Subject: [NEXTEL-1] Wireless: Just What the Doctor Ordered

From: [email-masked]
Date: Fri, 08 Aug 2003 02:21:50 -0400

Wireless: Just What the Doctor Ordered
Aug. 1, 2003

As medical records go electronic, hospital CIOs are finding that wireless networks
can get the records to where the doctors and nurses want to use them. CIOs in
other industries would do well to watch and learn.

Wireless health driven by HIPAA

Health care CIOs need to understand 802.11b security flaws and develop a solution
with IT enhancements as well as strict policies and procedures

ELECTRONIC MEDICAL RECORDS systems top hospital CIOs' agendas because they can
prevent errors, enforce standards, make staff more efficient, simplify record
keeping and improve patient care.

But the systems deliver only when doctors, nurses and other medical staff actually
use them.

In hospitals, where patients and medical staff are constantly moving, it's
difficult for staff members to take a break to enter patient data, or to order
tests and medications. So, even though many hospitals began installing data-access
terminals a decade ago at nurses' stations and near hospital wards, staff members
still tend to scribble notes a few hours before they enter data and place orders.
That can lead to transcription errors, delays in test results and incomplete
records when other staff look up a patient's status.

Health-care information has to be available anytime, anywhere. "We didn't see any
other way to do it other than wireless," says Tim Stettheimer, vice president and
CIO of St. Vincent's Hospital in Birmingham, Ala.

"If you're not entering data as you go, a lot of efficiency is lost. With paper,
it sits in a pocket for an hour, then sits in a bin," says Dr. Andrew Thomas,
assistant dean and internal medicine professor at Ohio State University (OSU)
Medical Center, a teaching hospital in Columbus, Ohio.

Where Health Care Leads the Way
Hospital CIOs pioneer wireless voice and productivity apps

/archive/080103/mobile_sidebar_1.html Read More

That's why wireless systems, especially those based on the 802.11b standard (also
known as Wi-Fi), are more widely deployed. This new conduit lets staff access and
update records and make orders at the point of care. That reduces errors and
delays, and fits into the doctors' and nurses' workflow. And they're inexpensive
to deploy, costing a few percent of the total budget of an electronic medical
records (EMR) system. Plus, they can be a springboard to services such as
communications badges and mobile sensors. (See "Where Health Care Leads the Way,"
right.)

More Patient Face Time
R. Bruce Brown, a physician at St. Vincent's, says he believes using mobile
technology to access and update medical records will help him spend more time with
patients.

 "If you're not entering data as you go, a lot of efficiency is lost," says OSU
Medical Center's Dr. Andrew Thomas.
Before Brown began using a wireless wearable computer from Xybernaut, complete
with an LCD screen mounted on his glasses, he commuted between his patients and
hills of paper. "I used to work on a stack of papers, then see the patient, then
go back to the patient's stack of papers," he says. "I spent only 20 percent of my
time on a patient in front of me." With wireless systems, where he can access
records and order needed tests while still with the patient, "I expect that to
increase to 50 to 60 percent." Brown has also seen the cycle time per patient—from
diagnosis to test result and later to delivery of treatment to the patient—shrink
from 24 hours using the old-fashioned paper methods to four or five hours with the
combination of EMR and wireless systems.

Wireless makes productivity sense whenever workers are mobile and work with
time-critical data, says Chris Kozup, a Meta Group analyst. And, notes Kathryn
Korostoff, president of consultancy Sage Research, the use of wireless can also
relieve staff constraints. "Hospitals are always understaffed," she says. "In the
face of economic hardship, wireless has a payback scenario. It's not a huge amount
of capital investment. They're clearly saving time for doctors and nurses, which
is their greatest asset." For the users, "it really becomes a part of their job
satisfaction—it relieves stress. It has a major effect on how people are satisfied
with their job," she adds.

However, wireless and mobile technologies have supported mission-critical needs
only in the past few years, and hospitals deploying the new systems continue to
wrestle with the best ways to deploy them and integrate them into their overall IT
structure. While wireless network security has become a straightforward issue for
CIOs to address, several other technology hurdles continue to require
experimentation and greater heterogeneity than many IT departments would prefer to
support.

Hospitals are early wireless adopters, and the issues they face and the benefits
they achieve apply to any industry—professional services, retail, inventory
warehouses—that has mobile workers within a building, Korostoff says.

At the Core: Laptops on Carts
Hospitals' wireless deployments typically involve setting up 802.11b access points
in patient wards, treatment facilities and in corridors in which patients travel.
Wirelessly enabled laptops affixed to carts are rolled from bed to bed and ward to
ward as needed so that doctors and nurses can access medical records and order
tests and medications wherever they are.

 OSU Medical Center's Dr. Andrew Thomas is getting efficiency through Enterprise
Systems Director Phil Skinner's (above) wireless systems.
Usually, these shared laptops complement existing wired desktops installed at
nurses' stations and other locations during earlier-generation attempts to
digitize medical records. Wireless tablets and sometimes PDAs often supplement
these laptops, either to provide staff with a dedicated device or for use in other
medical activities.

Some hospitals keep the mix of devices limited, while others let doctors choose
almost anything to encourage usage. "We have not found there is one perfect answer
to how people access information: wired PCs, laptops on carts, tablets, PDAs,"
says St. Vincent's CIO Stettheimer.

Consider four hospital deployments:

 OSU Medical Center has more than 1,100 medical staffers who care for 33,000
inpatients and 625,000 outpatients every year. It has set up 220 access points and
180 notebooks on carts. Although OSU hasn't tracked its wireless costs separately,
Enterprise Systems Director Phil Skinner figures it costs $600 per device—whether
it's a PDA, access point or wireless card—including setup, software and hardware.

 St. Vincent's has a similar setup of 168 access points and 18 notebooks for its
600 medical staff members (on average, 40 people per day access the wireless
network). The hospital cares for 19,000 inpatients and sees 140,000 outpatients
every year. St. Vincent's has three tablets dedicated to registration at patient
beds, so patients don't have to wait in a lobby, as well as 12 wireless notebooks
used by technical and administrative staff.

This fall, St. Vincent's will install an electronic order-entry system for
physicians, which will be available over 100 wireless PDAs and 60 tablets, as well
as more than 200 existing wired bedside computers. Stettheimer figures the
wireless infrastructure cost about $1 million, out of the hospital's $45 million
investment in IT.

 Memorial Medical Center in Springfield, Ill., a teaching hospital affiliated with
Southern Illinois University, also took this route for its wireless deployment.
The hospital, whose 550 physicians care for 22,000 inpatients and 450,000
outpatients, has about 150 access points for an initial six notebooks. CIO O.J.
Wolanyk expects the number to grow dramatically after the first users talk about
their experiences and as the hospital runs out of room for stationary terminals.
The wireless system cost $900,000 out of the three-year, $30 million EMR effort.

 St. John's Hospital, a block away from Memorial, is focused on using wireless
handheld scanners to record medication delivery; patients' wristbands, drug labels
and nurses' badges are all bar-coded. A nurse scans all three so that the system
can immediately track which nurse gave which patient which medication at what
time, says IS Director Gordon Lashmett. St. John's is implementing a wireless
system like Memorial's while it also completes its EMR rollout.

The common theme: inexpensive records access. "The investment is not atrocious,"
says St. Vincent's Stettheimer. "We take the Wal-Mart approach: It must be
affordable and present benefits up front, so it also usually has to be modular,
since health budgets are very tight."

We take the Wal-Mart approach to wireless investment: It must be affordable and
present benefits up front, so it usually has to be modular.
-ST. VINCENT'S CIO TIM STETTHEIMER
Despite these fiscal requirements, St. Vincent's has extended the wireless network
to cover the entire hospital, including the wing housing doctors' offices (already
wired for Ethernet connections). Memorial originally planned on having 802.11b
wireless access in just a few locations that were difficult to wire or where staff
was very mobile, such as in patient wards, but Wolanyk argued that it made more
sense to make the entire hospital wireless—including the parking structures and
cafeterias—so that doctors and nurses can access information anywhere.

Deployment Hurdles
Deploying wireless laptops has its challenges. Here's a rundown:

1. Battery life. Surprisingly, security and network management don't top the list.
Battery life does, whether that means a laptop, a PDA or tablet computer. "It's
hard to replace batteries a lot—charge, drain, recharge," notes OSU's Thomas.
Worse, staff members tend not to notify IT if a laptop battery is drained or if
the computer is not working, since the laptops are shared with 40 other users and
thus no one's direct responsibility. To encourage staff members to plug notebooks
into outlets to be recharged, OSU will raise the outlets' height as it remodels
units, he says.

Battery life is also an issue for PDAs, which usually can't be plugged in to
recharge. Still, says St. Vincent's Stettheimer, some physicians take them and
live with the four-hour battery times.

2. Security and network management. The typical IT concerns of security and
network management are largely handled by the current generation of wireless
routers and gateways. "Wide area wireless doesn't require that much expertise. The
device is doing the network implementation," notes Mark Lowenstein, head of
consultancy Mobile Ecosystem.

That doesn't mean hospitals simply plug in access points. Instead, they connect
access points via wireless routers such as those from Bluesocket, Cisco Systems,
ReefEdge and Vernier Networks, as well as use management software such as those
from Wavelink and XcelleNet. And they implement a host of access controls: virtual
LANs, policies for user IDs and passwords, authentication tools such as MAC
addresses (the unique media access control ID for each device on a network), the
802.1x wireless authentication standard, and basic key-oriented encryption such as
the wired equivalency protocol (WEP). Some hospital network managers also use
intrusion detection software and hardware.

3. Network performance. Even with security vigilance, traditional network
implementation issues remain. For example, the use of routers and virtual LANs can
introduce some delays as users roam among access points, notes Stettheimer:
Smaller devices such as PDAs that have less powerful radios to save on battery
life are more likely to drop connections as a user roams, he says, while some
access points don't reliably forward user log-in information to the next access
point as the person roams.

Reconfiguring access points' radio power levels solved the first issue, while
upgrading access point firmware addressed the other. Stettheimer's staff also had
to adjust LAN settings to optimize traffic between the wireless and wired segments
to prevent signal gaps that caused firewalls to reject some roaming users.

Ironically, it's the use of standard network security tools that can create
hand-off issues among wireless access points, says Meta Group's Kozup. The 802.11b
standard allows for and enforces efficient roaming, he says, but the use of
security mechanisms separates the unified 802.11 networks into segments. The need
to reauthenticate users when they pass from one network segment into another can
lead to service disruptions. Some of this may get simpler as wireless standards
are updated, Kozup says.

4. Access-point placement. This is not so much a hurdle as an important
consideration. Wolanyk of Memorial Medical says he originally thought he would
need 300 access points to provide wireless network coverage. A radio-placement
consultant helped him cut that in half, and in the process paid for its fee, he
adds.

Not Ready For Prime Time
Tablet PCs and slate computers are all on hospitals' radars because they are most
akin to familiar notepads, but none are yet appropriate for deployment.

Handhelds Across the Ward
A hospital installs docking stations so medical students can update data on their
PDAs

"We looked at Fujitsu and ViewSonic slates, but the battery is gone in two hours,"
recalls OSU's Thomas. "When the battery died, you had to reload the drivers for
the device because everything is in memory."

St. Vincent's is testing 20 tablets from different manufacturers. Whatever tablets
Stettheimer selects, he will not store data on them, even if he takes advantage of
their processing power to offload work from the servers. That's already the policy
for PDAs: no data stored on the devices. Instead, he uses XML on the handhelds to
query the EMR system for information that is read-only on the device screen.

Ongoing Experimentation
Wireless technology is still new and evolving, so hospital wireless systems—just
like their EMR systems—will evolve for years, and hospitals will choose different
paths for their deployments.

"We're right there on the edge. We can see it, but it's not quite there," says
Stettheimer about personal hospital information technology.

Meanwhile, doctors are used to changing their diagnostic technology annually, St.
Vincent's Brown says. At the same time, a more technically savvy crop of doctors
is entering the field, adds Brown, who prides himself on finding technology for
doctors faster than his IT department. (OSU, for example, will give entering
medical students the new Palm Tungstens this year, mostly to try out the new audio
capability for dictation.)

It will take an openness to experimentation by both users and IT managers to
ensure that wireless and mobile technologies deliver on their promise in today's
increasingly IT-based medical practice

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