Report from HIMMS 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

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).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.