“Clinical Grade" Requirements to Enable a Mobile Health and Advanced Workflow Environment by Laurence Beaulieu; Chief Architect, Healthcare Solutions Nortel Business Solutions

1. quot;Clinical Gradequot; Requirements To Enable
A Mobile Health And Advanced Workflow
Environment
Laurence Beaulieu
Chief Architect - Healthcare Solutions
Mar. 31, 2009
BUSINESS MADE SIMPLE
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2. The Challenges Facing Healthcare
Globally…
Improve Patient Care
Reduce Medical Errors
Reduce Wait Times
Contain/Reduce Costs
Enhance Clinician
Productivity
Healthcare providers are focused on improving patient care &
safety through increased efficiency of their limited staff and
resources, reducing errors,
and improving capacity to match increase in demand
2

3. How can we achieve improvement
in healthcare?
3

4. Healthcare Workflow Improvements with
Smart Context Aware Apps
Out of HIS
Clinician EHR,
Bounds (Patient Data,
Skills EMR, EPR
Policy Lab Data)
Automation of workflows
Event
Dynamic event driven workflows
Smart Context
Incident
Aware Engine Immediate access to information
Request
Real-time collaboration
“Presence” “Location” “Schedule”
Patient Nurse Physician Bio-Med Transportation
Housekeeping Pharmacy
Smart Context Aware systems: reduce human latency & error, free up staff,
reduce workload, eliminate delays, ensure consistency and accuracy, increases
capacity & throughput, engage the right people, log all events, enable faster care
delivery, enable audits, reduce wastage, reduce costs, improve collaboration
4

5. Adoption Challenges for Advanced
Workflow Solutions & Implications
Infusion
John is here”
Pump
X
“Dr J. Smith”
X
Challenges Implications
• Limited/no wireless voice and data • Demand on infrastructure and systems
• Limited/no RTLS, sensors, etc. needed
• Network & application performance • Flexible building block solutions needed
• Clinician trust and confidence • Drives mobility
• Elimination of parallel backup processes • Pervasive RF --- multiple RF sources and
and associated costs potential EMC concerns
• Security of private data • Workflow analysis/research
• Scalability
Investments needed to ready Healthcare organizations
to support advanced workflows
5

6. Need for better infrastructure
6

7. Carrier Grade Systems – Current Gold
Standard for Communications Networks
• Carrier Grade – Critical for public network telecommunications
products
• Carrier Grade attributes continuously being adopted, adapted
and evolved
• Hospitals typically not built to carrier grade standards
• Hospital “mission critical, life critical” workflows need new set of
requirements “Clinical Grade”
New requirements need to be met to support advanced
workflows – “Clinical Grade”
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8. Clinical Grade Solutions
Clinical Grade allows Clinicians to depend upon and trust the infrastructure
– it does not impede their work, neither does it require their attention
– they must come to assume that it is always there and always delivers
Key Attributes of Clinical Grade Solutions
• Availability/Resiliency
• Non-repudiation
• Pervasive Coverage of the
• Quality of Service (QoS) &
• Provides ability to evolve –
Facility and beyond
Performance
• Seamless mobility with “future-proof”
• Service Level Agreements
session permanence & • Human-system interactions -
(SLA)
adaptation ease and consistency
• Security
• Transaction integrity • Workflow engaged – Dynamic
• EMI Safety
adaptation to demand
Source: IEEE 2005 Paper: Clinical grade - a foundation for healthcare communications networks
Graves, A.F. Wallace, B. Periyalwar, S. Riccardi, C., Nortel, Ottawa, Ont., Canada;
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9. Clinical Grade Attributes Applied to
Elements of Healthcare IT
LAN, WAN HIT HIT Clinical Hospital
Clinical Grade Attributes Device
WLAN /Carrier Infrastructure Applications Systems Environment
Availability/Resiliency
Quality of Service (QoS) &
Performance
Service Level Agreements (SLA)
EMI Safety
Security
Pervasive Coverage of the
Facility and beyond
Seamless mobility with session
permanence & adaptation
Transaction integrity
Non-repudiation
Provides ability to evolve –
“future-proof”
Human-system interactions -
ease and consistency
Workflow engaged – Dynamic
adaptation to demand
9

10. Availability/Resiliency
Essential Application Critical Application
Service Service
Example of Alert Management, Nurse Call, Patient &
Application Services/ Nurse in Distress, Staff Tracking
Application Patient Monitoring
End-End Application < 3 min./yr < 15 min./yr
Service Path
Downtime (>99.99943%) (>99.99715%)
Major Application < 1 min./yr < 3 min./yr
Service (multi-
application service (>99.99981%) (>99.99943%)
impact) Downtime
End-user Application < 1 occurrence /yr < 2 occurrences /yr
service Failure Rate
Need for industry standards and guidelines
10

11. QoS & Performance
ITU-T G.1010 Recommandations on
Maximum Acceptable Delay
• Performance attributes: Task Category Maximum Acceptable
Delay
responsiveness, quality of
communication and dependability Interactive tasks << 1s
(Real time)
• Alarming/alerting services have ≈ 2s
Responsive tasks
stricter performance requirements (High priority transactions)
≈ 10s
Timely tasks
• Emergency situations raise (Messaging, Downloads)
performance requirements but Non-critical tasks > 10s
hard to quantify
• WLAN planning and engineering is Essential Critical
most challenging Application Application
Service Service
Example of Alert Nurse Call,
Application Management, Patient & Staff
Services/ Nurse in Tracking
Application Distress, Patient
Monitoring
≈ 2s
Need for industry standards Acceptable << 1s
Delays
and guidelines
QoS DSCP CS7 CS7
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12. EMI Safe
• 2.4GHz & 5GHZ WLAN devices
do not interfere with clinical Cellular
systems provider
services
• Cellular devices may impact old Carrier Network
clinical equipment
Cellular
Cellular
• Deploy dual mode handheld
devices (cellular to WLAN) to PSTN Gateway
Enterprise
Network
reduce use of cellular devices Call Servers,
inside hospitals Multimedia Servers
WLAN AP
Wi-Fi
• Avoid deployment of wireless VPN Gateway
systems that use the 125kHz and Internet
868MHz spectrum Wi-Fi Access Point
[JAMA. 2008;299(24):2884-2890]
• Implement centrally managed
and coordinated RF planning
12

13. Security
• Use biometric or other key secure
identifiers
• Secure encryption required on all
accessible paths
• Consider using network-centric computing
that allows for no / minimal information on
portable devices
• Consider location tracking portable
devices and invoking memory wipe if
device is removed by unauthorized
persons
• Use secure memory stick access
appliance
13

14. Transaction Integrity & Non-Repudiation
• Source and destination of all Nurse
Call “Alarm”
alarms, alerts and System
Text Msg
notifications must be logged Policy
Voice
Patient Clinical “Alarm”
• Use centralized alarm “Alarm”
Monitoring Alarm Clinician
System Management E-Mail Security
management for consistent Logging Bio-Med
SMS
Porters
Personnel
treatment, routing and logging Housekeeping
/Asset
“Alarm”
Tracking &
• Data sources must be notified Management
of transaction failures
14

15. Current State of Healthcare Systems
Characteristic Clinical Grade Situation Today
Essential Service <1-3 min./yr Many single points of failure, Limited App
Available/Resilient
Critical Service < 3-5 min./yr level resiliency, < 99.99%
Essential Service << 1 sec latency No differentiated services, no service level
Reliable (QoS Defined)
Critical Service ~ 2 sec latency engineering
Restricted access, biometrics, secure Good use of authorized access, limited
Secure
remote access biometrics, limited secure remote access
Pervasive (Anywhere, Anytime,
Pervasive WLAN Limited WLAN, Dept. level WLAN
Seamless)
Integrity (Traceable, Non-reputable) Centralized logging Limited logging, not centralized
Expandable, Vendor Independent App abstraction from infrastructure Tight integration of apps to infrastructure
Easy to Use, Flexible, Quick, Limited single sign-on, very little click to
Single sign-on, Click to communicate
Improves Workflow communicate
Centrally managed & coordinated RF No managed & coordinated RF plan;
EMI Safe
plan 125kHz deployed
Industry Challenge: Provide products & systems meeting Clinical Grade
Healthcare Challenge: Upgrade & build to meet Clinical Grade
15

16. Healthcare IT Standards/Guidance Needs
• Define classes of Healthcare services
• Essential e.g., patient or staff life safety
• Critical e.g., patient location tracking messages
• For each class of Healthcare service define:
• Availability requirements (up time %, e.g., 99.9999%)
• End-user application service Failure Rate (e.g., < 1 occurrence per year)
• Acceptable end to end delay (e.g., < 1 sec for life critical alarm messages)
• Quality of Service – Differentiated Services Code Point (DSCP) marking
• Mobility network
• Unlicensed (2.4GHz, 5GHz) or licensed spectrum
• Interface protocols
• Web Services interfaces between clinical systems (vs HL7)
• Clinical systems to mobile device interfaces (e.g., SIP)
Mix of: leverage existing IT standards, adapting existing standards,
or developing new standards
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17. Hospital Healthcare IT Policy & Strategy
Deploy advanced composite solutions to
enhance care delivery, streamline workflow,
Automated &
Dynamic Workflows increase operational efficiency, reduce medical
errors, while saving cost
Deploy “Clinical Grade” IT system
Unified Communications
enablers & integrate with clinical
devices, systems, and applications
Asset,
Patient & Mobile
Alarm
(e.g., fault tolerant, pervasive, future
Staff Comms
Mgmt
proof, transaction integrity, etc.)
Tracking
Build a “Clinical Grade” Network
VoIP MM IVR CC RFID RFID
Infrastructure (e.g., fault tolerant, high
WAN LAN WLAN performance, EMI safety, etc.)
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18. Mobility a key enabler
18

19. Mobility Use Cases – Text or Voice
Query Location
of Equipment,
Alerts, Alarms
Nurse Call Staff, Patients
Delivery
“Location –
System
Location
Closest Porter” Patient Monitoring
Service
System
Nurse Nurse
Physician
Bio-Med
Peer to Peer
Information Medication
Collaboration
Access eMR Info
“Location –
Lab
Closest Porter”
Results
Push or Pull
Guidelines
Nurse Nurse Nurse
Physician Physician Physician
Submit Work Team
Orders Formation Code Call
Medical Response
Team Call
Emergency Response
Nurse Porters Call
Nurse
Physician Bio-Med Physician
Housekeeping Security
Patient Reminder,
Follow-up
Hospital
Patient
19

20. Seamless Mobility
Call
Server
Carrier Network
Cellular
Hospital WLAN Network
Call
Server
Physician Physician
Session Continuity
Dual Mode PDA / Dual Mode PDA /
Smart Phone Smart Phone
Supported on WLAN inside Hosted off carrier
hospital and converts to an network outside of
extension on hospital Call Server hospital
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21. Mobile Device Requirements
Characteristics Nurses Physicians
Robust drop spec
No
MIL STD 810F Proc IV 516.5
Resistance to spraying water & dust protection
?
IP 53 standard
Resistant to Hospital Liquid Disinfectants ?
Extended capacity battery options
?
Up to 8hrs Talk Time / 160hrs Stand-By
Backlit keypad ?
Web Browser Trend
Screen Size - 3.5-inch (diagonal) widescreen
Trend
480-by-320-pixel resolution at 163 ppi
Push to Talk ?
WiFi - 802.11 a/b/g 802.11 & Cellular
Integrated Barcode Reader ?
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22. WLAN Challenges - Performance
• Predicting AP traffic load
Security Switch
• Radio coverage & channel
interference
IP Network
• Design and engineering trade offs for
Core Switch
data, voice and RFID
Security Switch
• Trade offs between 802.11
technology (a, b, g, n)
PoE Switch
• Sensitivity to physical changes
• Responsiveness in transferring large
files
AP
• Equivalent to wire: security,
resiliency, signal quality, capacity
• Simplified configuration: AutoConfig,
AutoRF
Wi-Fi Clients
22

23. Meeting hospital needs: Where we
should be going?
23

24. Direction Recommendations
Industry
Hospitals
• Provide “Clinical Grade” solutions
• Build “Clinical Grade” systems
• Develop guidelines & standards for
• Build-out pervasive WLAN
“Clinical Grade” systems
• Integrated business case & design
• Based on classes of services
- data, voice and RTLS
• Dependability, performance, etc
• Deploy real-time location systems
• Develop next gen mobile devices for
• Deploy mobile devices & systems
hospital user groups
• Nurses, physicians, porters.....
• Enhance today’s WLAN systems to
• Embrace mobility use cases improve robustness, performance,
engineering, deployability
• Enable seamless mobility with dual
mode clients
• Automate & optimize workflows using
smart context aware systems and
mobility
• Central management of RF
environment
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25. www.nortel.com/healthcare
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