Point of Care Data Networking

Point of Care Data Networking
by Kevin Breneman and Keith Ensor of Wellspan Networking and Telecommunications We will be presenting the NUTS & BOLTS of NETWORKING POC devices to the KEYPOC group.. We will be presenting a view from a FUNCTIONAL COMMUNICATIONS level as we in Wellspan Networking see the system. We view the METER as a small COMPUTER or PDA like a BLACKBERRY or PALM PILOT We won’t be discussing patient comfort, operator use, or strip chemistry, we will concentrate on meter to host communications. Our DESIRE is to explain in detail how the test data gets from the patient Point of Care to the hospital LIS and BILLING SYSTEMs and to present the TERMS and TECHNOLOGY involved. We hope to present NETWORKING KNOWLEDGE to help you better INSTALL & MAINTAIN your own POC DATA COLLECTION SYSTEM(s) Disclaimer: we are not endorsing or condemning the LIFESCAN system and iSTAT systems. We are only using them as examples in our presentation as they are the systems we are familiar with. Questions will be accepted and welcomed at any time during the presentation. Keith Ensor Kevin Breneman

GOAL = connectivity METER to HOST communications
Paperless read and results reporting of patient testing A single source of truth that is reliably copied verbatim to whoever needs the data Populate other systems with the collected data Eliminate hand written transposing errors Improve efficiency of existing available staff Revenue recovery for services rendered What are we TRYING to ACCOMPLISH?

GOAL = convenience for caregivers
A good system will be preferred over a manual system return more info then a manual system simplify an otherwise tedious task Integrate easily with other hospital systems Allow moderate degrees of customization Patient id format matching and checking Inclusion of desired extra fields Elimination of unwanted field requests Include security controls and honor patient privacy MANUAL should NEVER be better then an installed automated system! MORE DATA plus higher DATA integrity Integrity example: TIME of TEST is not what caregiver wrote down but what the ACTUAL TIME of the test was! CUSTOMIZING: PATIENT ID NUMBER FIELD CONTROL LENGTH, LEADING CHARACTER, QUICK CHECK PATIENT ID vs TESTER BADGE NUMBER Could you include a new field like a scan of the ROOM NUMBER? Could some one unskilled pick up a meter and EXTRACT PATIENT INFO, CORRUPT recorded tests, ADD bogus tests?

Wellspan Glucose System Components 1st Level
Lifescan meter Lifescan IR docking station Lantronix mss100 terminal server House wiring / interconnect Catalyst 5500 Ethernet switch decreasing user exposure We’ll be presenting the system at TWO levels. FIRST LEVEL…..equipment exposed to the user All this equipment within 300 feet of the DOCK location Failure causes: Drops, liquids, physical damage Unexplained damage: the dog ate it Theft and abuse Unauthorized, inexperienced repair attempts by uneducated “helpers”

Other “hidden” components 2nd Level
Core network components i.e. core or distribution router WAN links to annex’s (wan=wide area network i.e. across a phone company circuit) Lifescan Windows server, Lifescan Workstation QDXI / CLOVERLEAF interface engine Cerner interfaced Lab Info System Eclipsys interfaced registration / billing system Other systems LOW user exposure 2nd LEVEL MID and UPPER Level equipment KEY for the actual DATA INTEGRATION LOW failure rate ….. Less human exposure Failure causes at this level LOSS of UTILITY POWER SOFTWARE CHANGES OVER ZEALOUS NETWORK ENGINEERS!

Point of Care Data Networking Glucose Testing
Docking Station Components The components you’ll see most around the hospital These are also the items with the highest human exposure and therefore will be the items requiring the most service and attention. FIRST LEVEL USER EXPOSED: ELEMENTS of a LIFESCAN system you’d see at a nursing station or DOCKING location. GOOD: COMPACT SMALL EQUIPMENT, WALL MOUNTABLE, MODULAR CABLING, LED power status indicators on DOCK and Lantronix BAD: AC adapters, battery powered meter, replicates existing Networking equipment already owned BAD: A potential problem area I see here is the union connector for the AC adapter for the DOCK Wellspan UPDATED from REGAL to NEW BRAND AC adaptor for LANTONIX Tip: -UPGRADE AC brick if you have Lantronix REGAL’s -Tape power couplers

Wellspan Glucose System Components
3 1 2 6 Lifescan meter Handheld, self powered, Lifescan glucose meter “mini”-computer Touch screen user interface Input/Output Strip sensor i/o port Bar code reader i/o port IR (infra red) communications i/o port Duplicate "earphone” communications i/o port Battery powered Is it RUGGED….Can you DROP IT? SAFE case….no metal, no glass, all plastic no shock or telemetry equip hazard. No RF interference Nice if you can operate with ONE HAND CLEAR BRIGHT HIGH CONTRAST DISPLAY (backlit?) AUTOSHUT OFF after xx seconds of no use? Battery Savings. LOW BATTERY indication BEFORE you TEST & waste a strip or sample a patient. SAFE LASER….do not look into the LASER with your REMAINING EYE! BELT CLIP, HOLSTER, CART? Can it be CLEANED and STERILIZED? Can you afford to replace it? Can an unauthorized person use it elsewhere? POINT OUT I or O or BOTH Scanner reads symbology CODE 128 (and others) TURN OFF DECODE of UNUSED symbologies Set scanner rules / FILTERS for length, prefix, whatever you can. AVOID scan of nurse BADGE for PATIENT ID BADGE and ARMBAND print quality should be EXCELLENT. Scanning should work FIRST TIME. 5 4 7 Tip: turn off scanner decode of unused bar code symbologies

Lifescan meter dock IR port optical / infrared transceiver rj11 presentation serial data communications connector Meter “present” trigger It’s wall mountable so DO IT! Make cords custom length and consider custom color. The red cable connects a to b , the blue cable connects c to d EASY SUPPORT! If an AC outlet is not within reach of the provided cord have one installed. Don’t use extension cords. Added failure point Consider locking clamps for AC adaptors so the CAN’T be unplugged. FACT: Only when docked is a meter available for data upload download. -meter updates to flash memory -meter programming changes AC power adapter Tip: consider clamp locks for AC adaptors

Lantronix terminal server Status LED’s UTP rj45 Ethernet presentation AC power adapter connect It’s wall mountable so DO IT! Tout that this is a low cost commonly available device….. Good equipment despite use of AC adaptor. Uses common industry standard connections, RJ11 serial/(phone) cable, RS232 modular adaptor, rj45 network cable First real networking item that communications staff would typically take ownership of. We should NOT have purchased as we already own a big brother of this unit with 48 ports and a network interface. 30 $300 each Using our OWN would have cut CLUTTER at the nursing station as well as incorporated a more robust, secure device. LABEL it with its location, ip address, and hostname with a permanent label. We like the Brother PTOUCH labeling. Cheap, neat , lasting. CLOSE look shows this to be hostname 6east “PINGable” device which aids in troubleshooting Try this FIRST when you know it is working as your pc may be denied access to ping the LANTRONIX RS232 standard “db25” presentation serial data communications connector with rj11 adapter Tip: ECHO test if it’s alive and on-line. from your desktop pc issue the command: ping

House wiring / interconnect A reliable cable plant is key to a successful installation House wiring may be used for Ethernet, serial, or telephone connections Basically it’s nothing more then a “quality” extension cord for your wiring needs Learn your institutions wiring identification scheme. It’ll may help you locate devices. Report problems by connection id information At Wellspan the first three digits indicate the central wiring closet where the cable terminates and the remaining digits are the sequence number or patch location for that cable. Consider custom length cords. Bundling can be done but exact length cables stay out of the way Status LED’s Tip: Look closely and see the wall plate is numbered , AND , A typical modern cable plant will server a 300’ radius area around a central communications closet. The area covered however is typically only 2 dimensional and does NOT CROSS FLOORS vertically A well planned cable plant can accommodate, telephone, ethernet, serial data, intercom, misc low voltage sensors and uses EXTENDS the facilities of the secure communications closet to the “desktop”. Equipment in the secured communications closet is usually of higher quality, lower cost/port, and includes redundancy capabilities Example: comm closet term server has 48 ports instead of one like the lantronix Example: catalyst switch has dual power supplies (UPS fed) and hot-swappable components RJ45 jack presentation will allow the insertion of an RJ11 plug. GOOD and BAD Referred to in the industry as STRUCTURED WIRING. Structured house wiring. UTP Unshielded Twisted Pair with rj45 jack presentation UTP rj45 network cable

MID level network connectivity Network switch with fiber uplink telephone ports Network ports A typical WIRING CLOSET. Sometimes referred to as an IDF (intermediate distribution frame) We call this one IDF 66 CATALYST SWITCH is our first interest….note RJ45 jacks on the chassis cards. THEY are EXTENDED to the wall plate via the structured wiring. WIRING: 40 station runs per DESTINATION tray: RUNS are sequentially numbered. This idf appears to have 12 trays (12 * 40=480 wall jacks) SOURCE trays: Network ports and telephone extensions. Varying special requirements. The closet should be neat, secure, and be equipped with a simple local access device, telephone and a variety of POWER options Utility House Emergency power UPS backup power for smooth transitions. NOTE DUAL plugs on the Catalyst switch. Accepts TWO power sources! minutes to this point House wiring Wellspan network closet 066 6th flr main bldg

Tip: check the path. from your desktop pc issue the command: tracert Top level network connectivity CORE Router Core layer Distribution Router #1 Hospital 6th flr idf 66 meter location Distribution layer Distribution Router #2 Modern Networks employ and Access, Distribution, and CORE layer Few controls in the Access layer….Make a “local” call to anyone….in fact it’s like a party line in some cases Distribution layer offers access control and modularization. Think “long distance” and appropriate charges and checks. Core layer provides high tier direction but primarily offers high capacity linking so “calls are never blocked” U.S. telephone system is VERY much like DATA NETWORK routing. Routing in an ip network is analogous to the use of AREA CODES for U.S. phone calls. Every telephone company couldn’t manage every phone number but they can forward it “upstream”. The distribution router is the first upper tier to “reroute” a call, the CORE router is the know it all that has EVERY area code is. A non-existent AREA CODE call may actually have to be processed by the CORE before you get a “wrong number” reply. Introduce concept of HOP COUNT THREE HOPS from meter to Lifescan Server/Workstation USE of tracert command Routing introduces deterministic, repeatable, reliable transport. Core and distribution components provide a backbone or expressway for network traffic. Access layer 7th flr & POC dept idf 79 LIFESCAN Server location Hospital Data Center idf 159 Cerner LIS location

Other “hidden” components 2nd Level
Core network components i.e. core or distribution router WAN links to annex’s Lifescan Windows NT server QDXI / CLOVERLEAF interface engine Cerner mainframe interfaced Lab Info System Eclipsys mainframe interfaced billing system Lifescan Workstation and iSTAT CDS That Catalyst in the 6th floor wiring closet is ONLY the ACCESS switch for devices within 300 feet of it. Other SYSTEMS on OTHER network switches would include: QDXI / CLOVERLEAF interface engine…eliminate a full mesh between interfaces systems. Creates a HUB and SPOKE instead. Cerner interfaced Lab Info System.. An interface on Cerner connects directly to Cloverleaf which then connects to the Lifescan W/S Eclipsys interfaced billing system. SAME as CERNER Other systems CERNER QDXI Eclipsys

A typical glucose meter to LIS (lab info system) configuration Components Meter Docking station Ethernet / Terminal server Ethernet transport inter-network hub, switch, router Glucose System Server Lab Information System Other involved information systems Glucose Meter B w/IR linking POC dock Ethernet Terminal Server Ethernet Area Router FOCUS now on BLOCK LEVEL DATA FLOW FIRST on a block level from 10,000 feet up…… WHAT ARE THE COMPONENTS Ethernet Hub Ethernet Switch Glucose Server & Data Collector Lab Info System SUPER DOOPER HOST

A typical glucose meter to LIS (lab info system) configuration Glucose Meter A w/IR linking Router interfaces 1,2,3,4 join FOUR tcp/ip networks. Without the router we can not segment traffic. With the router we can have local traffic stay local & impart network access controls When a router is used each host must have knowledge that it needs to use the router for destinations not on its own subnet. Host AAA Ethernet Terminal Server 1 POC dock Ethernet Hub Ethernet Switch #1 Laser A Glucose Meter B w/IR linking Subnet 1 POC dock Ethernet Terminal Server 2 Ethernet Area/Core Router 1 2 4 Subnet 2 FLOW EXAMPLE METER A to LIS. NOTE LINK SPEEDS….. First IDENTIFY ROUTER and that METERS are on NETWORK 1 Meter IR to DOCK DOCK serial/rs232 to term server LOW SPEED, LOW PAYLOAD Term server ethernet to switch or hub HIGH SPEED, UP to HIGH PAYLOAD. Ethernet switch to distribution router for forwarding to destination (other area code) using the gateway declared on the terminal server in this case TERMINAL SERVER GATEWAY ADDRESS = network address of ROUTER INTERFACE 1 Core down to DESTINATION area code router interface 3 for processing by Lifescan W/S And so on to ……….interface 2 to cloverleaf DESPITE LIS and Registration being in same “area code” they had to go “LONG DISTANCE” to use the interface engine SWITCH vs HUB… HOST A to LASER A concurrent with our transmission….hub allows ONLY ONE at a time. HUB = Hotel with one phone line and all rooms on that party line. One inter-room call at a time SWITCH = Think of a skilled switchboard operator with a pile of patch cords managing multiple inter-room calls in a hotel. Ethernet Switch #2 3 System to System Interface engine (Cloverleaf) Subnet 4 Subnet 3 Ethernet Switch #4 Ethernet Switch #3 serial links Registration System Lab Info System UTP links Glucose Server & Data Collector Fiber links

Ethernet Area/Core Router 3 5 2&4 1 Ethernet Area/Core Router 6 7 Ethernet Switch #1 Ethernet Switch #3 Ethernet Terminal Server Glucose Server & Data Collector The 10,000 foot block view overlaying the technical networking components. Introduce TRUNK concept where TWO router interfaces can be delivered to one physical switch with virtual capabilities Network 2 and 4 are really two area codes owned by the same telephone company and are both multiplexed on a single physical connection. These are called Vlans or Virtual Lans Recall final step or LAB to CLOVERLEAF to REGISTRATION flow using VLANS DATA CENTER is where this often happens first because of high host concentration Like a big city split by a river and needing two area codes to effect efficient call routing WE’LL be coming back to this one!!! Ethernet Switch Glucose Meter B w/IR linking Ethernet Switch (#2 & #4) w/ VIRTUAL capability POC dock Ethernet Terminal Server Interface engine (Cloverleaf) Glucose Meter B w/IR linking Lab Info System Registration System POC dock

Point of Care Data Networking iSTAT Testing
Wellspan Components iSTAT Reading iSTAT meter = lifescan meter iSTAT IR docking station = lifescan docking station COBOX terminal server=lantronix terminal server Cisco Catalyst Ethernet switch Cisco distribution router iSTAT Windows server CDS-Central Data Station = Lifescan workstation TIME FOR A BREATHER….!! Compare istat components to equivalent Lifescan components….. Equipment is identical from a networking persons perspective iSTAT did not include mounting capabilities or were not used REMEMBER THAT…. Uses AC adaptors SESSION BREAK BETWEEN SLIDE 17 and 24 Scripted CDS to Cerner interface Cloverleaf NOT used!!!! NON - HL7 Likely Low Cost but LOW TECH….only works to Cerner. Un-expandable Looks like a user logged in on the system. Subject to Cerner changes!! uses a VT420 dumb terminal style of login and script to upload data NOT interfaced to Eclipsys interfaced billing/registration system

Component Functions Glucose meter
a limited function computer with i/o capabilities for: display and keyboard / bar code reader input test strip subsystem and input Optical communications port to transfer data base field type data. Input operator lists / badges Database type field parameters Output Patient id Patient test number Time Patient test result value DEVICE Technical specifics IR communications typically at 9600 bps IR tops out at 4 megabits/sec IR has its own protocol The meter is a pretty sophisticated computer!!! Multi function, multi i/o, touch screen! SESSION BREAK BETWEEN SLIDE 17 and 24

Docking Station IR (infra-red) linking to meter
Physical and/or Optical connection to meter May be passive or may provide expanded communications features absent in the meter to offer serial RS-232 communications to existing hospital owned standards based Networking devices like a hospital owned Ethernet terminal server. The data stream from the meter/dock is like a single file row of marbles coming down a tube in sporadic pacing. References to the docks data port may include the terms serial, asynchronous, com port, rs232 port, rs485 port. Adds reliability and automation to the UPLOAD process Provides AC line power for communications Triggering magnet in DOCK causes meter to automatically initiate upload sequence w/o user intervention Provides industry standard serial communications link. RS232, serial, asynchronous, DTE device, comm port, (all are used as terms to refer to such a connection) Small payload - Slow speed communications SESSION BREAK BETWEEN SLIDE 17 and 24

Asynchronous Ethernet Terminal server
A conversion device or communications converter to allow the connection of slow speed low cost devices to high speed Ethernet networks. (marbles to envelopes) Meter and dock speak asynchronously typically at only 9600 bits/second or about (9600/8) 1200 characters per second. Serial communication is typically referenced by bits or single characters Ethernet by contrast speaks at 106 bits/second or about (106/8) 1,250,000 characters per second with typical modern networks NOW using fast Ethernet 107 and gigabit 108 bit rates. Ethernet communication is typically referenced by packets of data Terminal servers most often emulate the original DEC Digital Equipment Corporation (now HP) DECserver200. They allowed the connection of multiple terminals to a single box which could then communicate on a base band ethernet backbone. This saved the need to run a wire from the host computer to each and every dumb terminal or printer. Aggregates serial stream data into a data packet or DATAGRAMS for forwarding as a “packet” on a high speed data network. PACKET is multiple characters i.e packet 1=“The quick brown fox”, packet 2=“jumped over the lazy”, packet 3=“dog .<FF>” SPEED consideration and INTEGRATION onto a common backbone is the advantage. SESSION BREAK BETWEEN SLIDE 17 and 24

Ethernet terminal server (cont)
The job of the terminal server is to “package” the async data into a larger package for efficient transport on a high speed network. i.e. Japanese subway “stuffers”. The data stream on the Ethernet side of the term server would be analogous to when a train comes by with open box cars and you fill each boxcar without the train stopping in a “clocked” loading fashion such that each boxcar represents a data packet from the terminal server. Many cars will leave only partially filled and sometime 2 or 3 cars may be needed for one big packet that has to be split up because it’s too big or takes to long to get in the current passing boxcar! One box car or packet may contain multiple individual threads between several meters on a common terminal server origination or source to a common destination such as the LIS host offering multiple threads to accommodate communications with each connected meter. Once a data stream begins from the meter the term server starts packetization. The train starts rollin ! Every x milliseconds a box car door slams shut and data continues to be loaded in the next boxcar Each boxcar has a source address of the server it came from (the city) and the home sending it. Communication closet terminal servers can support more then one slow speed device concurrently. i.e. 48 docking stations on ONE terminal server All docking stations can send at the same time and the term server manages the source identification by labeling each data stream with “tagging” information included in the ethernet packet. SESSION BREAK BETWEEN SLIDE 17 and 24

Cloverleaf (QDXI) interfacing and HL7
An interfacing program executing on the LIS receives the inbound testing information but at Wellspan the meter actually first sends to the Lifescan server (Lifescan Workstation) which then sends to an interface engine which then sends to Cerner (the LIS) via HL7 data exchange protocol. [HL7 = health layer seven] The advantage is that an enterprise hub and spoke interfacing plan can be adopted saving per host interface ports and resources. Consider this example “6 host hospital enterprise” full mesh interfacing…………..interfaces=n(n-1)/2 or 6(5)/2 =15 hub-and-spoke interfacing…..interfaces=n(1) or 6(1) = 6 A hospital with only 20 hosts would take 180 interfaces versus 20 interfaces A Lab Info system like CERNER would likely require the addition of a communications software module The module is typically a programming collaboration between the LIS vendor and in the in this case LIFESCAN Such modules written well require considerable development time and are costly but rewarding data feed input originating from the meter is integrated into the LIS as if entered manually by a user transposing data from written test results. USE of integration protocols like HL7 have reduced the cost of such ventures by using a standard based syntax. A huge benefit of using HL7 is that perhaps a single HL7 software module can be purchased for your LIS instead of one for each communications partnering requirement. BENEFITS of an INTEGRATED INTERFACE ENGINE REDUCED interface processes REDUCED LINK COUNT SESSION BREAK BETWEEN SLIDE 17 and 24 2 2 1 3 1 3 Hub and Spoke Full Mesh versus QDXI 6 4 6 4 5 5

LIS Laboratory Information System
The LIS is the eventual receiver of the collected test data. The LIS (Cerner) receives the data via the HL7 data exchange protocol from Cloverleaf interface engine. A communications application module purchased for the LIS must be running and “listening” for this inbound data stream. The Cloverleaf and the LIS being Ethernet capable devices exchange packets (boxcars) filled with Lifescan transaction data that has been aggregated by the Lifescan Workstation. TCP / IP protocols job is to direct and route those data packets to the appropriate software communications endpoint on the LIS host. This endpoint is often called the listener, the interface socket, or host virtual port. TCP/IP protocol is the networking protocol that carries the ethernet packet stream whether it be Packets from the terminal server carrying the raw meter data Packets to or from the Cloverleaf engine carrying HL7 transactions data TCP/IP is where the data gets it “state, city, and street” address we spoke of earlier SESSION BREAK BETWEEN SLIDE 17 and 24

…that old black magic…. DATA NETWORKING
The part we just skipped is Networking's specialty and what puts bread on the table for Keith and Kevin !!!!! What really happens when my glucose meter begins to upload data to the network. How does the meter data actually make it to the LIS host? What keeps the data from getting all jumbled together when 5 meters all upload concurrently? SESSION BREAK BEFORE THIS SLIDE (#24)

MAC and IP addressing MAC addressing
Every Ethernet device EVER made has a globally unique MAC or media access control Ethernet address assignment. This assignment is burned into the chip set of each and EVERY Ethernet communications port of any device that can be Ethernet attached. In our example the terminal server would have one and the LIS host would have one. A MAC address is 48 bits long and is almost always written and represented in the computer world in hexadecimal. 281,474,976,710,656 = possibilities example b-01-af-19 hex binary equiv 8,796,814,552,857 decimal equiv MAC media access control address My house will always be at latitude and Latitude: N, Longitude: no matter what they name your street or who lives in it. The mac address might be considered synonymous to my homes latitude and longitude Left part of the number manufacturer (left 24 bits or left 3 bytes) Right part is to be equivalent to the device serial number (right 24 bits or right 3 bytes)

IP addressing Example: 192.168.236.104
Every Ethernet device added to a tcp/ip network needs to get an assigned IP address. This assignment is typically awarded by your institutions network guru or IP address administrator. In our example the terminal server would be assigned an ip address so it could talk to other tcp/ip systems on your network. An ip address is a 32 bit number typically expressed in decimal format. The left portion of the assignment reflects the network (think area code) that the host is enrolled in and the right portion of the assignment reflects the host number in that network. (think your 7 digit phone number) An IP address is 32 bits long and is represented in the computer world in decimal using what is called dotted decimal notation. Example: Above in binary is Full decimal value would be 3,232,296,040 but this reference is not used as the dotted decimal notation more easily shows network enrollment 32 bits = 4,294,967,296 possibitlies Private REUSABLE addressing ranges: thru first dot boundary (/24 bit) thru second dot boundary (/16 bit) thru (/8 bit) IP address is an address awarded to a device independent of its mac address. The left side of the “address” reflects the network you belong to….the right side reflects your individual host or house identifier Think left side = zip code, right side = street number Unlike the mac address the network/host boundary can be shifted. A town with lots of short streets may want to use more digits for networks A town with only one or two really long streets may want to use more digits for host or house identifiers DEPLETION OF AVAILABLE #’s we are on a course to soon deplete all available 4 BILLION addresses Schemes were introduced in the early 90’s to avoid and defer this introduction of address translation Introduction of a reusable block for internal addressing thru first dot boundary (/24 bit) thru second dot boundary (/16 bit) thru (/8 bit)

IP addressing/subnet masking
Example: Above in binary is: Mask The above 32 bit mask allows 224 bits for network and 28 bits for host numbers MASK Value Typical masks are : allows last byte to be all host numbers 28 = 255 (actually 256-1) allows last 2 bytes to be for host numbers 216 = 65,535 allows last 3 bytes to be for host numbers 224 = 16,777,215 BUT they can be on a NON-classful boundary CUSTOM mask example allows only the last HALF of last byte to be host numbers 24 = 15 Every host in a tcp/ip network needs an ip address, a mask, and a gateway Mask indicates where the network / host boundary marker is. The mask is the masking tape that tapes over the COMMON NETWORK PART of the address that is not important when talking within your network. The MASK is the second requirement when giving a device an IP address assignment. VALUE THAT SETS THE BOUNDARY The left side of the “address” reflects the network you belong to….the right side reflects your individual host or house identifier WHY SHIFT THE BOUNDARY?? A town with lots of short streets may want to use more digits for networks A town with only one or two really long streets may want to use more digits for host or house identifiers The reason I show and 1 less for each network mask is because an all 1’s number like 255 is considered unusable for a host This is because an all 1’s address is a BROADCAST address that all hosts receive and process.

IP addressing/gateway
Network portion Host portion Example: Above in binary is: Gateway: Above in binary is: Mask The gateway address will always be a similar ip address to yours & in your local network. The gateway address you use will always be the ip address of a router interface. Your “GATEWAY” to the rest of the IP world. You talk to it. It talks to the next level on your behalf. The address you enter on your host for the GATEWAY will always be an address on YOUR network. It is who you DEFAULT to for getting beyond your network. “long distance” to another area code. Hence the name “default gateway” An ARP address resolution protocol table in your pc maps host ip addresses you talk to, to that device’s MAC address. Devices really talk MAC to MAC!!! The last part of giving a device an IP address assignment is to give it the address it uses to go out of its home network If the DESTINATION host you are seeking to talk to is NOT on your network you initiate a connection to your networks GATEWAY. The GATEWAY is a router The GATEWAY will know where to forward the message to and if it doesn’t it will forward it up to a tier that does. If there is no response or no known destination (or it’s down) you will get back an “unreachable” message Each router gateway encountered between you and your destination is referred to as a HOP. Your PC has a relational table called an ARP table that maps a destination ip address to a MAC address. If LOCAL it is the actual MAC address ---- If “long distance” it is the MAC address of the gateway router. If you can’t ping a Lantronix terminal server….see if you can ping it’s GATEWAY address. If you can the network is probably OK. If you can’t the router could be down. Tip: ECHO test the gateway. If it’s not alive then that net will be unable to talk outside of its own “area code”. from your desktop pc issue the command: ping

IP addressing / dhcp or permanent (static)
The ip address can also be awarded by machine from a pool of predefined available addresses. This technique is called DHCP or Dynamic Host Control Protocol. This works great for devices that join and leave networks and works well if no one needs to access your host. DHCP can be setup to award you a temporary ip address, your correct mask and your assigned gateway. A pc workstation works fine with a temporary dhcp address but a pc SERVER would almost always need to receive a permanently assigned address so other computers would know what to connect to. The addressing typically used by POC system component will likely always be static addressing because like a server the addressing is permanently awarded per device so that other systems can find the POC system components using the same address each time. Good static address example is which really is Good dhcp example is your office pc which only makes OUTGOING connections so it doesn’t really matter if you use a different address tomorrow. You could still for example get to google.com! IP addresses originally were all static and you always used the same one Devices like laptop and portable computers however dictated a need for dynamic addressing. If you were a summer visitor to a small town in New England in your Airstream RV trailer and wanted to receive mail there over summer vacation you’d use the network number (zip code) but you’d probably get a box number from a pool of available p.o. boxes at the local post office. You may have trouble receiving mail because no one will know you have this temporary address until they get notification from you or a friend. When you move your RV to Florida to a new location for the winter season you’d inherit a new address in a Florida zip code and a new P.O. box. The p.o box might even be the same number you had in New England but to the world it is different because the zip code makes it globally unique. This is how DHCP works. You inherit from the local authority a temporary address so you can send and receive communications NEW ENGLAND pool example FLORIDA pool example If this were the scheme in use (last “octet” = po box) the network/host boundary would be at the /24 bit point (after the third decimal point)

Wellspan Glucose System Networking
Here’s that picture again. Lets look at the Flow from LIFESCAN WORKSTATION to the METER to PULL data….. Glucose Server Data Collector IP: Gateway: Mask: Ethernet Terminal Server IP: Gateway: Mask: Glucose Meter B w/IR linking POC dock

Socket Communications
Socket communications is how the I.T. world refers to endpoints. Two systems that are ETHERNET capable will use socket to socket communications for each “flow” Meter A on term server 1 to the Lifescan Workstation would use a socket pair. Meter B on term server 2 to the Lifescan Workstation would use a socket pair. At least one endpoint must use an exclusive ip address or socket number to differentiate between the two flows. (reference slide 15) Connect to your LIS host and then to an Internet sites on your work pc and then click start and run and in the dos window that opens type netstat –a on your pc. It will show you an nice example of socket to socket communications example: pc to google Example pc to CERNER via telnet IP addresses are associated to MAC addresses at some point along the flow path….. An ARP table or address resolution protocol table manages this for you. Typically one on your pc for hosts in your zip code Another one on the upstream router for how to get to other zip codes Bring out the concept of source and destination addressing Introduce concept of my daughter at my house in my zip code writing to her boyfriend in another zip code at another house where he is the 3rd of 4 children. SOCKET COMMUNICATIONS Socket type/capabilities One host to a listener allowing one connection per socket…..POC term server One host to a listener allowing multiple connections per socket….telnet Use floppy copy orig > copy as an example of data flow. Tip:

Sockets that receive connections
are called “Listeners” because they are “at the ready” to receive an inbound connection. Are often called “services” or service sockets because they are typically tied via software to an application function like: telnet, or ftp, or webserver Custom receiver application like Glucose meter data collection. The boyfriend on the receiving end is the listener socket…… Aren’t they always…ha-ha The boyfriend may be programmed to receive and accept letters from many girlfriends i.e. telnet and ftp The boyfriend may be programmed to only accept one girlfriend input at a time i.e. single input like a Glucose listener.

Application to Socket communications
The application can however be coordinated with an initiating socket with the other endpoint being the listener. Printing is an example of such a reverse direction of socket communications because the printer is listening for a connection for its next print job. A listener may allow only ONE connection at a time or it may allow multiple concurrent connections. THE computer with the endpoint that INITIATES the communications is NOT the listener. Web server = example of multithreaded listener If the terminal server is the listener end = example of single thread listener. A busy listener will tell the end trying to connect to it that it is already busy or it may even allow a degree of queuing whereby it accepts a second, third or fourth connection but it may put that flow in a hold or stacking pattern till it can process the current “on deck” request.

Application to Socket communications
Click RUN, then click START then enter command (win98) or cmd (winxp) and in the dos window enter netstat –a at the prompt to view all the current socket connections on a pc. Here’s a partial clip from our Lifescan server. Tip: Active Connections Proto Local Address Foreign Address State TCP lfs_datalink: : LISTENING TCP lfs_datalink: : LISTENING TCP lfs_datalink: : LISTENING .. . TCP lfs_datalink: : LISTENING TCP lfs_datalink: : LISTENING TCP lfs_datalink:nbsession : LISTENING TCP lfs_datalink: : ESTABLISHED TCP lfs_datalink: : ESTABLISHED TCP lfs_datalink: : ESTABLISHED TCP lfs_datalink: :telnet TIME_WAIT TCP lfs_datalink: : ESTABLISHED TCP lfs_datalink: :telnet TIME_WAIT Protocol = tcp Local address is the hostname of the LIFESCAN workstation After the COLON in the Local Address is the socket number ON the LIFESCAN w/S Foreign address is the host name or address of the other end of the connection AFTER the COLON in the Foreign Address field is the socket number endpoint on the distant host State tells you what it’s doing: LISTENING: the software that receives on this socket started up the listener and it is running ESTABLISHED: the socket (could be a LISTENER) is connected to the listed host:socket TIME WAIT: the socket was in use but was torn down and is in HOLD mode so it is not reused accidentally FIN WAIT & CLOSE WAIT: one end closed and is waiting on ACK from the other…… could indicate problems or connection losses. netstat –a is a harmless command to view connection status. It can be executed at any time on any pc w/o impact.

Wireless adoption Current capabilities Future
Wirelessly connect the terminal servers Future Direct real time or “hot spot” wireless linking for each meter Would help eliminate those times when no one remembers to dock and upload the days work from a meter. Wireless Meter tracking…. Where did I lay meter icu01??? Wireless daily audit of transactions w/o docking. Meter peds06 did not report for 24 hours so the server will “look” for it and potentially alarm / a system manager if missing. Automated updates…. All meters will be software upgraded to now accept an additional bar code format for the new to be adopted patient id system. Or all meters will be upgraded to Lifescan operating system version 6.12 from 5.83 First wireless generation will be nothing more then wireless docking stations….easy to do and can even be done with your current cabled terminal servers by front ending them with a wireless bridge adaptor. Giving a term server a wireless connection may have unseen benefits like helping to keep the dock station neat because it could be on it’s own cart instead of competing for precious counter space at the nursing station.

What can POC users do to make for an optimal Network deployment at their institution?
Establish clear installation locations that are not overcrowded with other nursing functions. Name everything with a short, lower case, meaningful name during the design phase and stick with it. Too many devices here!! A horrid wire mess from msicu Where’s Waldo? Find the istat meter dock!!!!..???? The lifescan doc is on the wall. Note its clean install helps keep it easiest to find but front clutter impacts its accessibility. Compare integrity of Lifescan install (mounted and bundled to wall) with iSTAT install which was just splayed out on the counter. Would you want to troubleshoot and support the Lifescan or the iSTAT install if you had your choice? Recall how I pointed out that iSTAT had no wall mount option and Lifescan difference. Here is the result.

What might POC users be asking of POC vendors
for future product considerations give thought from a Networking perspective. Does the vendor’s devices allow you to use existing network resources. You may already own terminal servers? Why buy more? We shouldn’t have. Can they use DNS or dynamic DNS for naming simplification and connection destinations? A netstat will then show names instead of addresses! Can the peripheral devices be easily monitored for health status (SNMP, telnet and web access)? Does the system support test and training data collection while the production system is live?

Other “BEST” networking practices
Neat cable work eliminates problems Label devices and document connections Give EVERYTHING an enterprise unique name Think like a hacker when planning the install. Hospitals have been lax on security for too long. If the area is already cluttered don’t expect it to improve with the addition of another computing device. Something gotta go or new space must be allocated. If the installation looks permanent it will be permanent. If it is just splayed out on a counter it’ll be buried in charts and you can be assured of failures. If it didn’t require tools to install it then it won’t require tools to dismantle it and someone will. Consider a semi-annual or regular equipment inspection and be prepared to make repairs and corrections. Time the inspection with your annual review and tout how you’ve assured continued meter reliability. If it breaks you’ll get the blame so why not get the credit.

Thank-you Questions Keith Ensor Kevin Breneman

EXTRA CREDIT Keith Ensor Kevin Breneman

BEST PRACTICES: DNS Domain Name System
What’s DNS have to do with POC networking??? Forms a name to IP address relationship that is enterprise wide Enter every ethernet device in your DNS. You would submit to your DNS administrator the official hostname and its assigned ip address. They will add an “A” record to your enterprise DNS so the name can be resolved to an ip address Promotes good naming conventions Aids dramatically in troubleshooting Is the terminal server in ICU plugged in? The users say they can’t upload? Lookup the ip address of the Lantronix in ICU and find it is So you do a ping to ---- OR Is the terminal server in ICU plugged in? The users say they can’t upload? Ping the server by the enterprise naming convention for Lifescan terminal servers So you do ping ts-ls-icu01 (names should use only alpha and numerics and the special character “–” for best practice….add 01,02 at the end for when you expand.) What would the name of the terminal server be in pediatrics Any traces or netstat reports will now present the DNS name of the device in the output instead of the IP address. Much more people friendly!!!

PING example - success What’s a ping display look like when it is successful?

PING example - failure What’s a ping display look like when it fails?

Trace route example (tracert)
What’s a tracert display look like? Note tracert (and ping) commands are case sensitive. Two techniques shown Standard trace with name lookup tracert Modified trace with resolve of names disabled tracert –d

IP version 6 Futures Huge address space
128 bits of addressing capacity 3.40 X 1038 available addresses 340,282,400,000,000,000,000,000,000,000,000,000,000 MAC layer addressing can be auto-extracted into an IP address and address awards can be made from the router w/o a dhcp server. Dynamic but always reserved for your MAC! Return to a net 5 years later and get the SAME address! Integrated encryption already included. Can be made to work with existing IP version 4 networks

HL7 Health Level Seven is a syntax standard specifically designed by. the healthcare industry to facilitate patient data exchange between computer applications ..... Derived from the X12 EDI standard used for HIPPA compliant data transfer take a look at a typical HL7 ADT message. This message is sent when a new patient arrives at the hospital. The patient's demographics are entered into HIS (hospital information system) and then the information is communicated to all the other systems to avoid multiple entries of the patient's demographic information. MSH|^~\&|EPIC|EPICADT|SMS|SMSADT| |CHARRIS|ADTÂ04| |D|2.3| EVN|A04| |||CHARRIS PID|| ^^^2ÎD 1|454721||DOE^JOHN^^^^|DOE^JOHN^^^^| |M||B|254 E238ST^ÊUCLIDÔH^44123ÛSA||(216) |||M|NON| ~ |999-| NK1||CONROY^MARI^^^^|SPO||(216) ||EC||||||||||||||||||||||||||| PV1||O|168 ~219~C~PMA^^^^^^^^^||||277ÂLLEN FADZL^BONNIE^^^^|||||||||| || ||||||||||||||||||||||||| |||||| HL7 messages are ASCII messages and the standard requires that they be "human readable". The | (pipe characters) are considered readable

Security Planning and Considerations
Three A’s Authentication Multifactor Who you are = username Something you know = secret password Something you have = key or token Authorization What is allowed now that your in? Not all users should have full access Accounting Who are you, what did you do, and when did you do it? Audit trail Intrusion analysis

THAT’s ALL FOLKS!!!! REALLY!!!! Keith Ensor Kevin Breneman

presentation needs What host will provide:
Screen and projector setup with VGA input capability Cable for VGA connect to laptop from projector that can reach presenters laptop location Table or stand for convenient nearby location of 2 laptops to presenter with space for mouse navigation by presenter Extension cords / outlet for AC power for presenter laptop white board or flip chart w/markers of two colors Access to conference room 15 to 30 minutes prior to presentation for setup Hard copy of the presentation will be provided to each attendee. 3/15 POC mtg agenda for the day: registration networking lecture (keith &kev) break networking lecture &questions (keith &kev) lunch & vendor fair barcoding lecture Conference chairperson/contact: Beverly McAllister, MS, MT(ASCP)SC Laboratory Operations Manager Ephrata Community Hospital 169 Martin Ave Ephrata, PA Phone: Fax: What presenter(s) will provide: Final version of presentation ed to Bev M. by 3/10/2006 Laptop(s) and power point software and presentation file Laptop mouse and local cabling Spare laptop ready to be used to continue presentation in the event of equipment failure.

Point of Care Data Networking

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