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Managing Wireless Landmines

Agenda:Overview of wireless technology in hospitals

(Ken Fuchs)Real-world case studies (Ali Youssef & Shawn

Jackman)Best practices for deploying apps on hospital

WiFi networks & discussion (Phil Raymond et al)

© 2013 Association for the Advancement of Medical Instrumentation www.aami.org

OVERVIEW –WIRELESS IN HEALTHCARE

Ken Fuchs – Center for Medical Interoperability


Overview

• Wireless in Healthcare is pervasive and ubiquitous.

• Convergence of Information and Computer Technologies (ICT) multiplies the rate of Convergence of Medical Devices with ICT.

• Adoption and deployment of wireless medical systems outpace standards, regulations, and accreditation programs


Wireless – Ubiquitous and Pervasive!

• Hospitals• Physician Practices• Free-standing clinics, surgi-centers, ER’s, etc• Skilled nursing facilities• Rehabilitation hospitals• Long term care facilities• Assisted living facilities• Home Care services

– AND…


Wireless – Ubiquitous and Pervasive!

• Emergency and First Responder Services • Inter- and Intra-enterprise clinical and security

communications• Patient/family entertainment and hospitality services• Electronic Patient Records (aka, EMR, EHR, PHR)

– e.g., “Meaningful Use” requires physicians, other clinical providers, and physician practices and hospitals to use Computerized Provider Order Entry and ePrescribing regardless of location for Medicare and Medicaid…

• Self-managed personal wellness and medical care

• And more is coming!© 2013 Association for the Advancement of Medical Instrumentation www.aami.org

More Arriving Daily• Machine to Machine (M2M) communication

– Includes wireless Device-to-Device, Device-to-System, and System to System communications

– M2M began as proprietary, single-vendor solutions; now rapidly staged for open source, multi-vendor solutions

• Robotic food, pharmacy, and supply delivery• RFID for patient, product, or device location,

tracking, data capture, or data transformation• New iPhone, iPad, and Droid medical

applications released daily

© 2010 Elliot Sloane, all rights reserved. 7Courtesy of J. Wittenber, Philips Medical

A Wireless Medical Systems Map

© 2010 Elliot Sloane, all rights reserved.Courtesy: Continua Alliance

Personal Health

9

Wireless medical system networks– Body Area Network (ZigBee)– Personal Area Network (Bluetooth)– Wide Area Network (Wi-Fi)– Metropolitan Area Network

• Cellular• Wi-Max (4G)• 3G

WBAN

WPAN

WPAN + WBAN

WPAN

WBAN + WWAN

WWAN

WMAN

M2MWWAN

Aaarrrggghhhhh!!

• These current and evolving trends create a very challenging and dynamic challenge for the Healthcare Delivery Organization.

• Our panelists will discuss some actual situations that they encountered as well as best practices to consider.


WIRELESS CASE STUDIESAli Youssef – Henry Ford Health System


Agenda

• Introduction and WLAN overview at Henry Ford Health System (HFHS)

• 2 wireless case studies• Trends and observations


Introduction to HFHS • HFHS is a not-for-profit organization

primarily located in Southeast Michigan.

• More than 23,000 total employees.• 3.2 million outpatient visits and more

than 95,600 patients admitted (2012)• 16 Wireless Controllers• Over 4,400 wireless access points

and sensors• Overlay IPS/IDS• Over 100 facilities and 8 million

square feet of coverage.• 5,000+ concurrent guests daily• 10,000 concurrent Wi-Fi devices • 30,000 unique wireless devices in

airspace at the Detroit campus per month


Wireless Services


Guest Access

Medical Devices

Employee Devices

VoWLAN

RTLS

BYOD

Video over WLAN

Current Services Future Services

Case Study 1: Wireless medical devices

• Mobile ECG Cart Procured by 1 department

without IT, or Clinical Engineering oversight

Standalone bolt-on wireless bridge

802.11 b/g only (2.4GHz) Lack of support for WPA2 Static IP requirement


Case Study 2: Medical applications

• Growth of medical application use on consumer grade smartphones and tablets.

• Traditional architecture segmenting traffic by device type is inadequate• Prioritization by application/user is required.• Vocera example – purpose built device vs. application


Observations & Trends • Dynamic traffic and policy enforcement on the Wi-Fi network is key• Standard certification and onboarding process for wireless medical devices

– Phased approach to migrating all devices to authentication and encryption best practices

– Standard service catalogue for wireless medical devices


IT Request Submitted

• End to End tracking

Feasibility Study

•Wireless Team•Security Team•Clinical Engineering Team •Clinicians

Operating Level Agreement

•Service Level Management

•IT Governance

Procurement

•Standard service catalogue item created•Procurement purchase device

DEPLOYMENT USE CASEShawn Jackman – Kaiser Permanente


Agenda

• About Kaiser Permanente• Use case – path to a smartphone


Shawn JackmanKaiser Permanente

• About Kaiser Permanente• Use case – path to a smartphone


Introduction toKaiser Permanente

2012• 19+ million mobile visits to kp.org• 88+ million sign-ons to My Health Manager• 116+ million visits to kp.org• 32.3 million lab results viewed online• $169.4M invested in health research• 11.9 million online prescription refills• 94,292 babies delivered• $50.6B in operating revenue


9.1 million members650 medical facilities

17,000 physicians50,000 nurses174,000 employees

Network Statistics

• 50+ million square feet requiring Wi-Fi coverage; more than halfway there

• 17,000 APs• 80,000 daily Wi-Fi guest users• 145,000 active RFID tags• 100% WPA2 Enterprise/802.1X


Clinical MobileCommunications

Project Overview: Equip all clinicians with reliable, mobile communication device capable of voice, secure messaging and video; device consolidation.Goal: Leverage smartphones as a platform. Divest from ASDs and invest in a mobile platform.

Considerations: Wi-Fi is the chosen wireless medium to be used indoors.


Comparison

• VoWiFi phone versus a smartphone• What’s different?• What are these designed for?


VoWiFi Phone Features

• Application specific – voice• Designed for Wi-Fi only• Highly honed for Wi-Fi performance• Fast Secure Roaming• Rugged• Control over OS and versions• Primary market – enterprise


Smartphone Features

• Open application platform• Designed for cellular networks• Wi-Fi is for cellular data offload• Roams…sometimes• Not rugged• No control over OS• Primary market – consumers


Comments are not iPhone specific; applies to all major smartphones.

Real-time Applications• Real-time applications such as voice and video have

stringent performance requirements.• There are 50 fps required to transmit audio using G.711

or G.729 (common codecs). 100 fps for both directions.• Audio is buffered to “de-jitter” the variability of time of

arrival. If frames arrival variability exceeds de-jitter window, audio clipping will occur.

• Poor performance drastically affects end user experience.


Performance Considerations

• Infrastructure designed for performance.• Clients seeking to roam before connection

quality gets too poor. (non-sticky client)• Wi-Fi radio doesn’t go into excessive sleep

mode.• PHY rate transmission optimization.• Leverage Fast Secure Roaming protocols.• Support for QoS (airtime priority).


Results?

• Smartphones are sticky Wi-Fi clients; not designed assuming highly dense enterprise environment.

• Optimized for battery performance.• Weak support for enterprise security.• QoS support?• VoIP application prioritized in OS?


What can you do?• Different applications have different requirements for:

– Bandwidth– Capacity– Latency

• Is every application designed for an unreliable network connection?

• What is the device SLA for different applications?• How do multiple resident apps affect each other?


Ensure Safety

By testing devices, applications and infrastructure properly you identify problems early.

Consider risk mitigation and backup plans.

Controlled introductions.


BEST PRACTICESPhil Raymond – Philips Healthcare


System of Systems…


Smart phone apps

Wireless devices

• Its just a smart phone app, why do I care about wireless???

• Without wireless, no m(obility) in mHealth

• Smart phones are not single purpose devices…so sacrifices are made

• Robust and reliability require enterprise grade wireless

• So what is good enough?

Internet

Know your Connectivity RequirementsAnd your internet service provider’s requirements…

34

• Device usage model

• Clinical user and workflow, real time streaming, asynchronous

• Data security needs (HIPAA, ePHI)

• WPA2-PSK minimally

• Client – Server traffic

• Unicast best; m’cast & b’cast not L3 friendly

• 802.11 offers no guarantee for connectivity

• TCP or consider application layer ACK

• What ports are used?

• VoIP type deployment rules

• RSSI > -67 dBm, SNR > 20dB

• Support QoS/WMM Prioritization© 2013 Association for the Advancement of Medical Instrumentation www.aami.org

Trust but Verify

35

• System connectivity • From device to server, not just “on” the network

• Test in mixed device environment• Coexistence with all devices

• Test for impact of network outage• Clinical impact on loss of connectivity

• Certify HW platforms• Differences between vendors and even versions

• Mobility or roaming impact• Handover performance


IEEE 802.11: More than alphabet soup?

36

Speed• 802.11n• 802.11ac

RF & Network Mgmt

• 802.11k/v

QoS • 802.11e

Security • 802.11i

Mobility • 802.11r

• IEEE continuously enhances 802.11 at the PHY and MAC layer

• PHY = Radio• MAC = Data frames

Healthcare App

TCP or UDP

IP


Additional Resources

• AAMI site includes Wireless Workshop and 80001-1 and accompanying technical reports http://www.aami.org/wireless/ http://www.aami.org/publications/standards/80001.html

• Wi-Fi Alliance Design, Deployment and Management of Wi-Fi in Hospitals, published Q1,

2011http://www.wi-fi.org/knowledge_center_overview.php?docid=4700

Security guidance for Wi-Fi networks in Hospitals, published Q1, 2012http://www.wi-fi.org/sites/default/files/uploads/files/wp_201202_Wi-Fi_Security_for_Hospital_Networks-Final.pdf

Wi-Fi and the Quality of User Experience 2013 https://www.wi-fi.org/knowledge-center/white-papers/wi-fi%C2%AE-healthcare-improving-

user-experience-connected-hospital Additional Wi-Fi white papers, free to non-members

http://www.wi-fi.org/knowledge-center/white-papers

37© 2013 Association for the Advancement of Medical Instrumentation www.aami.org

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