Networking is making the world a smaller place.
Just a few years ago, X-rays and other medical images had to be delivered to doctors by hand, usually by a courier or by the patient himself. Thanks to advanced network technology, hospitals like the University of Pennsylvania Health Systems (UPHS of Philadelphia) instantly can deliver complex images to the University of Pennsylvania School of Medicine, a physicians’ primary care provider network of more than 250 physicians, a long-term care facility, several city and suburban clinics, and a home health and hospice service.
In fact, the chairman of the radiology department recently was able to sit in his mother’s kitchen in Israel and sign-off on charts, securely and quickly using a local phone number.
Basically, networking is the integration of three primary systems — imaging, information and communications.
Transmission technologies have undergone tremendous changes since the first modems sent data over an analog telephone line. Where an analog modem can transmit 5.6K bits per second, a fiber distributed data interface (FDDI) uses optical fiber to transmit at 100M bits per second. A wide area network (WAN) asynchronous transfer mode (ATM) can deliver speeds of up to 155M bits per second. Even faster yet is the new gigabit Ethernet, operated over a large area network (LAN), which can transfer 1,000M bits per second.
Since medical images are memory intensive, the speed of the transmission is a major factor. A typical CT exam, for example, would take 177 minutes and 46 seconds to transmit via a modem over a phone line. The same exam could be transmitted in just less than two seconds by ATM. An MRI exam would take more than four hours to transmit by modem, yet just five minutes utilizing a T-1 cable line, and just 3.1 seconds by ATM.
A starting point
The first and most important step in building a network is the strategic planning stage. Once healthcare facilities decide to install a network, they may become so enthralled with the new technology that they don’t take the time to plan properly.
“It is crucial for practitioners to become stakeholders in the strategic value of electronic communications prior to strategic installation,” says Terry Newmyer, managing director of KPMG’s National Healthcare Consulting Practice. “To do this wrong is worse than not doing it at all,” he adds.
He cautions that mistakes will have a long lasting effect, because “flaws will cause providers to withdraw.” This issue is especially true in the healthcare environment, which relies on empirical evidence to make decisions. Blunders will, therefore, destroy confidence and make it “more difficult to go down that path again.”
The first step, then, is to “conduct shared visioning — that is, to build a common vision among the stakeholders, a common vision with commitment across the medical community,” Newmeyer advocates. “Articulate the vision and the benefits of the vision, embrace the vision, and then install the structure.”
With everyone moving in the same direction, the next step is to evaluate existing infrastructure. “Today, the network should be expected to carry not just data, but voice, images, and even video,” advises David Armour, manager of clinical information technology for Health Care Services at Siemens Medical Systems Inc. (Iselin, N.J.)
In the past, hospitals have separated voice and data operations, but a 21st century network needs to carry all four information sets, Armour adds. Therefore, the initial needs assessment should consider all users of the system and their projected needs.
Benefits of networking
“Quickly accessible information leads to faster, more effective clinical decisions,” says Henri “Rik” Primo, director of Siemens’ Health Care Services. As a multinational company, Siemens is involved in medical networking as the world’s largest manufacturer of fiber optic cable and as a network consultant and installer.
Specifically, networking is designed to reduce cycle time for patient processing, provide a specialist’s or physician’s expertise to remote sites and be a key component of the electronic patient record.
Oak Valley Hospital (Oakdale, Calif.) uses a gigabit Ethernet system from Lucent Technologies Inc. (Murray Hill, N.J.) to help migrate 300 end points from shared to switched fast Ethernet and create gigabit links among the eight new Windows NT servers the new application requires.
“Quicker response time was the main thing we were looking for,” says David Rodriguez, Oak Valley’s information systems manager. “We went from seconds to milliseconds. It was like going from a one-lane road to a 10-lane freeway with the same amount of traffic.”
Bruce Patterson, a network specialist at 3Com Corp. (Santa Clara, Calif.), advises healthcare facilities to look further ahead into the future and discount technology that already may be six months old.
“Don’t drive the bus through the rearview mirror in terms of network technology,” he says. Rodriguez concurs, adding that hospitals “need to identify business needs and accommodate for growth.”
Oak Valley Hospital, for example, went from 100 to 160 personal computers in a matter of months and Rodriguez is already requesting more ports. “If we made one mistake, it was in underestimating the growth in ports,” says Rodriguez.
PACS (picture archiving and communications systems) is one option to accommodate networking goals, as well as on-call teleradiology, over-read radiology service, filmless radiology, interdepartmental distribution of images and reports, and to create an electronic patient record. Each of these applications has specific speed requirements. Interdepartment image distribution, for example, requires an ATM of fast Ethernet, while on-call teleradiology may be handled with a dial-up modem or ISDN.
PACS, however, are only as effective as the network on which they are run, and skimping in network technology could lead to disaster.
Just adding PACS to an existing LAN is not recommended. The PACS data would saturate an existing Ethernet LAN. A preferred solution would be to run a separate network for PACS, then connect to the existing LAN via a bridge. Deploying a PACS requires an open, standards-based network, a solid data communications infrastructure, extremely high reliability, and a tight security network.
The good news is that network technology is currently available for PACS, teleradiology and telemedicine. When requesting proposals from vendors, healthcare facilities should stress the clinical requirements of their system, since network cost and complexity increase with clinical requirements.
3Com Corp.’s Patterson advocates the use of a gigabit Ethernet, asserting that it is more capable of handling issues of security, bandwidth and cost efficiency.
“You get a private network at public network costs,” he adds.
Patterson says ATM technology has been the choice of the healthcare industry because of its quality of service capability. With data as important as that being transmitted in the healthcare field, there can be no room for error. In the last six months, gigabit Ethernet technology has matched ATM in terms of quality.
While gigabit Ethernet technology can speed data transmission over a LAN, virtual private networks (VPN) — such as the system used at the UPHS — are the latest technology in remote access.
VPNs are highly secure site-to-site or user-to-site communications that use the Internet or other public IP (independent provider) networks for their transport. VPN also potentially can offer cost-efficient delivery of clinical and administrative data from medical images to patient records.
Speed of deployment is another benefit of VPNs in the eyes of John Donahue, UPHS’ director of technology and communications services. His system was deployed in just two months after UPHS chose Fiberlink (Blue Bell, Pa.) as its vendor supplier.
“Remote access was the focus for us,” says Donahue. “Each facility had an individual IT department with no standards for remote access. We received a return on investment, because we shut down some older systems, and we now have the ability to deliver secure remote access. We can access data from anywhere in the world.”
Confidentiality
Proposed confidentiality and security regulations under Section 45 CFR, Part 142 of the Health Insurance Portability and Accountability Act (HIPAA) also must be addressed by facilities considering network installations.
The section is designed to encourage development of healthcare information systems with hospitals and healthcare delivery systems, the security of all patient-identifiable information and the ability to authenticate the identity of the people sending and receiving that information.
Primo advises facilities to ask their network vendor to provide a HIPAA guarantee in writing to ensure that mechanisms to comply with HIPAA are in place and are “economically feasible.”
For example, the privileges (doctor vs. nurse assess of records) already may be in the system. However, if proposed regulations change (i.e. nurses can only have access to patients on their wing of a hospital), the system may require additional sophistication and safeguards.
KMPG’s Newmyer says that confidentiality is critical, not only from a legislative and legal standpoint, but from a patient’s perspective. He notes parallels between healthcare and the financial services industry. These are the two areas where consumers are most concerned about confidentiality.
Healthcare has the same anxieties that financial services had a decade ago. The problem is, the healthcare industry lags far behind financial services in implementing that technology. For one reason, healthcare institutions, bedeviled by the Balanced Budget Amendment and having to place patient care as the top priority, generally don’t have the monetary or human resources to devote to adapting new technologies as the financial industry does.
Newmyer predicts that it will take four to five years for the healthcare industry to have the same level of technological sophistication the financial services industry enjoys.
“Properly done,” he adds, “medical imaging and record keeping is the proper way to build up customer confidence.”
3Com has launched “Security Net,” a Web-based resource center to help IT professionals with privacy and confidentiality issues. Through an agreement with the Computer-based Patient Record Institute (CPRI of Bethesda, Md.), 3Com’s Web site features an online version of the CPRI Toolkit: Managing Information Security in Healthcare.
In the future, technology will continue to improve, making data transmission faster, more accurate and more secure. Compression techniques like wavelet will greatly increase speed with minimal loss in perceived image quality. Wireless networks will allow expansion without major construction and recabling.
“We have wireless technology available now,” says Stephen Andrade, assistant professor and chair of the School of Technology at Johnson & Wales University (Providence, R.I.). “As soon as wireless consistently gets in the 10 Mbit range, it will take off as an alternative to expensive wiring.”
Andrade maintains that there will be no more security issues with wireless than there currently is in cable technology, since the data can be sent in encoded packets with sophisticated encryption schemes.
“The real future of networking will be the single source infrastructure for managing all information sets [data, images, voice and video],” says Siemens’ Armour. “The universal hardware plug for this type of operation really exists today. I believe the reason more hospitals haven’t gone down this road is historical momentum, not a limitation of technology.” 
