraph may include any combination of the following features. For instance, the medical network service may also obtain the one or more attributes of the patient when the patient is admitted to the clinical facility. The one or more attributes of the patient comprise one or more of the following attributes: age, gender, health condition, and medication associated with the patient. The medical network service can also identify the matching alarm profile template by at least selecting a neonate alarm template in response to determining that the age of the patient corresponds to a neonate. The neonate alarm template may have different alarm settings than an adult alarm template. The medical network service may also present the matching alarm profile template to a clinician for approval prior to associating the matching alarm profile template with the patient. The medical network service may also present the matching alarm profile template to a clinician for approval prior to associating the matching alarm profile template with the patient. The existing alarm settings profile may be generated at a second clinical facility different from the clinical facility and stored in computer storage for subsequent access.
Throughout the drawings, reference numbers are re-used to indicate correspondence between referenced elements. The drawings are provided to illustrate embodiments of the inventions described herein and not to limit the scope thereof.
A trend in hospitals today is to move away from big box hospitals that provide all services typically provided by hospitals and to provide smaller community hospitals closer to people in suburban communities. The smaller community hospitals can be more specialized and may, for example, include surgical centers that specialize in a few types of surgery or even a single type of surgery. Smaller community hospitals can provide efficiency gains in time and healthcare costs by being closer to patients and by focusing on a few areas of specialties. However, a drawback from having such facilities is that these facilities tend not to have the same financial capability as larger hospital organizations and therefore tend not to be able to afford expensive information technology network infrastructure for communicating between patient monitoring devices and clinician devices. In addition, such facilities typically also may not have the resources to purchase an electronic medical records (EMR) system, paging systems, or other systems that can be useful in caring for patients.
Furthermore, such systems can be expense for large hospitals to maintain as well. Hospitals prefer to focus on caring for patients rather than managing information technology and hospital networks. However, due to the realities of modern medical practice, many large hospitals and other clinical facilities have entire information technology (IT) departments to deal with internal networking issues including, for example, server maintenance and wireless networking maintenance. Because hospitals have a core competency in providing care for patients, hospitals tend to hire qualified IT personnel to staff their IT departments. However, as hospitals tend to reduce costs to improve patient care while impacting patients less financially, there is a risk that hospitals may be forced to cut IT costs for their IT departments and, as a result, may unintentionally compromise security and ultimately patient safety due to lower reliability of hospital networks.
This disclosure describes embodiments of a medical network service that can replace or supplement some or all of an expensive internally staffed clinical facility network with a cloud-based networking service. The medical network service in certain embodiments can provide networking services via software as a service (SaaS) technologies, platform as a service (PaaS) technologies, and/or infrastructure as a service (IaaS) technologies. The medical network service can provide these services to large existing clinical facilities such as metropolitan hospitals as well as to smaller clinical facilities such as specialized surgical centers. The networking services provided by the medical network service can replace and/or supplement existing IT networks in hospitals and other clinical facilities and can therefore reduce costs and increase security and reliability of those networks. In addition, the medical network service can provide synergistic benefits that can improve patient outcomes and patient care.
In addition, various embodiments of a medical edge router are described herein. The medical edge router can be an intelligent edge router or the like that provides redundant communications features for transmitting patient data to the medical network service.
Turning to the Figures,
In addition, the MNS 110 can communicate with the home/mobile clinician devices 118 over a network 108 and the home mobile patient devices 120 of a network 108. The example networks 108 shown can be local area networks (LAN), wide area networks (WAN), the Internet, an intranet, combinations of the same or the like. Any type of clinician computing device 118 can communicate with the MNS 110 including, for example, laptops, desktops, servers, work stations, tablets, wireless handheld devices such as cell phones, smart phones, personal digital assistants and wireless pagers, combinations of the same or the like. Likewise, the MNS 110 can communicate with any type of patient monitoring device 120 including bedside devices, body worn devices, telemetry devices, and the like. Any of these patient devices 112 can output parameter data, trend data and/or alarms which can be provided to the MNS 110 over the network 108 and then re-routed by the MNS 110 to institutions 112, 114, or computers thereof, and mobile clinician devices 118.
Advantageously, in certain embodiments, by providing network services to the various entities shown, the MNS 110 can provide greater reliability, security and therefore patient safety compared to existing networks in hospitals and other clinical facilities. The MNS 110 may be implemented in one or more computing devices, such as servers, which may be geographically located, for example, in a data center, or which may be geographically disbursed, for example, in multiple data centers. The MNS 110 can include enterprise-class networking capabilities of any state of the art or currently available data center today including, for example, load balancing features, failover features, intelligent network problem detection and resolution features, and the like.
Thus for example, one benefit that the MNS 110 can provide in contrast with existing hospital networks is that if a switch or other network device were to fail at an existing hospital network, that network would then go down and deprive patients of necessary care. In contrast, in the MNS 110, if a component such as a switch goes down, the MNS 110 may be able to reroute network traffic through other switches and other components and continue or resume critical patient care services for the various institutions and devices shown.
Further, the MNS 110 can be configured such that service level agreements (SLAs) can be provided to institutions so that guarantees of service can be met by the MNS 110. An example SLA guarantee can be that alarms processed by the MNS 110 can be provided to clinician devices in the institutions 112, 114 within a specified period of time, such as a few seconds or the like. The MNS 110 may also provide uptime guarantees through SLAs or the like.
Moreover, by providing network services from the cloud, in certain embodiments, the MNS 110 can provide synergistic effects that are greater than the benefits of simply moving the networking services out of the hospital and into a centralized data center. Many examples of synergistic benefits are described in detail with respect to
In addition to these features, in certain embodiments any of the data collected by the MNS 110 can be anonymized and provided to the external entities 116 including, for example, government agencies or research institutions for demographic and healthcare research purposes, additional examples of which are described below with respect to
Turning to
The MNS 210 includes, for example, a network management module 202. The network management module 202 can manage network communications with other networks, including networks in hospitals and other facilities as well as communications with mobile patient devices and clinician devices. For example, the network management module 202 can communicate with devices in hospitals and outside of hospitals, or inside of facilities and outside of facilities. The network management module 202 can provide the networking services described above with respect to
The MNS 210 also includes an EMR system 204 that can generally store patient data from any facility, including data collected from patient monitoring devices in patients' homes or while patients are mobile outside of their homes or out of facilities. For example, the EMR system 204 can include such information as parameter values, trend values, alarm histories, patient demographic data, patient condition data including diagnoses, patient medical histories, and patient medications, among a variety of other patient data. The data in the EMR 204 can advantageously be used by other components of the MNS 210 as described below to improve patient care.
A clinician portal 206 of the MNS 210 can provide a user interface or user interfaces that can be accessed by clinicians via their clinician devices to monitor the health status of their patients for whom they are responsible. The clinician portal 206 may, for example, be implemented in one or more web pages, mobile applications, or other network applications and may provide information about the wellness or relative wellness of each patient.
In one embodiment, a wellness score or index is computed for each patient by a risk analysis system 208 of the MNS 210, and the clinician portal 206 can depict these wellness indices among other parameter data, trend data and alarms for each patient. In one embodiment, the clinician portal 206 facilities triaging patients by providing functionality for patients to be ordered or ranked based on their wellness scores or indices as computed by the risk analysis system 208. Example features for computing wellness indices or risk assessments are described in Appendices IV and V. For example, the risk analysis system 208 can take into two or more parameters, such as any combination of the following parameters: oxygen saturation (e.g., SpO2), respiratory rate, pulse rate, heart rate, total hemoglobin level, methemoglobin, carboxyemoglobin, blood pressure, ECG output, encephalography output, or the like. The risk analysis system 208 can combine data from such parameters and reduce this data to a single value or data representation of the combination of those parameters. The single value may be, for example, an index or score that is on a scale of 0 to 10, where 10 may represent a most healthy state, while 0 may represent a least healthy state. Thus, such scores could be used to rank the relative health state or acuity of patient sicknesses and such numerical rankings can be output for presentation to clinicians in the clinician portal 206, thereby enabling clinicians to quickly triage patients.
Advantageously, in certain embodiments, the risk analysis system 208 also leverages aspects of the cloud-based infrastructure of the MNS 210 to improve the wellness index calculation. For example, the risk analysis system 208 may be able to access patient profile data from the MNS 210 that comes from previous hospital visits or other clinical facility visits from a single facility or multiple facilities to compute historical wellness indices or to compute a current wellness index. The risk analysis system 208 can also personalize the wellness index based on patient attributes stored in the EMR system 204. For example, the risk analysis system 208 can personalize which parameters are weighted more heavily in the combination of parameters that are output as a wellness index based on previous patient conditions listed in EMR system 204. In currently available systems, different institutions typically do not share their EMR data, and EMRs therefore cannot be used to correlate patient data from multiple institutions together and thereby improve risk analysis and wellness indices. However, such advantages can be made possible in certain embodiments by the centralized cloud nature of the MNS 210.
The MNS 210 also includes a patient profile manager 211. The patient profile manager 211 can manage patient profiles, which can include information about patient demographics, patient alarm settings, including alarm settings from previous visits to potentially multiple different facilities, patient conditions and so forth, and example features of which are described in greater detail below with respect to
The MNS 210 also includes an early warning system 216. The early warning system 216 can issue early warning alarms based on parameter measurements, indices such as the wellness index or other indices. The early warning system 216 can look for patterns in patients to facilitate detecting never events, including events that should occur never or rarely, like a patient dying in bed without any intervention, particularly when a patient is home and would not ordinarily be under the care of a hospital or have access to a system like the risk analysis system 208 or the early warning system 216.
An escalation module 218 of the MNS 210 can provide functionality for escalating alarms from a first or primary care provider to a second or subsequent care provider in case the primary care provider is unavailable. However, the escalation module 218 may also provide additional functionality such as obtaining information from a remote primary care provider and providing this information to a secondary local care provider who is local to the patient and can therefore intervene using the information provided by the first care provider. Such embodiments are described below in greater detail with respect to
An information exchange system 220 of the MNS 210 facilitates communicating information about patients to government or research institutions 118 described above with respect to
Further, the data provided by the information exchange system 220 can be valuable to government agencies or research institutions to determine the effects of local conditions on health conditions. It may be discovered, for instance, that patients that go to a specific facility or set of facilities in a region are afflicted with disease related to nearby coal mining which can be ascertained by research institution or a government agency that has responsibility over such activities. Accordingly, the information exchange system 220 can provide value data that can provide reports that can be used by external entities to improve patient care.
A journaling module 222 of the MNS 210 can capture clinician interactions with medical devices that are in the institutions and/or that are in patients' homes or that are body worn in mobile situations. The interactions can include any type of button press, alarm setting change, RFID tag interaction, or the like and can be recorded for the purposes of determining clinician response times to alarms or other measures of the quality of a clinician's care. The journaling module 222 can further leverage the centralized monitoring capabilities of the MNS 210 to compare the quality of care as journaled or otherwise calculated amongst different institutions as an apples-to-apples comparison because some or all of the data from these institutions can be provided to the centralized MNS 210.
Further, the journal module 222 can facilitate comparing the quality of care between different units in a hospital or other facility including different floors or groups of clinicians or shifts, or the like. The journal module 222 can also facilitate comparing similar groups amongst different facilities, such as an ICU group in two different facilities, and can thereby enable an organization to identify gaps or deficiencies of care in different facilities that can be corrected. This information can be provided in real time or near-real time so that adverse patient care outcomes can be quickly addressed, in contrast to the past where information about quality of care is often analyzed well after an adverse care event has occurred (or even after a patient has been discharged). Further embodiments of journaling and detecting clinician interactions with devices (including via RFID tags) are described in greater detail in Appendices I through III.
A telemedicine module 224 of the MNS 210 can facilitate telecommunications between clinicians and patients, including telepresence communications where clinicians can diagnosis, treat, or otherwise attend to the needs of patients remotely using audio visual systems or the like. The telemedicine module 224 can also be used in conjunction with features of the escalation module 218 described below with respect to
The process 300 begins at block 302 where a patient is admitted to a hospital. In the admission process, the patient may provide demographic information to the hospital, including the gender, age, weight, other health conditions that the patient has, medications that the patient is on and so forth. This information can be stored in the EMR described above with respect to
At block 304, the patient is assigned a monitoring device. The monitoring device may be a bedside device or a body worn device and could be used in an institution such as a hospital or at the patient's home or while the patient is mobile. At block 306 the patient profile manager 211 determines whether the patient has existing alarm settings profile in the MNS 210. An existing alarm settings profile may include customized alarm settings based on the demographics of the patient. Different types of patients may benefit better from different alarm settings. For instance, neonates or children may require different alarm settings from adults because their physiology differs from adults. Likewise, alarm settings can be based on gender, race due to physiological differences among races (however slight), as well as due to age and previous medical conditions or medications that a person is on or symptoms that the patient is reporting when admitted to the hospital.
If the patient has an existing alarm settings profile in the MNS, then the patient profile manager 211 transmits, uploads, or otherwise downloads the existing alarm settings profile to the monitoring device associated with the patient at block 308. Thus, it can be seen that an advantage in certain embodiments of the patient profile manager 211 is that the existing profile can be stored in the cloud and therefore accessed whenever that patient is readmitted to a hospital or other clinical facility. However, if the patient does not have an existing alarm profile, at block 310 the patient profile manager 211 can identify an alarm profile template that matches attributes of the patient, including any of the demographic attributes described above. So, for example, if the patient is a neonate, the patient profile manager 211 can access the stored template of alarm settings for neonate.
At block 312, the patient profile manager 211 outputs an option to use the alarm profile template to a clinician. The clinician can then decide whether to use that particular template, select a different template, or customize the template to meet the needs of the particular patient. Thus, continuing at decision block 314, the patient profile manager 211 determines whether the clinician accepts the template. If so, the patient profile manager 211 transmits, uploads, or otherwise downloads the alarm profile template to the monitoring device and provides options for the clinician to modify the template at block 318. Block 318 may also be reached after block 308 where the existing alarm settings profile is downloaded to the monitoring device. However, if the clinician does not accept the template 314 as described above, at block 320 the patient profile manager 211 can provide options for the clinician to manually adjust alarm settings or to select another template.
In alternative embodiments, instead of downloading or transmitting patient profiles to devices, each device may already have several patient profiles already installed, and the patient profile module 211 selects one and assigns it to the device for the particular patient.
At block 402, the device profile manager 212 outputs a device configuration adjustment user interface. An example of such a user interface is shown in
At block 404, the device profile manager 212 receives a user selection of a patient monitoring device or other device in the network from the user interface. The user may select any device shown in the user interface to obtain more data about that device, e.g., to change settings on the device or to set policies or rules for the device. At block 406, the device profile manager 212 receives user updates to the device settings and pushes those updated device settings to the devices over the network at block 408.
Turning to
The user interface 500 includes a device explorer 510, device configuration pane 520, and a current measurements pane 530. The device explorer 510 includes a tree 512 or hierarchy of facilities and devices, enabling users to select a facility, explore floors or subsections of that facility, and select devices within those floors or subsections. In the depicted embodiment, the tree 512 shown includes data representing a hospital that has an operating room floor, an intensive care unit (ICU) floor, and a general floor. The operating room floor option is expanded to show devices within the operating room floor. One of the devices 514 is shown selected by a user (e.g., using a mouse or touch screen input).
Advantageously, in certain embodiments, the user interface 500 can provide access to any device that connects to the MNS. Thus, network administrators can drill down into any device among several different facilities. In addition to a tree view, in some embodiments, other views of the devices can be shown, such as a topology view that shows interconnections between devices in the network.
Upon user selection of one of the devices 514, the device profile manager 212 can output details 522 of the device 514 in the device configuration pane 520. These details 522 include configuration settings about the device and possibly other information stored on the device, including patient profiles, device profiles, policies, what network the device is connected to (not shown), and optionally applications installed on the device and settings thereof (not shown). These details 522 can be selected by a user to adjust the configuration settings of the selected device 512. For example, a user can select specific patient profiles to add or remove to the device.
In one embodiment, each device can have one or more profiles. In one embodiment, each device has a single device profile that specifies where in the facility the devices belongs (such as what floor), what network the device is connected to, and so forth. Policies can also be associated with a device and may be part of a device's profile. Policies can include rules about how a device may be used and may be defined by users (including clinicians and/or network technicians or the manufacturer of the device). For example, a policy may be defined that states that a device is to be used for general floor monitoring and not intensive care or operating room monitoring. Accordingly, if a clinician attempts to associate the device with a patient in the ICU or operating room floor, software in the device (or in the MNS) can detect that the device is being used on the wrong floor and therefore may prevent operation of the device or issue an audio/visual warning to not use the device. The device or MNS can detect that the device is on the wrong floor, for instance, by analyzing network traffic to and from the device to determine where in the network the device is connected.
Another example of a policy is related to patient profiles. A user can define a policy that the device may be used only with neonates or only with adults. In another example scenario, a user can define a policy that the device will issue a warning if a user changes alarm limits on the device or changes alarm limits beyond certain thresholds. Another policy could be defined to state that alarm thresholds cannot be changed on the device unless the device is associated with an existing patient profile. Software on the device and/or the MNS can enforce the policies by warning users of violations and/or preventing operation of the device until the policies are complied with. Accordingly, the policies used in devices can improve patient care outcomes.
Advantageously, in certain embodiments, because the MNS may be implemented in a centralized cloud architecture, the user interface 500 can enable policies, profiles, and settings to be adjusted for a plurality of devices at once instead of one at a time. As a result, network and device maintenance can be streamlined. Likewise, the user interface 500 can facilitate pushing software updates to multiple of the devices at once. Example user interface controls 524 are shown, which are buttons in the depicted embodiment, for adding new profiles, policies, and updating devices.
Moreover, the device profile manager 212 can detect problems occurring in different devices and report these problems or a representation thereof on the user interface 500. In the depicted embodiment, a device health indicator 542 is shown that can reflect the health of a device on the network. The device health indicator 542 can be a light or graphic that is green, yellow, or red depending on whether a device is functioning well, functioning poorly, or not functioning at all. Other indicators may be used than a colored light, such as text, a graph, a number, 1-5 star ratings, or any combinations of the same or the like. The device profile manager 212 can score devices based on device performance and adjust the output of the indicator 542 accordingly. Instead of a separate indicator, a graphic for each device in the device explorer 510 could instead show colors for each device, corresponding to the health of each device.
The current measurements pane 530 depicts current measurements on the selected device 514 and is optional in some embodiments. A trend view button 532 can allow a user to see trends on these measurements. Like the device health indicator 542, a patient health indicator 544 is also shown that may have some or all of the same functionality as the device health indicator 542 except with respect to a patient. The patient health indicator 544 can also be displayed on a medical device associated with the patient, a clinician device remote from the medical device, or a nurse's workstation, to name a few examples. The patient health indicator 544 can reflect an overall health or wellness of the patient and may be based on the wellness index described above. In other embodiments, the patient health indicator 544 can include or be the wellness index.
At block 602, the network management module 202 receives monitoring data of a patient at the MNS via WiFi, LAN, or other networking technologies of the clinical facility to which the patient is admitted. Once the patient is discharged, the patient may be outfitted with a wearable home monitoring device 604. The wearable monitoring device may be the same device used to monitor the patient in the clinical facility. In addition, the device may be a mobile device that need not be wearable in some embodiments. The device may, for instance, be any of the devices or variations thereof described in U.S. patent application Ser. No. 13/010,653, filed Jan. 20, 2011, attorney docket number MASIMO.730P1, titled “Wireless Patient Monitoring System,” the disclosure of which is hereby incorporated by reference in its entirety.
When a patient is discharged, the patient typically leaves the hospital network. Accordingly, in currently-available systems, there is a typically a period of time where the patient is not being monitored once the patient leaves the facility. However, the network management module 212 can facilitate continued monitoring of the patient by receiving monitoring data from the patient via a cellular or satellite network at block 606. Then, if an alarm condition is detected at block 608, the network management module 212 (or the early warning system 216 using the network management module 212) can pass a notification from the MNS to a care provider 610. Accordingly, the MNS can facilitate a continuum of care for a patient and continuous monitoring even when a patient has left a clinical facility.
At block 702, the risk analysis system 718 receives parameter data from the patient monitor while the patient is in bed. When the patient is in bed, the patient is typically resting and may have a lower heart rate than when the patient is moving, all other factors being equal. However, when the patient moves, the patient's heart rate may elevate, and other parameters associated with the patient may change as well. It can be desirable to adjust patient monitoring to account for patient changes in movement or other situational context to avoid producing false alarms.
Thus, the location and/or motion of the patient are monitored at block 704. The location and/or motion of the patient may be monitored in several ways. One or more motion sensors may be included in the patient monitoring device, and the monitoring device may be worn on the patient. Thus, for example, the monitoring device may include a gyroscope, accelerometer, or the like that can determine whether the patient is moving, walking, or the like. Telemetry can also be used to ascertain where a patient is located and/or moving to. For instance, when a patient is wearing a patient monitor that communicates over wireless networks, the MNS can determine the patient's position by triangulation of nearby access points to which the patient's monitoring device is sending and receiving signals. In other situations, patients may take an assisted walk with a nurse or other clinician. The nurse or other clinician may have an RFID tag or the like that can be detected by the patient monitoring device (as described in Appendix III), giving a clue as to the movement and/or location of the patient.
Thus, the risk analysis system 218 determines at block 706 whether the patient is ambulatory or moving. If so, the risk analysis system 218 can adjust alarm settings for the patient due to the patient being ambulatory. For example, the risk analysis system 218 can increase a heart rate threshold limit that would trigger an alarm if it detects that the patient is ambulatory. If the patient is not ambulatory, the process loops back to block 704, where the patient is continued being monitored using existing alarm settings.
In other embodiments, the risk analysis system 218 may adjust patient monitoring differently. Instead of adjusting alarm settings, for example, the risk analysis module 218 can assign scores to patients based on their activity level and incorporate these scores into the wellness index described above. For instance, if the patient is walking, the risk analysis module 218 may lower the weight given to heart rate in calculating the wellness index so as to avoid an increased heart rate adversely impacting the wellness index calculation. The risk analysis module 218 can also take into account additional factors before determining whether to adjust the weight applied to the heart rate, however, such as the health conditions or diseases of the patient. If the patient has heart disease or some other condition, it may be prudent to alarm or indicate an adverse health condition whenever the patient's heart rate rises, no matter the activity level of the patient. Thus, the risk analysis module 218 may use the health condition of the patient to override other considerations such as patient movement.
At block 802, an alarm generated by a monitoring device is received by the escalation module 218. The escalation module 218 identifies a primary provider to be contacted by the alarm at block 804. The escalation module 218 may store a list of providers that are associated with a patient and may provide a user interface that enables users to adjust this list in certain embodiments. At block 806, the escalation module 218 determines the primary care provider's situational context. If the situational context of the primary care provider is that the provider is located far from the patient, the escalation module 218 may perform intelligent escalation as described below.
The situation where the primary provider is far removed from the patient may occur increasingly more commonly. In particular, as smaller clinics replace some functionality of larger hospitals, clinicians may not all be co-located in the same hospital. Further, modern travel conveniences make it possible for surgeons and other specialists to travel to patient sites and vice versa to perform patient care. Accordingly, a primary provider may be distant from several of his or her patients.
The escalation module 218 determines at block 808 whether the primary care provider is located remotely from the patient. If not, the escalation module 218 further determines at block 810 whether the primary care provider is available. The primary care provider may be off duty or unable to take a page, for example, in which case the escalation module 218 escalates the alarm to a secondary provider at block 814. Otherwise, the escalation module 218 can provide the alarm and optionally data from the monitoring device (such as trend data) the primary provider for possible in-person intervention at block 812.
However, in the scenario where the primary care provider is not located close by but may be available, the escalation module 218 can still provide the alarm and optionally data from the monitoring device to the primary provider for remote intervention at block 816. The primary provider may use telepresence technologies to interact with the patient, e.g., using the telemedicine module 224 of the MNS 210. The escalation module 218 can then receive instructions from the primary provider regarding an alarm response at block 818, e.g., through a user interface or telepresence technology. These instructions can include a diagnosis, recommended medication, or other recommended course of actions that the escalation module 218 can relay to the secondary provider along with the alarm at block 820.
Thus, in certain embodiments, the process 800 enables a remote primary care provider to provide instructions to a secondary, local care provider to better enable the secondary care provider to respond to an alarm. This process 800 can therefore improve upon currently-available processes, which typically require the secondary provider (who may be less familiar with the patient than the primary provider) to interpret the patient's alarm without guidance from the remote primary care provider.
In addition to the embodiments described above, in certain embodiments, clinician devices (including mobile devices) can interact with the MNS and/or with the patient monitoring devices directly. A clinician's mobile device, for instance, can receive alarms, trend data, parameter data, or any other data associated with a patient from the MNS or directly from the patient monitoring devices. The clinician's device may also receive data from multiple patients that are associated with the clinician, including features of the clinician portal described above. Thus, for example, the clinician's device may depict wellness indices for the various patients and thereby enable the clinician to triage alarms. The clinician device can also include the capability to silence alarms remotely (e.g., by transmitting an instruction input by the clinician to the patient monitoring device). In an embodiment, the clinician device communicates directly with the patient monitoring device using Bluetooth (e.g., if in the same room or nearby) or WiFi or another wireless technology. In another embodiment, the clinician device communicates with the patient monitoring device through MNS if the clinician (or the clinician's organization) is affiliated with the MNS (e.g., is a paying customer) but otherwise directly communicates with the patient monitoring device. In the scenario where the clinician is affiliated with the MNS, the clinician may be able to advantageously obtain trend data for a plurality of patients, whereas directly connecting to each patient device individually may or may not provide this functionality.
Further, in certain embodiments, each patient device includes a network communications module that enables the patient device to communicate with the MNS over a network. In anther embodiment, a gateway device (not shown) is provided in each room of a facility, or in a few rooms of a facility, which connects to the patient device and which communicates with a plurality of devices in the room or rooms. The gateway device may itself be a patient monitor that includes ports for connecting to other devices. The gateway device can receive data from these other medical devices and pass the data on to the MNS for storage in the EMR, analysis by the risk analysis module 218, and the like. Some examples of other devices in a typical clinical facility that can connect through the gateway device include ventilators, pumps, general oxygen equipment, and the like. An example gateway device that may be used with the features described herein is described in U.S. application Ser. No. 13/651,167, filed Oct. 12, 2012, titled “Medical Monitoring Hub,” the disclosure of which is hereby incorporated by reference in its entirety.
Moreover, any of the features described herein can be implemented in conjunction with features from any of the following applications, the disclosure of each of which is hereby incorporated by reference in their entirety: U.S. application Ser. No. 11/633,656, filed Dec. 4, 2006, attorney docket MASIMO.537A, titled “Physiological Alarm Notification System”; U.S. application Ser. No. 12/904,925, filed Oct. 14, 2010, attorney docket MASIMO.609P1, titled “Systems and Methods for Storing, Analyzing, Retrieving, and Displaying Streaming Medical Data”; U.S. application Ser. No. 12/904,377, filed Oct. 14, 2010, attorney docket MASIMO.756A2P1, titled “Medical Monitoring System”; U.S. application Ser. No. 13/269,296, filed Oct. 7, 2011, attorney docket MASIMO.840A, titled “Risk Analysis System”; and U.S. application Ser. No. 13/371,767, filed Feb. 13, 2012, attorney docket MASIMO.892A, titled “Medical Characterization System.”
Turning to
One of the major challenges associated with providing network-based medical monitoring services for hospitals and other clinical facilities is network connectivity. Networks, including the Internet, are prone to network failure and therefore, it can be desirable to provide for redundancy in communication channels or pathways that access the MNS. Advantageously, in the depicted embodiment of
As shown, the point-of-care devices 912 are arranged in a patient area 910, which may be a hospital or a subset thereof. The point-of-care devices 912 can be patient monitoring devices, such as any of the patient monitoring devices described above, and can monitor any physiological parameter of a patient, such as oxygen saturation, blood pressure, heart rate, ECG parameters, respiratory rates, hemoglobin, and the like. The point-of-care devices 912 can be bedside devices or body-worn patient monitoring devices, and in general, may provide physiological parameter data, trend data, alarms and alerts to clinician devices over a network. Further, the point-of-care devices 912 can provide such data outside of a hospital network to clinician devices over the Internet 950 (or other wide-area network) through a medical edge router 920.
In the depicted embodiment, the medical edge router 920 communicates with the network operation centers 970 over multiple communication pathways, including multiple Internet Service Provider networks 940. For convenience, this specification generally refers to the Internet Service Provider networks 940 as ISPs. The medical edge router 920 can be an intelligent edge router that provides redundant communications for transmitting patient data, among other features. For instance, in one embodiment, the medical edge router 920 can attempt to send patient data, including physiological parameters, trends and/or alarms, to the MNS in a network operations center 970 over a first one of the ISPs 940. If the first ISP 940 is unavailable, the medical edge router 920 can attempt to communicate with the MNS through a second one of the ISPs 940, and so forth, until the medical edge router 920 has attempted to contact the MNS through most or all of the ISPs 940.
In one embodiment, if the ISPs are unavailable, then the medical edge router 920 can attempt to contact the MNS through a wireless ISP 944; for example, by communicating wirelessly through a local access point 942, which then communicates via the ISP 944. In other embodiments, the medical edge router 920 can attempt to first communicate through broadband mechanisms, such as wired LAN, WAN or wireless or satellite-based broadband, prior to using dial-up or lower bandwidth links. In yet another embodiment, the medical edge router 920 performs back-up communications to clinicians via cellular networks if the ISPs 940, 944 are unavailable. In such instances, the medical edge router 920 may, for instance, send a text message (via SMS) or email or other communication to one or more clinicians that includes some or all of the data obtained from one or more point-of-care devices 912. Since text messages and emails tend to be limited in length, the medical edge router 920 can instead summarize data obtained from the point-of-care devices 912 and send the summarized data over the cellular network or other network.
In some embodiments, the ISPs 940 or 944 may be available, but one or more of the network operation centers 970 that host the MNS may be down and unavailable. Accordingly, it can be useful in such circumstances for the medical edge router 920 to communicate via SMS or email over one of the ISPs 940 or cellular networks (not shown), to clinicians. In any case, when communicating via SMS or email, the medical edge router 920 can reduce the amount of data sent or selectively prioritize the data sent to clinicians, to send higher-priority data in view of the reduced bandwidth available, in such communication of channels. In one embodiment, for example, the medical edge router 920 can send a summary of the alarms or parameter values from the point-of-care devices 912 to a clinician via SMS or email or a similar mechanism, without sending trend data, which can consume a significant amount of bandwidth. In another example, medical edge router 920 prioritizes alarms over parameter values over trend data, such that if an alarm is to be transmitted, the medical edge router 920 can transmit the alarm to a clinician device, instead of more bandwidth-intensive data. If no alarms are to be transmitted, the medical edge router 920 can transmit more bandwidth-intensive data.
In yet another embodiment, the medical edge router 920 is also connected to an uninterruptible power supply or UPS 932 that can provide the medical edge router 920 with continued power, should mains power become available. The UPS 932 can also power other systems in the clinical facility, including the point-of-care devices 912 and a local server mirror appliance 930. The local server mirror appliance 930 can be a server or other computing device that includes some or all of the functionality of the MNS described above. In one embodiment, the local server mirror appliance 930 includes important or critical patient care functionality of the MNS. For example, the appliance 930 may include a portion of the functionality of the MNS and may operate in parallel with the MNS to calculate parameter values or a wellness index in case of failure or inability to contact the MNS over the network.
Also shown is a VPN 960 through which the point-of-care devices 912 can connect to the network operation centers 970. The VPN 960 can provide security for such communications, although the VPN 960 may be optional in some embodiments.
It should also be noted that in certain embodiments, the computing environment 900 of
Turning to
The example medical edge router 1020 shown includes a data logger 1021 and a routing module 1022 that both receive the input packets. The data logger 1021 can be a packet-sniffer or the like that copies the input packets and thereby makes the input packets available to a traffic inspector 1023. The data logger 1021 may also store the packets for subsequent analysis, including analysis for determining conditions leading up to a network communications failure after the failure occurred. The traffic inspector 1023 can inspect the input packets logged by the data logger 1021 to determine whether any of the input packets include alarms. If an alarm is detected, the traffic inspector 1023 can notify the routing module 1022 of such an alarm condition, enabling the routing module 1022 to prioritize the distribution of packets that relate to include alarms (including optionally packets having parameter data associated with the alarms).
The routing module 1022 includes a failover module 1024 that can receive communications from the traffic inspector 1023 about alarms and can select destinations for the packets accordingly. The routing module 1022 also communicates with one or more routing tables 1025 that can be populated using any suitable routing protocol, such as the Border Gateway Protocol (BGP) commonly used in routers in the Internet. The routing module 1022 can route the input packets to appropriate routers or switches in the Internet (or other networks) based on the information stored in the routing tables 1025. The routing module 1022 can update the routing tables 1025 over time, using BGP or another protocol.
The failover module 1024 can provide the redundant failover features described above, at least in part, with respect to
The routing module 1022 can prioritize alarms, as described above, when detected by the traffic inspector 1023. When an alarm is included in an input packet, as indicated by the traffic inspector 1023, the routing module can prioritize the alarm by broadcasting the alarm over multiple or all channels used by the routing module 1022. For instance, the routing module 1022 can broadcast such packets over multiple ISPs, or over both wired and wireless ISPs, or over both an ISP and a cellular network, or the like.
Packets are sent from the routing module 1022 to a network interface card 1030 that can implement the data link and/or physical layers of the TCP/IP network stack. The network interface 1030 includes, in the depicted embodiment, an Ethernet or wired modem 1032, a wireless (e.g., WiFi) radio 1034, and a cellular radio 1036. The network interface 1030 outputs the output packets based on instructions from the routing module 1022. For instance, if the routing module 1022 instructs the network interface 1030 to send packets over a wired ISP, the network interface 1030 can send such packets via the Ethernet or wired modem 1032. Conversely, if the routing module 1022 instructs the network interface 1030 to send such packets via a WiFi or wireless link, the wireless radio 1034 of the network interface 1030 can transmit such packets. Similarly, the cellular radio 1036 can transmit certain packets over cellular networks (such as SMS packets), as instructed by the routing module 1022. The components of the network interface 1030 are example components only and could be added to or removed from in other embodiments.
In the depicted embodiment, the medical edge router 1020 also includes a loudspeaker 1026 and a display 1027. The loudspeaker 1026 can output audible alarms when network connectivity is detected as being down by the medical edge router 1022. For instance, whenever an ISP becomes unavailable, or another network communications channel becomes unavailable, the routing module 1022 can cause the loud speaker 1026 to issue an audible alarm. Likewise, the display 1027 can output visual alarms in response to the routing module 1022 detecting a network communication path being unavailable, enabling network personnel to troubleshoot the medical edge router 1020 when needed. The medical edge router 1020 can also send SNMP packets to IT personnel to alert IT personnel of network failures, failover conditions, and the like.
In addition, the medical edge router 1020 can also include a precision time service 1028 that can apply time stamps to packets sent by the routing module 1022. This precision time service 1028 can be synchronized or substantially synchronized with time services used by other medical edge routers 1020 in the hospital network or in other hospital networks remote from the medical edge router 1020 shown. Accordingly, packets received by the MNS in any one of the network operation centers 970 can maintain a synchronous or time-ordered view of the packets. It can be beneficial to maintain a synchronous or time-ordered view of medical data received from the point-of-care devices 912 to ensure or attempt to ensure that alarms and other data are received in the proper time order, so that clinicians can take appropriate action based on such data.
In one embodiment, the precision time service 1028 communicates with one or more GPS satellites to obtain a precision time value. In another embodiment, the precision time service 1028 communicates with an atomic clock, or the like, to obtain a precision time value, although other techniques may be used to obtain precision time values.
The medical edge router 1020 can have many other features than those shown in
Turning to
At block 1102, the edge router attempts to communicate with the medical network service (MNS) through a first ISP. At block 1104, the medical edge router determines whether the ISP is available. If so, the edge router is able to communicate its message to the MNS, and the process 1100 ends. However, if the ISP is not available, then the medical edge router determines at block 1106 whether all ISPs are unavailable, or whether the MNS is not responding. If all ISPs are unavailable, it may be helpful for the medical edge router to contact the MNS using another communication pathway, such as cellular or wireless. However, some ISPs may be available while the MNS is not responding, in which case it may also be useful to use a different communication pathway to provide patient information to clinicians.
If all ISPs are unavailable or the MNS is not responding, then the edge router can attempt to communicate with the MNS through the next ISP at block 1108, looping back to block 1104. However, if all ISPs are unavailable or the MNS is not responding, then the edge router can send reduced data to the clinicians via an alternative mechanism, such as email or SMS, at block 1110. For example, the edge router can transmit a summary of patient monitoring data over a cellular network or via email to clinicians. In one embodiment, in response to detecting that all IPSs are unavailable or the MNS is not responding, the routing module 1022 sends a request to the local server mirror appliance 930 or the point of care devices 912 for a summary of the patient monitoring data. Then, upon receipt of the summary data, the edge router can communicate the summarized data over an alternative communications channel. In other embodiments, the local server mirror appliance 930 and/or the point of care devices 912 send summary data to the edge router together with more verbose patient monitoring data so that the edge router can send the summary data without delay in case of communications pathways to the MNS or clinicians becoming unavailable.
Turning to
At block 1202, the edge router receives input packets, and at block 1204, analyses those input packets to identify any patient monitoring alarms. For instance, the traffic inspector 1023 of the edge router 1020 can identify any patient monitoring alarms in a given packet. In one embodiment, the traffic inspector 1023 searches for a particular payload in a packet that indicates that an alarm is in the packet, and in another embodiment, alarm information is included in a header of the packet.
If an alarm is detected at block 1206, the traffic inspector 1023 sends the alarm over multiple communication channels for redundancy at block 1208, such as over multiple ISPs, or over a wired ISP and a wireless ISP, or over an ISP and over a cellular network, combinations of the same, or the like. If an alarm is not detected at block 1206, then the process 1200 can loop back to 1204, effectively allowing the traffic inspector 1023 to continue to monitor for the presence of alarms.
Many other variations than those described herein will be apparent from this disclosure. For example, depending on the embodiment, certain acts, events, or functions of any of the algorithms described herein can be performed in a different sequence, can be added, merged, or left out all together (e.g., not all described acts or events are necessary for the practice of the algorithms). Moreover, in certain embodiments, acts or events can be performed concurrently, e.g., through multi-threaded processing, interrupt processing, or multiple processors or processor cores or on other parallel architectures, rather than sequentially. In addition, different tasks or processes can be performed by different machines and/or computing systems that can function together.
The various illustrative logical blocks, modules, and algorithm steps described in connection with the embodiments disclosed herein can be implemented as electronic hardware, computer software, or combinations of both. To clearly illustrate this interchangeability of hardware and software, various illustrative components, blocks, modules, and steps have been described above generally in terms of their functionality. Whether such functionality is implemented as hardware or software depends upon the particular application and design constraints imposed on the overall system. The described functionality can be implemented in varying ways for each particular application, but such implementation decisions should not be interpreted as causing a departure from the scope of the disclosure.
The various illustrative logical blocks and modules described in connection with the embodiments disclosed herein can be implemented or performed by a machine, such as a general purpose processor, a digital signal processor (DSP), an application specific integrated circuit (ASIC), a field programmable gate array (FPGA) or other programmable logic device, discrete gate or transistor logic, discrete hardware components, or any combination thereof designed to perform the functions described herein. A processor can be a hardware processor comprising digital logic circuitry. Further, a processor can be a microprocessor, but in the alternative, the processor can be a controller, microcontroller, or state machine, combinations of the same, or the like. A processor can also be implemented as a combination of hardware computing devices, e.g., a combination of a DSP and a microprocessor, a plurality of microprocessors, one or more microprocessors in conjunction with a DSP core, or any other such configuration. Although described herein primarily with respect to digital technology, a processor may also include primarily analog components. For example, any of the signal processing algorithms described herein may be implemented in analog circuitry. A computing environment can include any type of computer system, including, but not limited to, a computer system based on a microprocessor, a mainframe computer, a digital signal processor, a portable computing device, a personal organizer, a device controller, and a computational engine within an appliance, to name a few.
The steps of a method, process, or algorithm described in connection with the embodiments disclosed herein can be embodied directly in hardware, in a software module executed by a processor, or in a combination of the two. A software module can reside in RAM memory, flash memory, ROM memory, EPROM memory, EEPROM memory, registers, hard disk, a removable disk, a CD-ROM, or any other form of non-transitory computer-readable storage medium, media, or physical computer storage known in the art. An example storage medium can be coupled to the processor such that the processor can read information from, and write information to, the storage medium. In the alternative, the storage medium can be integral to the processor. The processor and the storage medium can reside in an ASIC. The ASIC can reside in a user terminal. In the alternative, the processor and the storage medium can reside as discrete components in a user terminal.
Conditional language used herein, such as, among others, “can,” “might,” “may,” “e.g.,” and the like, unless specifically stated otherwise, or otherwise understood within the context as used, is generally intended to convey that certain embodiments include, while other embodiments do not include, certain features, elements and/or states. Thus, such conditional language is not generally intended to imply that features, elements and/or states are in any way required for one or more embodiments or that one or more embodiments necessarily include logic for deciding, with or without author input or prompting, whether these features, elements and/or states are included or are to be performed in any particular embodiment. The terms “comprising,” “including,” “having,” and the like are synonymous and are used inclusively, in an open-ended fashion, and do not exclude additional elements, features, acts, operations, and so forth. Also, the term “or” is used in its inclusive sense (and not in its exclusive sense) so that when used, for example, to connect a list of elements, the term “or” means one, some, or all of the elements in the list. Further, the term “each,” as used herein, in addition to having its ordinary meaning, can mean any subset of a set of elements to which the term “each” is applied.
While the above detailed description has shown, described, and pointed out novel features as applied to various embodiments, it will be understood that various omissions, substitutions, and changes in the form and details of the devices or algorithms illustrated can be made without departing from the spirit of the disclosure. As will be recognized, certain embodiments of the inventions described herein can be embodied within a form that does not provide all of the features and benefits set forth herein, as some features can be used or practiced separately from others.
| Number | Date | Country | |
|---|---|---|---|
| 61703643 | Sep 2012 | US | |
| 61713418 | Oct 2012 | US | |
| 61738362 | Dec 2012 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 17061495 | Oct 2020 | US |
| Child | 18530852 | US | |
| Parent | 15498194 | Apr 2017 | US |
| Child | 17061495 | US | |
| Parent | 14030360 | Sep 2013 | US |
| Child | 15498194 | US |
