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Report from HIMSS Health IT conference: building or bypassing infrastructure

Today the Healthcare Information and
Management Systems Society (HIMSS)
conference wrapped up. In
previous blogs, I laid out the
benefits of risk-taking in health care
IT followed by my main
theme,
interoperability and openness
. This blog will cover a few topics
about a third important issue, infrastructure.

Why did I decide this topic was worth a blog? When physicians install
electronic systems, they find that they need all kinds of underlying
support. Backups and high availability, which might have been
optional or haphazard before, now have to be professional. Your
patient doesn’t want to hear, “You need an antibiotic right away, but
we’ll order it tomorrow when our IT guy comes in to reboot the
system.” Your accounts manager would be almost as upset if you told
her that billing will be delayed for the same reason.

Network bandwidth

An old sales pitch in the computer field (which I first heard at
Apollo Computer in the 1980s) goes, “The network is the computer.” In
the coming age of EHRs, the network is the clinic. My family
practitioner (in an office of five practitioners) had to install a T1
line when they installed an EHR. In eastern Massachusetts, whose soil
probably holds more T1 lines than maple tree roots, that was no big
deal. It’s considerably more problematic in an isolated rural area
where the bandwidth is more comparable to what I got in my hotel room
during the conference (particularly after 10:30 at night, when I’m
guessing a kid in a nearby room joined an MMPG). One provider from the
mid-West told me that the incumbent changes $800 per month for a T1.
Luckily, he found a cheaper alternative.

So the FCC is involved in health care
now
. Bandwidth is perhaps their main focus at the moment, and
they’re explicitly tasked with making sure rural providers are able to
get high-speed connections. This is not a totally new concern; the
landmark 1994 Telecom Act included rural health care providers in its
universal service provisions. I heard one economist deride the
provision, asking what was special about rural health care providers
that they should get government funding. Fifteen years later, I think
rising health care costs and deteriorating lifestyles have answered
that question.

Wireless hubs

The last meter is just as important as the rest of your network, and
hospitals with modern, technology-soaked staff are depending
increasingly on mobile devices. I chatted with the staff of a small
wireless company called Aerohive that aims its products at hospitals.
Its key features are:

Totally cable-free hubs

Not only do Aerohive’s hubs communicate with your wireless endpoints,
they communicate with other hubs and switches wirelessly. They just
make the hub-to-endpoint traffic and hub-to-hub traffic share the
bandwidth in the available 2.4 and 5 GHz ranges. This allows you to
put them just about anywhere you want and move them easily.

Dynamic airtime scheduling

The normal 802.11 protocols share the bandwidth on a packet-by-packet
basis, so a slow device can cause all the faster devices to go slower
even when there is empty airtime. I was told that an 802.11n device
can go slower than a 802.11b device if it’s remote and its signal has
to go around barriers. Aerohive just checks how fast packets are
coming in and allocates bandwidth on that ratio, like time-division
multiplexing. If your device is ten times faster than someone else’s
and the bandwidth is available, you can use ten times as much
bandwidth.

Dynamic rerouting

Aerohive hubs use mesh networking and an algorithm somewhat like
Spanning Tree Protocol to reconfigure the network when a hub is added
or removed. Furthermore, when you authenticate with one hub, its
neighbors store your access information so they can pick up your
traffic without taking time to re-authenticate. This makes roaming
easy and allows you to continue a conversation without a hitch if a
hub goes down.

Security checking at the endpoint

Each hub has a built-in firewall so that no unauthorized device can
attach to the network. This should be of interest in an open, public
environment like a hospital where you have no idea who’s coming in.

High bandwidth

The top-of-the-line hub has two MIMO radios, each with three
directional antennae.

Go virtual, part 1

VMware has customers
in health care
, as in other industries. In addition, they’ve
incorporated virtualization into several products from medical
equipment and service vendors,

Radiology

Hospitals consider these critical devices. Virtualization here
supports high availability.

Services

A transcription service could require ten servers. Virtualization can
consolidate them onto one or two pieces of hardware.

Roaming desktops

Nurses often move from station to station. Desktop virtualization
allows them to pull up the windows just as they were left on the
previous workstation.

Go virtual, squared

If all this talk of bandwidth and servers brings pain to your head as
well as to the bottom line, consider heading into the cloud. At one
talk I attended today on cost analysis, a hospital administrator
reported that about 20% of their costs went to server hosting. They
saved a lot of money by rigorously eliminating unneeded backups, and a
lot on air conditioning by arranging their servers more efficiently.
Although she didn’t discuss Software as a Service, those are a couple
examples of costs that could go down if functions were outsourced.

Lots of traditional vendors are providing their services over the Web
so you don’t have to install anything, and several companies at the
conference are entirely Software as a Service. I mentioned Practice Fusion in my
previous blog. At the conference, I asked them three key questions
pertinent to Software as a Service.

Security

This is the biggest question clients ask when using all kinds of cloud
services (although I think it’s easier to solve than many other
architectural issues). Practice Fusion runs on HIPAA-compliant
Salesforce.com servers.

Data portability

If you don’t like your service, can you get your data out? Practice
Fusion hasn’t had any customers ask for their data yet, but upon
request they will produce a DVD containing your data in CSV files, or
in other common formats, overnight.

Extendibility

As I explained in my previous blog, clients increasingly expect a
service to be open to enhancements and third-party programs. Practice
Fusion has an API in beta, and plans to offer a sandbox on their site
for people to develop and play with extensions–which I consider
really cool. One of the API’s features is to enforce a notice to the
clinician before transferring sensitive data.

The big selling point that first attracts providers to Practice Fusion
is that it’s cost-free. They support the service through ads, which
users tell them are unobtrusive and useful. But you can also pay to
turn off ads. The service now has 30,000 users and is adding about 100
each day.

Another SaaS company I mentioned in my previous blog is Covisint. Their service is
broader than Practice Fusion, covering not only patient records but
billing, prescription ordering, etc. Operating also as an HIE, they
speed up access to data on patients by indexing all the data on each
patient in the extended network. The actual data, for security and
storage reasons, stays with the provider. But once you ask about a
patient, the system can instantly tell you what sorts of data are
available and hook you up with the providers for each data set.

Finally, I talked to the managers of a nimble new company called CareCloud, which will start serving
customers in early April. CareCloud, too, offers a range of services
in patient health records, practice management, and and revenue cycle
management. It was built entirely on open source software–Ruby on
Rails and a PostgreSQL database–while using Flex to build their
snazzy interface, which can run in any browser (including the iPhone,
thanks to Adobe’s upcoming translation to native code). Their strategy is based on improving
physicians’ productivity and the overall patient experience through a
social networking platform. The interface has endearing Web 2.0 style
touches such as a news feed, SMS and email confirmations, and
integration with Google Maps.

And with that reference to Google Maps (which, in my first blog, I
complained about mislocating the address 285 International Blvd NW for
the Georgia World Congress Center–thanks to the Google Local staff
for getting in touch with me right after a tweet) I’ll end my coverage
of this year’s HIMSS.

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