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Nevada Rural Hospital PartnersNetwork Connectivity Overview 2010

Todd RadtkeRegional CIO – NRHP775-827-4770 todd@nrhp.org

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About NRHP

Established in 1987 14 Rural Nevada Community Hospitals NRHP hosts shared applications and

provides IT services NSHE/SCS NevadaNet is our WAN and is

critical to supporting our vision Supporting member viability by implementing

shared health information technology solutions

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NRHP Mission: Improve the viability of rural hospitals through shared services, resources, and advocacy

Hospital viability depends on -A supportive operating environment -Adequate financial resources -Quality human resources -Appropriate array of high quality services -Adequate facilities and technology

The technology vision: NRHP members maximize productivity, economic efficiency, the quality of care, and patient safety through the application of appropriate technology to the

processes of clinical care and hospital management

ManagementCapability and Applications

Knowledge Connectivity Funding

NEVADA RURAL HOSPITAL PARTNERS INFORMATION MANAGEMENT VISION

When detail is added to that statement, the vision is one in which, someday, NRHP hospitals will have integrated internal information systems that support clinical and administrative functions. Members will have access to high speed connectivity that supports communication, telehealth, data transfer, storage and recovery. NRHP hospitals will have electronic medical records and other tools designed to enhance the quality of care, access to information, productivity, and financial viability. All types of closed records will be in digital format. When it makes economic sense, web-based applications will be shared among member hospitals over secure connections. Members will have qualified Information Management personnel supported by centralized expertise. Processes that assist members with good decision making, and implementation support, will be in place.

NEVADA RURAL HOSPITAL PARTNERS INFORMATION MANAGEMENT VISION

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Management Knowledge Connectivity Capability and Applications Funding

Manage Change

Develop members' internal expertise

Develop standards and policies

Establish decision making process

Assist members to comply with regulations

Provide for systems control

USCC - Maintain/expand

NevNet and allow access

ORH/UNSOM - support, coord., and

CAH funding

NRHP - obtain grant funding - HRSA, OAT, SHIP, and

possibly utilize loan pool

Member funded internal budgets

Provide central expertise

Establish need

Complete research

Pilot project

HIPAA

Document information systems

Provide ongoing education

Maintain control of access and usage

Provide sufficient bandwidth and redundancy

Establish and maintain secure

connections

Provide for information systems

support

Establish, monitor and maintain LANs

and WAN

Develop and maintain security

applications

Develop PACS capability, including standardized RIS

Integrate members' legacy software within hospitals

Develop expertise at Board levels-

members and NRHP

NNAHEC - Coordinate NevNet

telemed, USF discounts, other funding, cmprsd.

video

Develop and expand document mgmt

program

Develop and maintain central data

storage

Develop data disaster recovery capability

Expand Telehealth applications, incl.

teleradiology

Maintain communication

applications

Plan for long-term conversion to EMR

Expand capacity of compressed video

Develop applications for

quality & pt. safety

Establish and commit NRHP strategic plan

Develop decision making guidelines

Address sustainability issues

Provide for backup and support

Develop shared applications

Revised 4/08

Provide secure data backup

NEVADA RURAL HOSPITAL PARTNERS COMPONENTS of INFORMATION MANAGEMENT

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Information Management Components: Connectivity Establish and maintain network security Provide sufficient bandwidth and redundancy Maintain control of access and usage Manage wide area network (WAN) Monitor and report network usage Provide for backup and support

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Information Management Components: Capability and Applications Process Improvement

Integration, document management, PACS Shared Radiology Archive Long Term conversion to EMR Maintain communications applications Develop and maintain shared applications Develop disaster recovery capabilities Develop clinical applications Expand telehealth applications

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Current NRHP IT Services Provide centralized I.T. expertise Educate NRHP Board and member I.T. staff Support IT decision-making re: integrated systems, electronic health records, and health

information exchange Maintain and support a secure Wide Area Network Host member email services Host central software applications Integrate members’ legacy software systems Maintain and support a central electronic archive Enhance/expand members’ PACS capability, teleradiology functionality, efficiency and

support Maintain relationships that enhance members’ connectivity Manage the Universal Service Fund discounts for members Provide I.T. leadership at the State level, helping to shape responses to rural needs Manage I.T. grant-funded programs and reporting Assist members with vendor negotiations Manage NRHP’s I.T. vendor contracts and software licenses

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Shared Applications that depend on NevadaNet Hosted Email and shared calendaring

900 plus users Spam management Enhancements – shared calendars, webmail –

Shared HL7 integration Over 1 million messages a month are processed Reduces data entry of patient demographics into clinical applications ( lab and

radiology ) Sharepoint sites

Risk Management, LiCON, Member CEOs and IT Web Site Hosting

Hosted at powervps ( not on nevadanet ) Shared Credentialing application Shared Risk Management SGMS firewall reporting Central PACS Archive – 450,000 studies to date

Primary PACS archive is hosted at Pennington with a plan to move to SCS data center

Secondary archive is located at NRHPs offices

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DISRN Radiology Network

UNR UNSOM Pennington Data Center - Reno, NV

Great Basin

NorthStar Imaging MedWeb

Desert Radiology

PGH - Lovelock, NV HGH - Winnemucca, NV BMGH - Battle Mountain, NV

WBRH - Ely, NV

CCH - Fallon, NV

SLMC - Yerington, NV

BC - Boulder City, NV

100Mbps

DILS - Caliente, NV

MGGH - Hawthorne, NV

- Central Archive - 7 year storage- Secondary read site - redundancy- Central RIS - scheduler, charges, front desk administration- Ability to import patient demographics from each hospital admitting system ( HL7 or scripting ) and attach to exam or send export file to radiologist- Each hospital needs to be able to produce digital copies for patients to take off-site- NevadaNet WAN will support the DISRN project- Develop central RIS

Owyhee Indian Heath

Desert Imaging

MedWeb

MedWeb / NovaRad

MedWeb

DR systems

MedWeb

GE

CVMC - Minden, NV

Phillips Easyweb

RadSight Archive Station

Web based access to support teleradiologists from northstar ( typical )

RadSight Connect station

image acquisition devices ( typical )

CT, ultrasound, MRI, Flouro, Film scaner, xray, etc

Forward copy

RadSightDiagnostic Station

TYPICAL TOPOLOGY

Central RIS( future )

IE

RadSight Connect station

RadSight Connect station

RadSight Connect station

RAID Storage Archive

Konica CR

DISRN ProjectDiagnostic Imaging System for Rural Nevada

Konica CR

Konica CRKonica CR

RAID Redundancy

and tape backup

Northstar access point( forward studies from BMGH, HGH, etc

NevadaNet T-1

Public InternetSite to Site VPN Security

NetworkMgmt

NRHP - Reno, NV

Dual T

-1s

WindowsAuthentication

Server

Phase 1

Dry LaserFilm Printer

100Mbps

Nye Regional

MedWeb

RadSight Connect station

RadSight Connect station

RadSight Connect station

RadSight Connect station

VPN

Radiology Vendor AccessRoute studies to vendorsImport reports from vendors

PACSMesquite, NV

Central PACS Archive 1_14_07

Interface Engine Patient Demographics and Billing data from hospital

information systems

Central Medweb

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NRHP Tele-radiology Archive Overview

NevadaNet

Typical Hospital Server

Typical HospitalInformation System

UNR Data Center5000GB Archive

NRHP Office5000GB ArchiveReplication Site

Robotic Tape Library

MIRRORDATA

PRIMARY

SECONDARY

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NRHP Network Connectivity

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NRHP Network Overview

Redundant Sonicwall PRO3060s provide network security, including intrusion prevention, gateway anti-virus and content filtering services

All site to site traffic is secured IPSEC VPN Hub ( NRHP and Archive locations ) and

Spoke ( hospitals ) topology

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LCSDBM

Humboldt Gen.Winnemucca

Northeastern Nv. Regional Hospital - Elko

Battle Mtn. Gen. Hosp.BM (2)

Nevada Rural Hospital Partners

Grover C. Dills Med. Ctr.Caliente

WNCCCarson

LCSDPanaca

CCSNHTC

Pahrump

GBCEly

GBCWinne

ECSDElko

Pershing GeneralLovelock

NCSDTonopah

Nye County Hosp.Tonopah

Carson Valley Hosp.Minden

Owyhee Community Owyhee

NRHPReno

Churchill County HospitalFallon

CENICSACRAMENTO, CA

Mt. Grant Hosp.Hawthorne

South Lyon Med. Ctr. Yerington (2)

CENIC Los Angeles, CA

(Internet & Internet2)

WNCC - Lovelock

Incline Community Hosp. Incline Village

Wend

William Bee RirieEly (2)

LAS VEGAS METRO FIBER LOOP

IRPPOP

WilTelPOPReno

RENOMETROFIBER LOOPInternet, Internet 2 &

BRIN

WilTelPOPLV

SCSLas

Vegas

Smith Valley Med. Ctr.Wellington

Boulder CityHospital

UNRRedfield

ECSD Eureka

SCSReno

SCSElko

Carlin Fire

Academy

Mesa View Regional Hosp.

Mesquite

Yellow: Sites currently on the NevadaNet Backbone

Future

2007

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WAN status Current T-1s are not sufficient to handle our traffic – recommend 6-10

Mbps for tele-radiology and future applications.

Some sites have upgraded to dual T-1s NRHP, WBRH, BCH and HGH

Sites that need additional bandwidth SLMC, MGGH

Sites that need to install new T-1s to isolate from the bundled education circuits PGH, NRMC, GCDMC

Battle Mountain 10mbps wireless connection to the fiber backbone with a T-1 as a backup is working well

NRHP will develop an infrastructure plan to increase bandwidth and provide redundant links – the issue is funding ( direct or grant )

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Challenges

WAN - Single and dual T-1s with no out of band backup (DSL, alternate routing, etc)

QOS – priorities critical applications to maximize bandwidth

Lack of bandwidth Cost of T lines a major barrier

Redundancy is critical to NRHPs ability to host clinical applications

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Current Issues

Last mile connectivity Opt-E-man might be a solution, 10Mbps $700 per month

per end, would need NSHE support / design - Can NSHE support this ?

QOS – at one time SCS proposed a MPLS layer to support QOS – is this still an option ?

Video scheduling – NRHP members require the ability to schedule telemedicine consults – Can we manage our own video calls ?

SCS support – 8x5 only, can members call circuit provider after hours ?

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Current Projects

SLA with SCS to co-locate one rack at the data center – target July1 2010

Upgrade to 6Mbps at NRHP offices Humboldt fiber upgrade Caliente – offered 50M fiber – Need SCS

support for video connectivity (T-1 or dry pair) Reviewing Smith Valley clinic connectivity –

possible T-1 to Yerington network

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Grants update

BTOP NRHP is involved with 3 applications

NSHE – fiber access points Hwy50 and I80 NHA – fiber network, data centers and shared EMR DOIT – microwave build-out and last mile

NRHP also has a request into senator Reid for IT infrastructure upgrades including routers, LAN equipment, PCs, servers and additional video equipment

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Conclusions

Expand NRHP members network infrastructure: Statewide broadband communications will allow healthcare organizations to

access and exchange information rapidly. NRHP and SCS have been working to expand the NevadaNet infrastructure and provide a quality of service level to healthcare data

Expand hospital health information system capabilities: Expand the use of HIT within hospitals to enhance the capture and storage

of complete patient health information electronically in a uniform manner. Member hospitals utilize electronic information systems but need to focus on eliminating the paper records and providing access to the electronic data that they do have. The data being captured is frequently fragmented in disparate systems throughout the hospital.

Enhance the use of EMR systems in community-based practices In order for patient health information to be useful, it must be captured

electronically at the point of care.

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Wrap UP !

NRHPs mission to support members depends on NevadaNet !

Co-locating shared applications to SCS and resolving last mile issues is a top priority

Redundancy is still a concern – DSL or other broadband would require NAT re-

design Alternate routing via link to nearby facilities Off NevadaNet options – MPLS cloud, etc