The Freedom of Wireless

Since the late 1990s, wireless networks have become integral to healthcare providers' IT strategies. And why not? Reduced medical errors, enhanced efficiency, improved quality of patient care and diminished costs are some of the clear benefits. And as more applications become mobile, giving clinicians and nurses real-time access to patient records and history, mobile technology will bring hospitals closer to our nationwide goal of electronic medical records.

 "Wireless is something where until you set it up, you don't really know all the benefits that you can get from it," says Kevin Torres, executive director of information services (IS) for Long Beach Memorial Medical Center and Miller Children's Hospital, part of MemorialCare Medical Centers in Southern California.

Mobile technology was first deployed in IS, expanded to a wireless PDA (personal digital assistant) project and then used to create an ER tracker. "A button is placed on incoming patients as they enter the ER and this helps us track the location of patients," says Torres.

The medical team also uses Vocera Communication Inc.'s hands-free voice activated badges that run on a wireless infrastructure. More than 600 hospital personnel can now communicate wirelessly throughout the enterprise.

St. Agnes HealthCare in Baltimore is on their second-generation wireless local area network (WLAN). Nurses use it for point-of-care documentation. "During the past few years, we have gone through several different variations of mobile carts, from touch-screen tablets to finally what we think works best - the everyday laptop," says Larry Lawson, director of IS.

Communication and workflow improved at St. Agnes with the deployment of Vocera and its integration with the hospital's Rauland-Borg nurse call system. "Initially the concept seemed very well suited for the nursing staff, but it has evolved to ancillary services and support groups such as patient escort, housekeeping and security," says Lawson. "For the nurses, it allows hands-free communication to their nursing counterparts, physicians and support services. It allows them to be mobile and communicate at the same time versus having to go back to the nursing station."


THE NECESSITIES

Facilities such as Long Beach Memorial, Miller Children's and St. Agnes that are maximizing wireless networks and technologies often make it look easy. But what's the first step to wireless success? A meticulous site survey, insists St. Agnes' Lawson. "There are so many variations of building structure that you just can't place access points every 50 feet away," he says.

Site surveys determine how architectural structures and various pieces of medical equipment within the hospital will interact with radio waves. Metal, for example, causes signal attenuation and is a WLAN's worst enemy.

Hospitals typically contract with a telecommunications vendor to perform the site survey. However, Kurt Induni, network services manager at Ochsner Clinic Foundation of New Orleans, suggests IT departments use a company's site survey as a guideline and the internal logic and knowledge of the facility to fill in the blanks.

"We paid for a site survey, but found that their recommendations did not work very effectively in the facility," explains Induni. "The placement is touchy business."

WLANs in hospitals also require robust access points. They are the bridge between the wireless world and the wired infrastructure. The cost of enterprise access points are declining steadily, according to Jim Geier, principal consultant and founder of Wireless-Nets Ltd. in Dayton, Ohio. "Access points cost about $300 today, down from $800 a year and a
half ago."

Each mobile computing device used by physicians and nurses require wireless interface adapters. A radio card that plugs into a laptop typically costs about $50 to $70, says Geier. "For a desktop, you can buy a PCI card," he continues. "Other types of mobile devices have wireless LAN cards built in, such as PDAs and tablet PCs."

Wireless middleware is an add-on. "It helps maintain connection," explains Geier. "Someone may be in a condition where they have lost connectivity and the middleware helps save the connection."

Children's Memorial Hospital in Chicago utilizes a wireless LAN for its pharmacy point-of-care tracking system. In addition to the 802.11b Cisco Systems Inc. network, the hospital installed InnerMobile, InnerWireless Inc.'s in-building wireless distribution system, to eliminate "dead zones" and extend coverage. This addressed architectural problems, such as metal pans in between floors and lead-lined walls in medical imaging, explains William Brook, director of IT.

The InnerMobile system interfaces with the hospital's primary cell phone vendor to allow mobile calls throughout the facility, except ICU and cardiology. Despite its controversy, Brook says the hospital performed a study throughout the facility to see if cell phone frequencies "step on" any of the medical equipment. The only place for potential conflict was cardiology because of the older generations of equipment, says Brook.

With a portal product from Microsoft and Citrix Systems Inc., physicians and nursing staff can access from anywhere multiple applications, including medication lists, lab results, the clinical information system and images from PACS. "Wireless reduces paperwork and brings us closer to a goal of an electronic health record," states Brook. "The overall goals are to increase accuracy, keep the patient in the hospital as little as necessary, and have some productivity gains for clinical staff."

No specific measurements are in place for the latter, but Brook questions if "productivity gains" mean a nurse spending 10 more minutes with a patient? "I think it is," he says.


THE WIRELESS PILLARS

WLANs are built on standard protocols - 802.11a, b and g - developed by the Institute of Electrical and Electronics Engineers (IEEE). Many hospitals have installed the 802.11b standard, which has a data transfer rate of 11 megabits per second (Mbps). Both the 802.11a and g standards offer a throughput speed of 54 Mbps. "We are seeing a lot of healthcare providers upgrading from 802.11b to 802.11a or g to get the higher speeds so that they can deploy heavier bandwidth applications," says Lynn Lucas, VP of marketing and product development for Proxim Corp.

"The g standard is 2.4 gigahertz (GHz) and is backward compatible with 802.11b," continues Lucas. "The a standard is in the 5 GHz band and it is not compatible with b clients. The immediate thought would be to go with g because existing clients will then be compatible. But with g you only get three channels. Sometimes, especially in OR settings, you need more than three channels in order to get good bandwidth. The a standard offers up to 13 channels."

Tech-savvy Lifespan, a multi-site healthcare system based in Providence, R.I., has installed a WLAN that provides a combination of all three 802.11 standards. "Having 802.11 a,b, and g WLAN capabilities gives us flexibility in the way we operate within our healthcare system," says CTO Dave Hemendinger. "802.11a is a technology that allows us to focus a higher speed WLAN signal within a shorter distance to accommodate wireless communication to a specific area. This deployment is a perfect fit for us, specifically within our operating room and emergency department environments. 802.11b and g are the typical wireless WLAN technology we have deployed throughout our clinical floors. The g provides a little more 'oomph.' If I need to place a diagnostic PACS workstation out on the clinical floor and need to do it wirelessly, I will do it under the 802.11g format."

While PACS images are bandwidth intensive, Lifespan is able to transmit them wirelessly. "There are a lot of great things you can do with your infrastructure these days if designed correctly," says Hemendinger. "You can provide physicians with PACS images in a slightly lower resolution for reference purposes at a much higher speed. At the point of care, most physicians are looking at an image for reference purposes.


HORSE AND CARRIAGE - COVERAGE AND SECURITY

As the government pushes for the widespread adoption of electronic health records and more hospitals implement technologies that automate steps in workflow, wireless will be a complementary - and perhaps necessary - application.

Ochsner Clinic Foundation is an integrated healthcare delivery system that consists of multispecialty clinics in New Orleans, Baton Rouge and Covington, La., a 478-bed acute care hospital, a 71-bed sub-acute facility and 35 remote clinics. Ochsner employs more than 600 physicians. The core of Ochsner's medical information system is a repository that can be accessed from any computer at any affiliated location.

Now physicians are not tethered for connectivity. "At Oschner, as an increasing dependence on automated medical records and an automated process support [such as order entry] grew, the need for wireless technologies increased," says Lynn Witherspoon, MD.

Despite an earlier attempt to deploy wireless technology that proved to have varying levels of latency - where sessions got disconnected "capriciously" - the hospital persisted in its journey down the wireless path and installed an 802.11b Cisco network. "Today we no longer hear complaints from anybody about loss of session," Witherspoon says.

Coverage and security, like horse and carriage, drive wireless success. If security measurements are not in place, anyone outside the perimeters of the hospital can get full access to all the information that is traveling through the air. Rogue devices, denial of service attacks and intrusion quickly become IS nightmares, not to mention violations of HIPAA compliance.

"The biggest misconception today is that wireless is not secure," says Proxim's Lucas. "The industry did have security issues several years ago. That is something a lot of people remember. But what they have not been caught up to speed on is that those issues have been fixed. It is very easy to deploy a secure wireless network."


GOING FORWARD

Mobile technology, like computerized physician order entry systems, creates a shockwave of culture change. Inadequate planning, implementation and training will inhibit how well (and how fast) the technology is adopted by the hospital staff.
   
"It may sound like a minor change, but to the people doing the job, if it's not implemented in a way that works with their workflow, it may cause them to not adopt the new technology," says Lucas. "From my discussion with healthcare IT personnel, thinking about the social aspects of the technology is the biggest challenge."

Lucas suggests a champion lead the project, such as a head nurse or department head, who communicates with the IT staff. Consider the following:

• The size of each mobile device?
• Does staff have to carry it or is it on a cart?
• How readable is the screen?
• How fast or slow is data entry?
• How much is staff really changing the workflow process?

Once the obstacles are overcome, the benefits will be rewarding all around. "As far as I am concerned, wireless is made for healthcare," says Lifespan's Hemendinger. "As medical records become more electronic in nature, I don't know how you could do it without mobile technology."
 

Tightening the Lid: Wireless Security in Hospitals
University of Pittsburgh Medical Center Secures its WLAN

Security is one of the biggest challenges healthcare organizations face in deploying wireless local area networks (WLANs). However, it should not be the reason hospitals avoid unwiring their facility. With sufficient planning on top of enhanced security mechanisms, hospitals can reap the many benefits of WLANs, such as improved patient safety and care, increased productivity and decreased turnaround times.

The University of Pittsburgh Medical Center (UPMC) installed a 802.11b Cisco network for bedside medication administration using Bridge Medical's MedPoint-MedAdmin application. Nurses can validate right at the bedside that each patient receives the right medication ordered by the physician and supplied by the pharmacy.

Bob Hedglen, technical services manager of information services at UPMC, says three mechanisms are used to fortify the network: a non-broadcasted SSID (service set identifier), WEP (wired equivalent privacy) encryption and tied down MAC (media access control) addresses.

All WLANs must use proper forms of encryption and authentication. UPMC will eventually go to more advanced forms of encryption, such as EAP (extensible authentication protocol), WPA (Wi-Fi Protected Access) or LEAP (Lightweight Extensible Authentication Protocol). For now Hedglen says they are limited to the devices that do - and most frequently don't - support them.

"When we started deploying wireless, we would have wanted to go with a higher level but the issue became the vendors would not support it," says Hedglen. "Not only the handhelds, but also different versions of Windows would not support enhanced encryption standards. We were looking at PEAP (protected extensible authentication protocol) which allows single-sign on. A big complaint among our clinical staff was creating extra work for them with the multiple login prompts and they were reluctant to change unless we could not do it."

UPMC contracted with AirDefense, which supplies security technologies for wireless networks, to help meet HIPAA requirements when using mobile applications. According to Hedglen, AirDefense "monitors" the air and manages wireless devices. "It immediately tells us if it finds a device that does not have encryption turned on," says Hedglen.

AirDefense sensors are installed in wireless zones. For the areas without sensor coverage, IS uses AirMagnet's Handheld to perform "sweeps" that detect rogue access points and devices. Several devices have been found in default with the network. Since getting hospital staff to adhere to the wireless policy has been a challenge, Hedglen says internal mechanisms are in place to better disseminate wireless information, such as in the hospital's monthly publication, technical councils and executive meetings.

Despite the challenges and obstacles, Hedglen says WLAN security has been a success at UPMC due to a cross-disciplined team of network and security administrators that was developed a year before the project was implemented. "The technical group discussed features on how to control [wireless] and as well as its administrative burden," explains Hedglen. "Wireless opens you up and you have to control it. Policies are in place here. For an organization, you can't buy low-end systems off the shelf because they do not have the features that allow you to merge it into a large organization. You have to plan before you start implementing."