Riding the Wireless Wave

Thinking about installing a wireless network? Join the club. It is an affordable, practical and smart solution. Adding to the allure is a growing list of benefits. Radiology departments report that wireless is a tremendous boon to productivity in intake areas because information can travel with a technologist instead of remaining at a fixed computer.

A wireless network provides physicians with immediate access to information, and it can eliminate the grueling hours nurses spend on chart-entry by allowing them to enter information as they work. In short, wireless can increase productivity and improve patient care across the enterprise - when it is deployed effectively.

This ultra-productive wireless utopia is not for the faint-hearted though. The most successful wireless installations are well-planned initiatives that address genuine problems. Clyde Hewitt, principal with Phoenix Health Systems (Montgomery Village, Md.), explains, "Hospitals need to identify their requirements. It's not ready, fire, aim. It's ready, aim, fire."

A wireless installation lacking leadership, vision and planning could leave the hospital open to security breaches or become a financial black hole that fails to demonstrate a return on investment (ROI).

Paul Chang, M.D., director of the Division of Radiology Informatics at University of Pittsburgh Medical Center (Pittsburgh, Pa.), recommends wireless wannabes start the process by asking a series of questions:

• Is there a need for mobile decision-makers? What can the hospital do to improve their productivity?
• What problems can wireless solve?
• Where does wireless make sense?

Radiologists might yearn for wireless solutions, but they fail the screening test because they hold a primarily sedentary position and have little need for mobility. Other healthcare professionals, however, are a different story.

A cross-functional team that includes the chief information officer or IT director, HIPAA officer, chief nursing officer and chief operating officer can assess wireless needs and devise a solution. Defining objectives upfront leads to better implementations and makes it easier to calculate ROI. Once initial questions have been answered, a hospital can move onto the next step-finding the best wireless solution, which typically includes a wireless LAN (aka "WiFi" or 802.11b), but can also include cell phones, PDAs and Blackberrys.
   

A VISIT TO THE DARK SIDE

As the planning team researches wireless, it needs to consider the downsides - performance and security, or lack thereof.

Technophiles may overlook the reality of wireless performance. Wireless forces users to take a giant step backwards in performance. Chang warns, "Users are going from switched to shared network resources. Even the newer flavors with increased bandwidth [802.11a and 802.11g] are still shared bandwidth." Wireless applications should work well in a shared bandwidth environment. Bandwidth hogs, like traditional PACS, should be avoided.

The second, more disturbing downside is security. Wireless networks are inherently insecure. Without adequate security measures, wireless networks provide unauthorized users an open door into the hospital network. The least benign scenario is the script kiddie [aka network hacker] who just wants free wireless access. Hospitals have not been exempt to war chalking, where aficionados label free wireless access points on a sidewalk. The really bad guys hack into the network and create a HIPAA nightmare.

Hewitt recommends that hospitals develop a security plan before purchasing the first piece of hardware, which allows the hospital to buy the right components to improve security.

Hospitals can choose from an assortment of encryption and security mechanisms on the market. Wired Equivalent Privacy (WEP), typical of current "Wi-Fi" implementations, is insufficient.

Rick Hampton, wireless communications manager for Partners HealthCare Systems (Boston), says, "Until security standards are ratified, the next best option is a proprietary system. These, however, are usually password-based mechanisms and can be subject to dictionary attacks [hackers use common words to gain improper access]. Long passwords consisting of random numerals and letters changed on a frequent basis can hamper dictionary attacks, but they present other problems if made too complicated. People can't remember them and leave the password on a Post-it attached to the computer."

Some third-party encryption programs provide coverage on an application-by-application basis, potentially leaving security gaps. Virtual Private Network (VPN) technology provides more comprehensive coverage by securing both the pipe and the user. Still, hospitals need to face reality - any wireless security mechanism can be broken.

The next step? Redundancy. The hospital that neglects a wireless continuity plan is courting disaster. Suppose a hospital implements a totally wireless system for clinical point-of-entry without addressing redundancy. If that system fails at any point, the hospital cannot run its business. (For more on disaster recovery and business continuity, see story on page 34.)


UNWIRING THE FUTURE

Wireless is an ongoing revolution with new applications and tools coming down the pipeline at breakneck speed. New and improved PDAs may be equipped with a bar code scanner, allowing a nurse to swipe a drug, the administrator and patient name, automating the records and likely preventing potential adverse drug events. A mere wireless PDA might control high-resolution monitors stationed throughout the hospital.

PC Tablets may become more prevalent, allowing intake clerks to gather and enter patient information and avoid paper altogether in radiology. A patient signature could be collected on the tablet to initiate billing and document a formal consent and authorization acknowledgement.


IN AN INSTANT

Finally, radiofrequency identification (RFID) holds great potential. RFID devices can be concealed in high-value equipment integrated with an access control system to record the movement of equipment into and out of a hospital, streamlining the physical security program. Patient wrist bracelets can be augmented with RFID, which would be automatically detected for medication and tests and linked to billing and inventory control. "Imagine the efficiency," concludes Chang.
 

Wireless Troubleshooting at a Glance

Wireless users and vendors are quick to tout its benefits. Like all good things, wireless is not without challenges. In fact, they come in mind-boggling array of flavors - security, redundancy, interference and more. Some potential problems can be addressed proactively through thoughtful system design; others must be addressed as they arise. Many of the most vexing technical problems rely on human solutions - education and communication.


SECURITY

Problem: Wireless security systems cannot provide 100% protection

Solution: Hospitals administrators and system designers need to weigh security risks vs. benefits and set security policies where the two meet. Look at security policies as a moving target and evaluate on a regular basis. Remember he end user is the weakest link in any security program; educate and involve users in the security plan.

Problem: Hacker sitting in the parking lot

Solution: Solve this problem upfront. Design the system with smaller radio cells to keep the signals inside the facility by carefully placing more access points set at low power (and bandwidth is better, too).

Problem: Physician has invested $65 and set up a personal wireless network. Hackers are accessing the hospital network via the rogue access point

Solution: Purchase new hardware and software solutions built into the network to automatically detect and lock out rogue access points. Raise awareness of problems associated with rogue access points in the comprehensive staff education plan.


PERFORMANCE & INTERFERENCE

Problem: A high-powered Bluetooth (short-range wireless specification) device may cause interference

Solution: When purchasing Bluetooth devices manufactured for other environments (barcode scanners used in warehouse operations) insist that the Bluetooth device manufacturer decrease the power of the device to the level just necessary to perform in its intended environment.

Problem: An ongoing interference audit indicates rising interference. Performance is slipping

Solution: Perform a thorough site survey before installation; do not locate access points near or on common walls with galleys or break rooms to avoid potential interference with microwaves or electric knives.

• Sweep for unapproved devices. A gradual, uniform rise throughout the hospital often points to other wireless devices being brought into the hospital. Sudden, sporadic, localized rises typically indicate discrete interferers.
   
• Consider additional access points. Some experts recommend no more than 10 devices per access point.
   
• Plan for interference by anticipating new wireless technologies; expect three times the number of devices per access point as you think you'll have.
   
• Remember 802.11b is not the only wireless solution. Consider 802.11a, 802.11g, cell phones, Blackberry devices, hand-held radios, two-way pagers.

Problem: An RF (radio frequency) wireless device is causing interference with non-wireless devices

Solution: IS and Biomedical Engineering should work together to identify potential incompatibilities between wireless devices and non-wireless devices, including medical equipment, before deploying RF wireless systems.

Problem: Biomeds and physicians express concern about competition between telemetry devices and wireless signals

Solution: Studies have shown that wireless LANs do not interfere with medical devices when installed as specified by the medical telemetry manufacturers.


APPLICATIONS

Problem: Everyone is clamoring for wireless devices and applications

Solution: Proposed wireless applications must pass a needs test.

• Does performing the application on a fixed PC present a productivity or patient care problem?
   
• Is the application a bandwidth hog?
   
• Will the application run with short breaks in communications typical of wireless networks?
   
• Does the application require a great deal of security?
   
• Is it a mission-critical application?

REDUNDANCY

Problem: The hospital depends on the wireless application

Solution: Install wired outlets to run the application off the wired network. Consider 802.11a or 802.11g for redundancy.


HUMAN RESOURCES

Problem: The hospital plans to make a significant commitment to wireless, but is concerned about security, interference and all of the above

Solution: Create the position of wireless communications manager. Make sure the manager understands radio wave propagation and spectrum management, or commit to the necessary training. Adopt a comprehensive education program targeting the entire campus, not just wireless users.

Wireless in Action

Marshfield Clinic (Marshfield, Wis.) began its wireless journey 2 1/2 years ago, exploring a variety of devices and applications in an ambitious attempt to streamline workflow and improve patient care across its 43 sites. The wireless initiative builds off other IT ventures; all sites are connected by a WAN, and patients have a universal identification number and common electronic medical record (EMR). Wireless was a logical next step.

The first attempt consisted of the development of eScript, a computerized prescription writer. The target platform was the PDA connected to the network by 802.11b. The drawbacks, however, were soon apparent. Any PDA application developed needed to be available on the physicians' desktop. This forced the clinic into dual development, Windows CE for the PDA and C++ for the desktop. To compound the problem, the clinic was seeking a point-of-care device to review EMRs. Looking at a true EMR on a PDA is akin to viewing a room through a keyhole, and radiology images are virtually worthless on a PDA, explains Thomas Berg, director of clinical information services for Marshfield Clinic.

The next venture employed thin-client tablets on the wireless network. The thin-client approach allowed Marshfield Clinic to leverage the already developed C++ applications for the desktop and return to a single development environment. It also addressed the EMR and radiology image issues, but did not easily facilitate physicians dictating a voice clip to be shipped to transcription.

The team eventually turned to Windows XP for PC Tablets, which generally runs its development without modification. Shipping dictation clips is no problem, and the 12-inch display serves up even large CT and MRI studies appropriate for clinician/patient consultation. Using the XP's Ink Over Forms capability instead of paper forms also provides the clinic with the ability to manage thousands of forms in its system.

Marshfield Clinic's wireless plan is still percolating. The ultimate payoff could come in 2007 when Marshfield plans convert to a chartless environment. "It will be a great fiscal savings," opines Berg, "but the real dividend is the improved patient safety and care."