Healthcare organizations are driven by high service standards and are seeking to transform themselves by providing higher quality care, becoming safer, becoming more efficient and providing better experiences for patients, families and staff alike.
Network infrastructure has always played a critical, yet inconspicuous role as the highway over which data flows within an organization and between organizations. Software applications must run efficiently on this network highway using data in countless ways to give healthcare providers the tools they need to improve the quality of care . While more emphasis is often placed on software solutions, it is important to understand the modernization occurring in data center and in the campus environments to support those business critical applications. Today, it is necessary for organizational leaders to align costs, simplicity, scalability and redundancy to ensure environments can meet and exceed patient safety and end-user demands.
Building upon its innovation and market leadership in Storage Area Network (SAN), Ethernet fabric, and end-to-end IP network technology, Brocade has continued to evolve its network architecture for healthcare environments, the basis for high reliability built upon value and accountability.
Brocade helps healthcare organizations all over the world by:
Over the coming weeks, a series of whitepapers and architecture guides will be released with details surrounding Brocade’s healthcare network reference architecture.
Brocade networking solutions help the world’s leading organizations transition smoothly to a world where applications and information reside anywhere. This vision is realized through the Brocade One™ strategy, which is designed to deliver key business benefits such as unmatched simplicity, non-stop networking, application optimization, and investment protection.
Innovative Ethernet and storage networking solutions for data center, campus, and service provider networks help reduce complexity and cost while enabling virtualization and cloud computing to increase business agility.
To help ensure a complete solution, Brocade partners with world-class IT companies and provides comprehensive education, support, and professional services offerings.
To learn more about Brocade's healthcare solutions, please visit www.brocade.com/healthcare.
The content in this primer was provided by the following key contributors.
Healthcare Business Lead: Matt Roberts, Director of Healthcare Solutions
Lead Architect: Prasad Bal, Strategic Solutions Lab
Healthcare Architect: Abdul Wahid, Global Solutions Architect
Date Version Description
09-12-2013 1.0 Initial Release
The healthcare industry is a highly complex ecosystem. New models of care and financing are dissolving traditional walls as the community becomes the healthcare enterprise. This convergence is evident in the blurring of boundaries between healthcare segments: hospitals are bonding tightly with physician practices; health systems are taking on risk with payers; payers are acquiring health information exchanges (HIEs); large health plans are acquiring medical practices and hospitals to proactively shift toward payment reform and accountable-driven care. The brick and mortar method of healthcare service is now being replaced by technology which allows patients to be examined, consulted and treated anywhere and anytime.
The convergence is demanding tight integration between many diverse components, which historically have been completely separate entities. These industry organizations vary from small to massive in scale with regards to people, processes and systems. Additionally, there are many government regulations regulating the daily operations. Few industries fundamentally touch and impact lives like the healthcare sector. Key segments that comprise the industry are listed below:
As the core components of the healthcare delivery model become more tightly integrated, greater emphasis is put on enhancing communication, collaboration and care coordination. While many healthcare functions are geographically dispersed, it is imperative that data is exchanged, in a timely, secure manner. Healthcare organizations are driven by high-quality, high-service standards, and a network infrastructure must provide the critical support to allow each facility the delivery of safe, effective and efficient next generation healthcare each patient deserves.
The purpose of this document is to provide a solid understanding of the role that network infrastructure plays within the healthcare ecosystem.
By most standards, the majority of healthcare organizations had fairly simple, unsophisticated networks throughout the later portion of the 20th century. The funding of a new U.S. backbone by the National Science Foundation in the 1980s, as well as private funding for other commercial backbones, led to worldwide participation in the development of new networking technologies, and the merger of many networks. The commercialization of networking technology in the 1990s resulted in its popularization and incorporation into virtually every aspect of modern human life. All voice calls were on their own dedicated network. Any amount of data that was needed for communications had its own dedicated network. Additionally, environmental and physical security had its own separate network. External connectivity was through low speed WAN links to the regional service providers. As Ethernet matured, a converged network approach gave birth to integration of voice, video and data under a common platform. The healthcare industry eventually took advantage of both cost savings as well as a reduction in wiring infrastructure that came with this convergence. That convergence of technologies though, was rudimentary in comparison with the multitude of technologies that can be converged today.
Over time, healthcare IT networks have gotten increasingly sophisticated. Industry vendors have started taking advantage of the network to enhance their product capabilities. Intra-venous drip systems can now be controlled and timed electronically, eliminating delays and human error. Smart beds can be programmed over the network to raise and lower patients, saving valuable man hours. Medical imaging such as X-rays, CAT scans and ultrasounds have become digital, enabling them to be transmitted over the LAN or WAN - where they now can be read remotely by radiologists. Prescriptions are transmitted directly over the network to the pharmacist, eliminating delays and errors in interpreting handwriting, as well as cutting down adverse drug events (ADEs) through drug-drug, drug-allergy and drug-food interaction checking. Video conferencing has become readily available, further minimizing the distance barrier and allowing medical staff to collaborate more efficiently with patients and clinical care teams. Medical students are taking advantage of online classroom offerings, as video has become a primary resource for expert teaching whether onsite or throughout remote locations.
As organizations rapidly adopt into the latest and greatest healthcare technology solutions, greater emphasis is placed around the technical challenges associated with sharing and accessing up-to-date, relevant clinical data. Patient information, historically, had been stored at a local level – but with more decentralization and diversification efforts underway, organizations are looking for a solution that allows providers to easily manage, share, analyze and report data across virtual boundaries and platforms, and ultimately improve quality of care.
A major drive for this change in the United States was the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009. A main objective of the HITECH Act is to promote the adoption and usage of an electronic health records (EHRs), which are digital versions of paper medical records. Prior to the passage of the HITECH Act, many US healthcare systems were patient information islands. Each hospital and clinic within a health system stored records of only their own interaction with their patients. This information was not shared (and nor could it be easily shared) with any other medical facility. Many patient records were on paper and stored massive medical record departments, and consequently, these facilities had no quick way to distribute and receive the information.The HITECH Act created a financial incentive program to increase the pace of EHR adoption and offset a hospital and individual provider’s costs. Under the HITECH Act, up to US$36.5 billion taxpayer funding will be available to create a nationwide network of interoperable medical records.
In order to receive EHR financial payouts, certain “meaningful use” objectives must be met. Meaningful use is the set of standards defined by the Centers for Medicare & Medicaid Services (CMS) Incentive Programs that governs the use of EHRs and allows eligible providers and hospitals to earn incentive payments by meeting specific criteria. Through the implementation of the program, incentives range from US$44,000 for eligible professionals to a base of US$2 million for eligible hospitals. Stage 1 of the 3 stages of the meaningful use objective covered the first two core years of the program (2011-2012). The focus of Stage 1 was on electronically capturing, sharing and using patient data to track key clinical conditions. Stage 2 will go into effect in 2014 and will focus on advancing clinical processes by requiring more rigorous health information exchange. The mandates of the HITECH Act are expected to result in technological upgrades across the healthcare industry. In the US, healthcare spending exceeds US$2.5 trillion and accounts for over one-sixth of the economy. Thus, industry-wide technology changes are likely to have a profound impact on the economy.
Similar to the US, the United Kingdom has been making strides in adopting into technology to reduce spending per capita. Each year the UK government and healthcare charities spend over £2 billion on healthcare research. This level of investment has led to the development of many new and improved treatments, devices and diagnostic tools. However, despite the developments to improve health outcomes and productivity the National Health Service (NHS) often lags behind the rest of the developed world in terms of implementation. In order to address this issue, the NHS Technology and Adoption Centre (NTAC) was formed in 2007. Funded by the Department of Health, NHS Institute and NHS South West, the NTAC was commissioned to provide a more systematic approach to technology adoption, essentially helping overcome requirement barriers. As the NHS comes under increasing pressure to make financial savings while improving patient outcomes, the NTAC systems become even more valuable.
Growth is starting to impact the gulf countries in the Middle East, as more emphasis is being placed on state-of-the-art care delivery in new facilities using innovative technology. The Ministry of Health (MoH) provides 60% of health services to over 28 million Saudi National citizens and other residents – and operates over 300 hospitals and 2,000 primary healthcare facilities distributed across the vast geography of the Kingdom of Saudi Arabia. The MoH has announced new plans for focusing on training, technology advancement and knowledge-sharing to expand its healthcare infrastructure. Within this plan, critical initiatives are focused on improving patient outcomes through interoperability between parts of the healthcare system – improving data access, patient safety and the quality of healthcare. This effort would support the MoH in achieving an integrated solution for the management of patient information records across Saudi Arabia, maximizing the flow of patient information records between hospitals and primary healthcare facilities.
Widespread global healthcare technology adoption will, in no question, ultimately increase in the need for technical expertise across the healthcare spectrum. As more applications, collaboration tools and end-users place demands on the technical infrastructure, continued pressures will rise and outdated infrastructures will no longer be able to support the next-generation healthcare model.
In the US, after the HITECH Act was signed into law, broadcasted to public and then digested by healthcare organizations, many industry pundits expected the financial incentives to cause an upswing in the adoption of EHR technology. Unfortunately, EHR implementation has actually been slower than expected (primarily in the outpatient setting), due to a few key factors:
Regardless of country or continent, a cost-benefit analysis of each healthcare IT deployment weighs heavily on the mind of every healthcare IT decision maker. While costs are critically important, usability also plays a vital role in the initial success of a deployment – in addition to sustained usage of the technology. EHRs and other medical technologies must be user friendly, integrating with hospitals’ or practices’ systems to truly benefit an organization or else the money spent on them is essentially seen as being wasted. Usability had often focused on patient safety issues of the system and adequate training of the end-user to support their workflow. However, usability in today’s healthcare environment must extend beyond the end-user and into the technical infrastructure that is pressured more than ever to support 24x7 data access through hundreds of applications, communication devices, terabytes of medical images, voice dictations, videos and many other technologies critical to patient care.
As greater emphasis is placed on interoperability and enhanced use of clinical IT systems, the technical infrastructure must continue to evolve in order to support next generation requirements. Virtual desktop infrastructure (VDI) is an example of a technology platform that offers end users a full desktop experience where data can be accessed anytime and anywhere. Using desktop virtualization, an organization can host and centrally manage virtual servers in their data center while the user accesses their "desktop" on any number of devices, including smart phones or thin-client devices. There are many benefits to streamlining data access through a VDI deployment, they can include: enriched security, rapid client deployment, enhanced user experience, dependable back-ups and disaster recovery, simplified management, uncomplicated remote user support and lower costs through reduced power consumption, support and hardware.
As desktop virtualization initiatives continue to increase across healthcare enterprises, mobile device strategies become paramount. There are many options when it comes to deploying and supporting devices for anywhere, anytime system access. From fixed workstations in patient rooms to thin-client nurse workstations to mobile workstations on wheels (WOWs), the majority of today’s computing devices can be setup within a desktop virtualization platform.
In addition to traditional end-user devices, the evolution of the tablet has started to change the face of modern medicine. Surgeons, physicians, nurses and residents regularly use these devices to check emails, patient notes, journal articles or to access digital images. Tablet usage also is not limited to the common-place, hallways and offices, as sterilized tablets are frequently found in operating rooms and other patient-centric locations. Along with massive adoption in tablet technology, physicians, nurses and administration also have expectations that their smartphone should be supported through the care delivery process in the same manner. As smart technology quickly becomes the preferred route for data access at home and in the workplace, hospital IT leaders must be vigilant about policies on personal computing devices and encryption of data.
Any new network architecture for the healthcare provider environment must take the proliferation of mobile devices into deep consideration. This will not only impact wireless access points and controllers, but it will continue to put stress on the entire wired infrastructure as well.
Healthcare organizations, specifically providers in the acute and ambulatory setting, are often challenged with the technical, regulatory and integration requirements of transitioning to a state of connected care. As technology continues to rapidly evolve, vendors supplying clinical information systems, medical devices, digital imaging equipment/systems and real-time communication platforms will be more dependent on the network infrastructure in order to provide a true return on investment (ROI) to their healthcare customer/partner. These unique requirements will influence the network design and will be vital in the successful delivery of secure, agile and reliable patient care products and services.
Clinical information systems are typically integrated information systems designed to manage the medical, administrative and financial aspects of a hospital or outpatient setting. Information systems can come in many forms and be found within many departments, such as laboratory, radiology, pharmacy and even on each floor of a hospital. With the evolution of the electronic medical record (EMR) and the electronic health record (EHR) the common goal is driven around improving patient care through information integrity, data sharing and decision support.
The majority of these information systems support both wired and wireless connectivity and operate over a Layer 3 network. In fact, the majority of healthcare organizations are beginning to rely more heavily on wireless 802.11a/b/g/n/ac to access data at the point of care. Wireless tablets, laptops and workstations on wheels (WOWs) give end-users the flexibility of retrieving and inputting data regardless of physical location.
It is important to consider both wired and wireless strategies when designing the network – as key characteristics such as redundancy, bandwidth and coverage will all be critically important for information system performance and general availability.
Medical devices vary greatly in complexity and application, and are broken into specific classifications for the United States, Australia, Canada, European Union (EU), European Free Trade Association (EFTA) and other countries/regions.
In the United States, under the Food, Drug and Cosmetic Act, the Food and Drug Administration (FDA) recognizes three classes of medical devices, based on the level of control necessary to assure safety and effectiveness. The classification procedures are described in the Code of Federal Regulations, Title 21, part 860 – also known as 21 CFR 860. In order for a medical device to be cleared by the FDA for sales and marketing, a manufacturer must complete the regulatory pathway for 510(k) clearance. Approximately 99% of new medical devices enter the marketplace via this process, and rarely requires a clinical trial process. Class I devices present the lowest potential risk and are subject to the least regulatory control. Class II and Class III devices are those for which general controls alone cannot assure safety nor have insufficient information assuring safety and effectiveness.
The European Union (EU) recognizes four specific classifications, ranging from low risk to high risk – Class I, Class IIa, Class IIb and Class III. The authorization of medical devices is guaranteed by a Declaration of Conformity, which is often issued directly by the manufacturer. A Certificate of Conformity is then issued by a Notified Body, which has been accredited to validate the compliance of the device to the European Directive. Once certified, the medical devices should have the CE mark on the packaging, insert documentation, etc.
Each manufacturer has unique models of medical devices, where the network architecture design must meet the specified requirements for safety and risk aversion. Devices such as patient monitors, smart infusion pumps and mobile cardiology/radiology machines are typically controlled by the manufacturer to ensure they are functioning as reliably as possible. In the majority of cases, there will be subsystems of servers and applications associated with the medical devices in order to achieve optimal performance and functionality. For example, patient monitors will always need to stay in connection with database servers in order for the central stations to accurate report current status at the bedside. If the patient monitor loses connection with the servers, the server and monitor will most likely timeout and revert back to a localized monitoring mode – and worse case – potentially causing a clinician to miss an alarm at the central station.
Most manufacturers will have a set of defined principles on how the medical devices should operate over the campus local area network (LAN). Each manufacturer is different based on their product, as they may choose to leverage Layer 3 routing with advanced multicasting, while others maintain Layer 2 as the preferred method of routing. Vendor selection will often drive special requirements where segmentation may be necessary for the devices to safely and properly work. Key vendors that actively sell and deploy wired and wireless patient monitors include Draeger, GE, Philips and Welch-Allyn.
In the United States, device manufacturers must meet and adhere to 510(k) compliance; however network infrastructure vendors’ routing and switching components currently do not fall under the same scrutiny. It is always best to check with your vendors to ensure compliance and safety when implementing device technology.
Medical images are at the heart of healthcare diagnostic procedures. They provide not only a noninvasive mean to view anatomical cross-sections of internal organs, bone and tissues of patients but also a mean for radiologists and physicians to evaluate, monitor and treat a patient’s diagnosis through an array of imaging modalities, such as X-ray (XR), ultrasound (US), computed tomography (CT), nuclear medicine (NM), positron emission tomography (PET) and magnetic resonance imaging (MRI).
Recently, techniques have been developed to enable CT, MRI and ultrasound scanning software to produce 3D and 4D images for physicians. These imaging techniques produce very large amounts of data, especially from CT, MRI and PET modalities.
A picture archiving and communication system (PACS) is a medical imaging technology which provides storage and access to images from multiple modalities. Electronic images and reports are transmitted digitally via PACS, eliminating the need to manually file, retrieve and transport film throughout the healthcare organization.
A PACS typically consists of four major components:
The data center and campus network permit exchanges of images and related information between the imaging devices and the PACS, between the PACS and the workstations and between the PACS and other information systems such as a radiology information system (RIS) or health information system (HIS). A PACS may often times have a separate and dedicated local area network (LAN) to accommodate bandwidth requirements and to avoid performance disruptions related to the medical facility LAN. Likewise, there may also be instances where the PACS may reside on the medical facility LAN where performance and bandwidth requirements may not be an overarching concern.
PACS bandwidth requirements typically depend on the imaging modalities and their respective workflows. For example, a LAN adequate for ultrasounds may not be adequate for other modalities. The network traffic of a PACS system often times varies in a cyclical fashion throughout the day. There may be periods of very high traffic, separated by periods of low traffic. Network design must take into account both peak and average bandwidth requirements and the potential delays that are considered “tolerable” by end-users.
In an effort to help standardize all aspects of medical imaging, the National Electrical Manufacturers Association (NEMA) holds the copyright to the Digital Imaging and Communications in Medicine (DICOM) standard. DICOM enables the integration of scanners, servers, workstations, printers and network hardware from multiple manufacturers into a PACS. It is the industry standard for handling, storing, printing and transmitting information through application and communication protocols. DICOM files can be exchanged between two entities that are capable of receiving image and patient data in DICOM format on any LAN or WAN, provided the that the intermediate network layer protocol is TCP/IP . Issues of conformance and functionality must be considered when purchasing individual imaging devices, as well as when purchasing or upgrading a PACS.
It is advantageous to always have communication between the PACS, RIS, HIS and EMR or EHR when possible. Communication is often implemented using a standard called Health Level 7 (HL7) for the electronic exchange of alphanumeric medical information, such as administrative information and clinical laboratory data. HL7 to DICOM translation, for instance, is a step in the RIS or HIS providing work lists to the imaging devices. HL7, like DICOM, applies to the application layer in the network protocol stack.
As PACS and DICOM standards have been widely adopted by hospitals, health systems and larger physician offices, technology continues to evolve to make workflows more simplistic and natural for end-users. Patient-centric vendor neutral archives (VNA) seamlessly consolidate disparate imaging
systems into one repository using the latest interoperability standards.
Essentially, the VNA is used to unite islands of storage and present a single point of access to entire patient clinical records. The archive will typically collect images and data from a variety of systems such as imaging exams, lab data, video files and JPEC images to create a cohesive patient portfolio - allowin gthe clinician to quickly retrieve critical documentation in stances where an immediate medical decision is required. The VNA architecture supports interoperability and integration standards and protocols such as HL7, DICOM, non-DICOM and others. While VNA deployments have taken a slower path to adoption, there are many benefits and assurances, which can include: anywhere and anytime acccess, platform integration without migrating existing archives and meeting all patient privacy regulations.
Whether upgrading or replacing an existing medical imaging solution, it is vital to ensure the campus and data center networks offer the redundancy and performance necessary to handle the uptime required for image storage, retrieval and transfer.
As the healthcare industry rapidly evolves with new technological advances such as EMRs and highly sophisticated PACS and/or VNAs, it is important to note that communication must still exist within and outside of each department. Ideas about health and behaviors are shaped by the communication, information, and technology that people interact with every day. Communication is central to healthcare, public health, and the way our society views health. These processes make up the context and the ways professionals and the public search for, understand, and use health information, significantly impacting their healthcare decisions and actions. Today, many tools are being leveraged to breakdown the bottlenecks, streamline normal day-to-day communication activities and ultimately increase correspondence and productivity.
For many facilities, the implementation of IP telephony was a first step towards modernizing their communications capability. In fact, the majority of new installations are IP-based and include a succinct wired and wireless device strategy – eliminating older TDM PBX systems that can no longer scale with the growth of the organization and with end-user demands.
In order to enhance productivity, unified communications (UC) platforms have been deployed to enhance collaboration across healthcare organizations and with members of the public, and are expected to deliver significant savings through streamlined maintenance, management and lower costs. With a unified communications solution that integrates all communications tools into a single interface, critical information can be exchanged by email, voicemail, text messages or even video.
Often healthcare staff tend to have access to a range of rich call handling and telephony features including unified messaging, allowing them to access voice messages from anywhere across the organization. Additionally, many of the platforms will also provide agent and supervisor tools to drive productive interactions with callers, alongside real-time and historical reporting available to monitor operational efficiency. Organizations typically don’t have to overhaul their current telephony infrastructures to reap the benefits; they can adopt unified communications in whatever configuration fits the specific need and budget. However, migrating the telephony network to VoIP is often the first step towards enabling unified communications – then the organization can determine what applications to deploy and which departments will truly benefit the most.
Within healthcare environments, it is important to understand end-user and departmental requirements before deploying communication technologies. There most likely will be a wide range of end-points telephony throughout the organization, such as public, administrative, audio conferencing, patient room, nursing station and physician phones. The organization must determine whether a phone with a fixed location is suitable for the department and workflow, opposed to a wireless phone that may create more flexibility but require more technology coverage.
While voice communication will always play an important role in healthcare delivery, video has recently become prevalent in daily healthcare activities, and based on the circumstance can be the preferred method for communication. Today, physicians use video to consult with other physicians, communicate directly with patients and transmit real-time medical information such as images to other clinicians while reviewing face-to-face. These capabilities did not exist several years back and are now becoming more and more mainstream. Like audio, video has jitter and packet-loss requirements that are used to eliminate potential delay and degradation issues that may impact the value and overall experience of the solution. Direct video communication between two clinicians will have more strict delay parameters than a broadcast that may be used for educational purposes in an academic medical center classroom environment. Another consideration would be the type of streaming that would be required, such as low-definition vs. high-definition. Lower resolution streams will significantly reduce the bandwidth requirements while high resolution will require a much higher level of bandwidth.
A UC platform has been proven to improve the coordination within the organization, making the entire staff much more efficient. However, before deploying a UC solution, it is vital to ensure the data center and campus networks offer the redundancy, overall bandwidth and Quality of Service (QoS) necessary to handle the traffic flow and uptime needs.
There has never been a greater time where network managers have been under increasing pressure to allow for BYOD. In fact, those that have not yet implemented a plan of action are now hearing questions about when it will be supported by the organization. As with all technology that is considered within a healthcare environment, a formal BYOD policy will help alleviate the majority of pain associated with compliance and device access. Many professionals are simply not aware of the high levels of security that are now the foundation of current enterprise-level solutions that make BYOD possible. If the organization doesn’t want to allow staff to access certain applications while they are logged into the facility’s wireless network with their own devices, with a formal BYOD policy that can be arranged. Consider mobile device management (MDM), network access control (NAC) and firewall solutions to augment a more robust BYOD strategy for the organization.
While supporting a BYOD policy is heavily focused on the wireless infrastructure, network professionals must consider that if the core infrastructure doesn’t have a solid foundation, the organization is at risk for supporting bandwidth demands through wireless connectivity. It is critically important to review the current campus and data center infrastructure to strategically avoid any potential points of network congestion.