Maximizing Wireless Across the Enterprise

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More healthcare organizations are transmitting patient health information over wireless LANs, giving care-providers real-time access to mission-critical data in countless locations. Clinical information tools and decision support technology that increase patient safety are now being brought to the fingertips of physicians and nurses on compact, sophisticated mobile computing devices. And as wireless hardware, software, Wi-Fi standards and security protocols improve, the question is not when to deploy wireless, but rather how to utilize it to meet its maximum potential.

In the Healthcare Information Manage-ment Systems Society (HIMSS) 2004 Leadership survey, 300 executives managing the information technology (IT) operations at more than 700 U.S. hospitals and healthcare organizations reported the urgency to adopt more IT; particularly bar-coded medication management (52 percent), electronic medical records (52 percent), clinical information systems (52 percent) and computerized physician order entry (51 percent). The pressure to implement healthcare IT mounts on both state and national government levels: President George Bush wants Americans to have electronic health records by 2014.

Where does wireless factor into this?

Everywhere. The practicality of wireless in healthcare is that it brings myriad clinical information systems to the fingertips of doctors, nurses and clinicians at the point of patient care. With a personal digital assistant (PDA), a physician can within seconds look up the clinical history of a patient in the emergency room; a nurse down the hall can update patient information via tablet PC while at the bedside rather than scurry back to a wired PC, while another care provider can more safely administer medication with the help of a wireless cart and bar code scanner.

Minimizing the burden of paperwork and associated costs, the right wireless strategy can improve operational efficiency and dramatically reduce medical errors, which already take the lives 195,000 Americans annually, estimates HealthGrades. Frost & Sullivan reports that adverse drug errors alone accumulate an estimated cost of $4,600 per error to the hospital, not to mention liability costs.


The time is right



While studies indicate the advantages inherent with going wireless, medical professionals are in many cases demanding nothing but unwired care. Physicians are more tech-savvy than once perceived. Forrester Research says physicians own more technology and go online more often than do other consumers, particularly in the adoption of PDAs. Physicians are five times as likely to carry a PDA than are typical consumers, Forrester reports.

Demographics factor into this. Frost & Sullivan reports that an estimated 80 percent of medical students and residents use PDAs as part of their daily work. A report in the Journal of the Medical Informatics Association found that overall prevalence of PDA use decreased with age: trainees were more likely than attendings to use PDAs for patient care resources, such as medical references and medical calculators.

Physicians on the wireless bandwagon discover that PDAs grant anywhere access to clinical histories, treatments, medications, tests, lab results and insurance information. The mini-sized devices tap into distant hospital locations and access patient record systems, insurance companies or hospital database systems.

At Berkshire Health System, a 330-bed, two-hospital system in Pittsfield, Mass., physicians utilize PDAs with embedded PatientKeeper software to connect them to the hospital's Meditech electronic CPOE, EMR and PCS (patient care system). While doctors and clinicians prefer handhelds, nurses like laptops fixed on mobile carts to perform assessments and real-time charting, as well as retrieve vital patient information.

These computers on wheels, a.k.a. COWs, souped up with more ergonomic and compact designs, are being wheeled into the ER and surgery suite. For medication management, nurses wheel them next to a patient's bed and use a bar code scanner (which is sometimes wireless) to confirm that the medication was ordered by the physician and administered correctly by the pharmacy.


Wireless becomes reliable


Chuck Podesta, CIO of Berkshire Health System, says the hospital implemented a Cisco Systems Inc. 802.11b (2.45 GHz, 54 Mbps) wireless network for Meditech's PCS. "At the time we purchased PatientKeeper, their only mode of network connection was infrared stations set up throughout the facility," explains Podesta. "They now have the ability to connect to wireless so we are now migrating to wireless fidelity [Wi-Fi] so that we have one standard for wireless."

The advent of 802.11 Wi-Fi standards, also available in b (2.45 GHz, 11 Mbps) and a (5 GHz, 54 Mbps) flavors, fueled healthcare's adoption of wireless. The industry likes - and needs - the reliability and durability of Wi-Fi.

In 2004, The FocalPoint Group estimated the total U.S. medical Wi-Fi market to be $495 million. This included Wi-Fi equipment, Wi-Fi networking and systems integration, and also mentoring, control and optimization. By 2010, the group said the Wi-Fi market will reach nearly $2 billion.

802.11b is the most popular LAN [local area network] standard, but hospitals are turning to the g standard as a higher bandwidth alternative. According to Steve Lewack, director of technical services and communications at Columbus Regional Healthcare System in Columbus, Ga., the hospital uses an 802.11b network and is starting to push out g in a few select areas where the bandwidth requirements are much higher. "Certain applications are thirsting for more bandwidth, such as PACS images which can range from 10 megabytes (MB) and 350 MB," says Lewack.

Nearby in North Carolina, physicians and nurses at Wake Forrest Baptist Medical Center rely on an 802.11a wireless network to access an EMR that houses nine years of patient data. Now on their second-generation wireless LAN, the hospital started in 1996 with a proprietary Symbol wireless infrastructure that had a staggering one-megabit throughput. The hospital is now starting to infiltrate the educational and research environment.


Do's and don'ts


More than 4,500 untethered doctors, nurses and clinicians at Wake Forrest have wireless access to more than 50 applications via Citrix Systems' MetaFrame platform, including IDX System Corp.'s inpatient record system Last Word, Medscape's Logician outpatient record system and IDX's outpatient scheduler, to name of few.

Wireless needs a well-planned strategy. "You can't deploy wireless just for wireless sake," says Jon Brown, IT security officer. "You need a reason such as [to allow care providers to access] the CPOE or EMR. Wireless to do wireless will spend you a lot of money and you will not see the return."

The clinical information systems are accessed via mobile laptops mounted to med carts. Brian Uzwiak, manager of network technology services, says the hospital deployed COWs with the 802.11a network since there is not yet a functionality for PDAs and Pocket PCs with this a standard. "We are limited to the 802.11a protocol because we could not use b or g in our children's hospital. They are using a wireless patient monitoring system that operates in the same frequencies as these protocols," explains Uzwiak.

Eventually, the hospital will implement b and g coverage outside the children's hospital, as well as a public wireless network for patients and visitors.

Uzwiak says success depends on coordination with other departments that may have devices that use radio frequencies in order to eliminate conflicts. "There have to be clear policies and someone who arbitrates when a conflict arises," he says. "The other thing we learned is maintenance; upkeep and support of the client devices is equally as important as the maintenance of the wireless network itself. If you have a physician who uses a wireless device and he or she can not get to what [information] he or she wants to get to, they will not use the technology."


Reap what you sow


Consistencies in a hospital's networking layer are imperative to efficiently managing a wireless network, says Tim Stettheimer, PhD, CIO at St. Vincent's Hospital of Birmingham, Ala. The flagship digital hospital of Ascension Health System, St. Vincent's partnered with Cisco in 2001 and worked with Bell South to design and engineer a wireless network that spans one million square feet. "If you try to mix and match technology for your network, especially as you get into wireless and move toward technologies such as Voice over IP (VoIP), you can get into some real challenges, such as when isolating, diagnosing and fixing the problems quickly," he says.

Doctors, nurses and clinicians utilize PDAs and tablet PCs to freely access the hospital's clinical data repository, which contains eight years of patient data. "We recognized that there were certain things that a stationary computer could not do that a mobile computer could," explains Stettheimer. "One of the most important of those was the continuity of the information environment for the care provider."

With a goal of zero preventable errors, St. Vincent's installed McKesson's electronic order entry and decision support system. The closed loop system tightly integrates with St. Vincent's pharmacy system that integrates with the medication dispensing system, which also talks with the medication administration system. The clinical decision support system can be wirelessly accessed, but the medication administration is not Wi-Fi enabled.

Once pilot projects are complete and  a secure WLAN is in place, unwired hospitals can leverage their infrastructure by introducing new mobile technologies. St. Vincent's is implementing radio frequency identification (RFID) technology in three areas. Smartcards that are RFID-enabled have been deployed in an outpatient diagnostic center to identify people as they enter areas of the facility. These will soon be used throughout the entire campus.

Next, a badge from Radiance will broadcast its location to installed Radiance antennas to determine patient and employee location. Also, the employee location can be tracked when he or she utilizes Vocera communication badges. "Through the combination of Wi-Fi and RFID signal tracking, we can determine location information for badges as well as tablets and other wireless devices," says Stettheimer.

The administrative-rich information will be displayed on an Awarix unit dashboard installed in each medical unit. The large flat-screen replaces the traditional white board, displaying key information from clinical, ADT, environmental services, transportation, and location systems.


Security in layers


Real-time access to boundary-free data unearths a plethora of challenges, most notably security. Healthcare providers must pay careful attention to HIPAA regulations that aim to protect the privacy of private patient health information as well as guard against rogue users, particularity professional hackers who can wreak havoc to a wireless network.

Just ask John Halamka, CIO of Harvard Medical School and CIO of CareGroup Healthcare Systems. The WLAN at Beth Israel Deaconess, part of CareGroup and within close proximity to the prestigious Massachusetts Institute of Technology, withstands a hacking attempt every seven seconds.

Security must be dealt with proactively to safeguard the network against security attacks. Halamka says that private health information transmitted over Beth Israel's airwaves requires an alphabet soup of encryption and authentication protocols: WPA (Wi-Fi protected access), PEAP (protected extensible authentication protocol), TKIP (temporal key integrity protocol), and MIC (message integrity code).

Security for patients and families who want to use Beth Israel's WLAN is no different than Starbuck's security model; users in this case are given a temporary identifier for temporary access. Voice data transmitted over the air using Vocera technology are protected using the WPA protocol. Finally, Halamka explains that RFID is secured with the WEP (wired equivalent privacy) standard.

Lewack at Columbus Regional says the hospital uses wireless LAN security and management tools from various companies to fortify its network. "We require encrypted sessions between our wireless devices and AirFortress, an AES encryption gateway that secures and encrypts traffic between our devices and our network with 256-bit encryption," says Lewack. Installed on each mobile computing device is an AirFortress secure wireless client that allows mobile devices to securely connect with the wireless gateway. "We wanted a network where we could control what devices were and were not connected to it," he says.

Columbus Regional also uses Air Defense for round-the-clock monitoring and intrusion protection, a necessity in a healthcare environment. AirDefense's technology incorporates distributed sensors and a server. The remote servers monitor all WLAN activities and communicate with the server, which correlates and analyzes the data for IT to access through a web-enabled console. "The system also looks at the operational performance of the wireless network and lets us know when throughput and performance are affecting users," says Lewack.

For all remote users who come into the hospital with their wireless devices, Lewack says they require a VPN connection to the network. "This uses a Cisco VPN Concentrator system to secure the tunneled communications between the device and the network," says Lewack. In addition to a network user ID and password, Columbus Regional has broken up the WLAN into unrouted VLANs which force all wireless devices to access on the encrypted gateways. This reduces the number of accidental associations of non-authorized devices.

Why risk an attack? "You have to keep in mind that when everything is encrypted, we are looking at the convenience of the physicians to be able to get the information more easily," says Lewack. "The more easily they can get the information, the sooner they can get the diagnosis and allow patients to receive treatment and leave."


Conclusion


Beth Israel's Halamka sees wireless as no longer an option, but an enterprise utility. In the wake of mounting pressure to adopt more sophisticated clinical information systems and decision-support technologies that improve operational efficiency and increase patient safety, healthcare organizations are turning to wireless to put these tools into the hands of care providers at the point of care. Since power is going where power has never been before, IT and network engineers experienced with the rigors of wireless technology suggest outside consulting. Most wireless users in hospitals suggest piloting a project before deploying it throughout the enterprise. Also, test out a variety of mobile computing devices. If the mobile devices aren't user friendly - and the WLAN lacks integrity - physicians and nurses won't use them.