There are few more challenging demands of an IT professional than designing and implementing an efficient and effective network between several sites in a healthcare system, yet that expectation has become the norm in this era of multi-institution healthcare organizations. To develop a superhighway of efficiency, careful planning and meticulous attention to network configuration must become the order of the day.

One of the most critical steps to networking off-site facilities occurs before the first wire is laid.


Advice from the 30,000-foot view

Ward Keever, executive director for executive services of CTG Healthcare Solutions in Cincinnati, established his expertise with years of experience as CIO of a couple of large health systems, including the Medical Center of Delaware (now Christiana Health) and the University of Pennsylvania. Evaluating the needs of the end-users and assessing the current and projected technology is a vital up-front activity to offer the best chance that a multi-site network will function seamlessly and avoid immediate obsolescence.

Keever largely credits the young network engineer he hired with developing a very robust backbone that featured FDDI (Fiber Distributed Data Interface) that supports data rates of up to 100 Mbps installed through the walls of the hospital, even though the technology which would capitalize on the speed of that wire was not fully developed at the time. Because labor costs for laying the wire was far in excess of the cost of the fiber itself, and they didn't want to have to upgrade their backbone within a couple of years, using high-speed, fiber-optic cable proved to be a good decision.

Assessment also includes testing the sites that will reside on the network to determine if wireless solutions will work well. Keever said that an open Emergency Department might be a great place for a wireless system, while an older building with thick walls filled with asbestos might require hard-wiring.

Another bit of advice that Keever offers is to make sure that the "politics" of networking is addressed up-front. Each department will want to have the network configured to enhance their activities, but where conflicts could arise, the CEO needs to gather department heads together and make decisions for the one set of standards and single infrastructure that will be adopted.

Finally, Keever suggests that besides an expert network engineer (whom he asserts must be compensated well to prevent losing to another industry), a good security person is essential to establishing a valid network. Someone who is very familiar with all of the regulations and legal aspects from HIPAA (Health Insurance Portability and Accountability Act) regulations to JCAHO (Joint Commission on Accreditation of Health Organizations) requirements will prove invaluable in establishing policies and incorporating necessary precautions to insure patient privacy.

John Quinn, principal and CTO of healthcare practice for Capgemini Health, adds that if an institution plans to employ an internet service provider for a portion of the functional network, they must negotiate up-front how much bandwidth the end-users will require. For example, if radiologists will be sending large image data files over the network, and thereby utilize significant bandwidth, the internet service provider must be apprised when the contract is drawn up. While most internet providers will charge a premium price for putting radiology services on their backbone, ethical business practice demands that they be informed.

Pat Pothier, marketing director for SBC Communications, stresses the importance of a networking company performing a thorough assessment of the health customers' needs prior to developing the network solution. The SBC process includes asking the prospective client about their strategic business plan goals and objectives, so that they can determine priorities in
network configuration based on their size, location and applications that will flow over the wires. They want to understand the case mix, any new services the healthcare facility plans to develop, outcomes they are attempting to effect, the number of critical care departments and other factors that will impact network utilization.

Basic network design demands a security focus for perimeter and core segments, including intrusion detection. Wireless services require security as well, that could include encryption and the use of a VPN (virtual private network). Depending on the devices and applications employed, encryption would be accomplished through hardware or software solutions.


Solutions from the frontlines

Dan Allee, technical specialist at Hancock Memorial Hospital and Health Services in Greenfield, Ind., is using Extreme Networks to connect their 100-bed hospital with physician groups in seven locations. There are other remote sites including a wellness center that's within a mile and a half of the hospital, and a remote clinic 18 miles away. They have that facility connected via fiber, as are two of the physician practices that are off-campus. Additionally, they have connected their headquarters in a building that houses physician offices, an immediate care unit and occupational health to the hospital with fiber. They will be deploying a PACS within a couple of months.

Besides moving the usual data across their network, they also have deployed VoIP (voice over IP) on many of the phones on the network. This enables them to take advantage of their primary ISDN trunk lines in the hospital to run all of the phones in the physician practices, which offers significant cost savings without noticeable difference in functionality.

"In using the Extreme equipment, the only difference we see about the wiring closet in the hospital versus the wireless closet in one of the clinics is the difference in a GBIC (gigabit interface converter)," says Allee. "It's a media converter that converts an Ethernet connection to fiber." They placed multimode fiber in the hospital and a building that is on campus but not attached to the hospital. In the other buildings, they used single mode fiber, so they use GBICs to drive that.

Joseph Porges, founder of Image Management Systems and Support (IMSS) Corp. in Fort Lauderdale, Fla., uses AMICAS software and AT&T networks to connect their seven hospitals currently in the network, with an increase to 15 hospitals plus they will begin to service imaging centers in Shanghai, China, soon.

"IMSS developed additional software that resides on top of the AMICAS software, providing a worklist and online wet read reports, with patient information and physician electronic signature and time stamp at the bottom," explains Porges. They have all of their facilities wired over the AT&T network, and he considers it highly reliable.

They use multiple T1 capacity, but are considering going to a larger pipe, as the business grows even larger. Currently, their radiologists read 10,000 studies a month.

"Our transmission is done via a secure net, so we're using SSL [Secure Sockets Layer] technology, and we encrypt all of our transmissions and decrypt them at the point of arrival," explains Porges.

Finally, he notes that all of their equipment is off the shelf, which facilitates replacement components when necessary. This also makes their service more affordable to small- and medium-sized hospitals.

Charles S. Rice, CIO of South Jersey Healthcare in Vineland, describes their use of NEC Solutions for the communications network in a new regional medical center that opened in August 2004. The center consolidated two other acute-care centers into this 262-bed healthcare facility, all with single patient rooms. Additionally, they maintain another community hospital, outpatient services and an Emergency Department.

Rice says that they employed NEC networks to provide both regular land phone lines and wireless telephone services. Besides routine mobility functionality, they tied their nursing call system into the phones, so that patients can call their nurse over a wireless telephone during the evening and night shifts. During the day, the nurse call line goes to the nursing station where the unit clerk triages calls to notify other departments of needs if necessary. The other benefit to this system is that if a nurse pages a physician, the call back is routed directly to the nurse.

Since they were able to wire the hospital from scratch, they've expanded the use of wireless phones to other departments such as transport or dietary.

One other feature of the NEC network they appreciate is the TouchPass biometric authentication for staff who need to access the HIS or PACS. They registered all of the physicians as they were oriented to the new facility. Eventually, they plan to expand this functionality to registration of patients.

"It's not capturing a fingerprint, it's an arithmetic equation based on the high and low points on the fingerprint," says Rice. The staff member approaches the console, presses a finger to the device, and it logs the individual into the intranet screen, thereby permitting access to all of the intranet segments for where they have been cleared.


Conclusion

Networking off-site facilities demands high availability and dependability as well as security for confidential patient data. Configuring that network requires careful planning and assessment of end-user needs.

A gifted network engineer is valued above rubies.