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Point of Care Data Networking by Kevin Breneman and Keith Ensor of Wellspan Networking and Telecommunications Keith Ensor

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Presentation on theme: "Point of Care Data Networking by Kevin Breneman and Keith Ensor of Wellspan Networking and Telecommunications Keith Ensor"— Presentation transcript:

1 Point of Care Data Networking by Kevin Breneman and Keith Ensor of Wellspan Networking and Telecommunications Keith Ensor Kevin Breneman

2 page 2 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

3 page 3 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

4 page 4 Wellspan Glucose System Components 1 st Level Lifescan meter Lifescan IR docking station Lantronix mss100 terminal server House wiring / interconnect Catalyst 5500 Ethernet switch decreasing user exposure

5 page 5 Other hidden components 2 nd Level Core network components i.e. core or distribution router WAN links to annexs (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

6 page 6 Point of Care Data Networking Glucose Testing Docking Station Components The components youll 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. Tip: -UPGRADE AC brick if you have Lantronix REGALs -Tape power couplers

7 page 7 Wellspan Glucose System Components Lifescan meter 1. Handheld, self powered, Lifescan glucose meter mini-computer 2. Touch screen user interface I nput/ O utput 3. Strip sensor i /o port 4. Bar code reader i/o port 5. IR (infra red) communications i/ o port 6. Duplicate "earphone communications i/ o port 7. Battery powered Tip: turn off scanner decode of unused bar code symbologies

8 page 8 Wellspan Glucose System Components IR port optical / infrared transceiver Meter present trigger AC power adapter Lifescan meter dock rj11 presentation serial data communications connector FACT: Only when docked is a meter available for data upload download. -meter updates to flash memory -meter programming changes Tip: consider clamp locks for AC adaptors

9 page 9 Tip: ECHO test if its alive and on-line. from your desktop pc issue the command: ping Wellspan Glucose System Components UTP rj45 Ethernet presentation Status LEDs AC power adapter connect Lantronix terminal server RS232 standard db25 presentation serial data communications connector with rj11 adapter

10 page 10 Wellspan Glucose System Components UTP rj45 network cable 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 its nothing more then a quality extension cord for your wiring needs Learn your institutions wiring identification scheme. Itll 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 LEDs Tip: Structured house wiring. UTP Unshielded Twisted Pair with rj45 jack presentation

11 page 11 Wellspan Glucose System Components Network switch with fiber uplink House wiring Network ports MID level network connectivity Wellspan network closet th flr main bldg telephone ports

12 page 12 Wellspan Glucose System Components Top level network connectivity Distribution Router #1 CORE Router Distribution Router #2 Hospital 6 th flr idf 66 meter location 7 th flr & POC dept idf 79 LIFESCAN Server location Hospital Data Center idf 159 Cerner LIS location Access layer Distribution layer Core layer Tip: check the path. from your desktop pc issue the command: tracert

13 page 13 QDXI Other hidden components 2 nd Level Core network components i.e. core or distribution router WAN links to annexs Lifescan Windows NT server QDXI / CLOVERLEAF interface engine Cerner mainframe interfaced Lab Info System Eclipsys mainframe interfaced billing system CERNER Eclipsys Lifescan Workstation and iSTAT CDS

14 page 14 Point of Care Data Networking 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 Ethernet Switch POC dock Lab Info System Ethernet Terminal Server A typical glucose meter to LIS (lab info system) configuration Ethernet Area Router Ethernet Hub SUPER DOOPER HOST Glucose Server & Data Collector

15 page 15 Point of Care Data Networking Glucose Meter A w/IR linking Ethernet Switch #1 POC dock Lab Info System Ethernet Terminal Server 1 A typical glucose meter to LIS (lab info system) configuration Ethernet Area/Core Router Ethernet Hub Registration System 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. System to System Interface engine (Cloverleaf) Glucose Meter B w/IR linking POC dock Ethernet Terminal Server 2 Ethernet Switch #2 Ethernet Switch #4 Fiber links UTP links serial links Glucose Server & Data Collector Ethernet Switch # Subnet 3 Subnet 4 Subnet 2 Subnet 1 Host AAA Laser A

16 page 16 Wellspan Glucose System Components Glucose Meter B w/IR linking POC dock Ethernet Terminal Server Ethernet Switch Ethernet Area/Core Router Lab Info System Registration System Ethernet Switch (#2 & #4) w/ VIRTUAL capability Glucose Server & Data Collector Ethernet Switch #3 Glucose Meter B w/IR linking POC dock Ethernet Terminal Server Ethernet Switch #1 3 2&42&4 1 Interface engine (Cloverleaf) 5 6 7

17 page 17 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 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

18 page 18 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

19 page 19 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.

20 page 20 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 10 6 bits/second or about (10 6 /8) 1,250,000 characters per second with typical modern networks NOW using fast Ethernet 10 7 and gigabit 10 8 bit rates. Ethernet communication is typically referenced by packets of data

21 page 21 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 its 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.

22 page 22 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 QDXI Full Mesh Hub and Spoke versus

23 page 23 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.

24 page 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?

25 page 25 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

26 page 26 IP addressing 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)

27 page 27 IP addressing/subnet masking Example: Above in binary is: Mask The above 32 bit mask allows 2 24 bits for network and 2 8 bits for host numbers MASK Value Typical masks are : allows last byte to be all host numbers 2 8 = 255 (actually 256-1) allows last 2 bytes to be for host numbers 2 16 = 65, allows last 3 bytes to be for host numbers 2 24 = 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 2 4 = 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.

28 page 28 IP addressing/gateway 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 devices MAC address. Devices really talk MAC to MAC!!! Host portion Network portion Tip: ECHO test the gateway. If its not alive then that net will be unable to talk outside of its own area code. from your desktop pc issue the command: ping

29 page 29 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 doesnt really matter if you use a different address tomorrow. You could still for example get to!

30 page 30 Wellspan Glucose System Networking Glucose Server Data Collector IP: Gateway: Mask: Glucose Meter B w/IR linking POC dock Ethernet Terminal Server IP: Gateway: Mask:

31 page 31 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 Tip:

32 page 32 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.

33 page 33 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.

34 page 34 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. Heres a partial clip from our Lifescan server. netstat –a is a harmless command to view connection status. It can be executed at any time on any pc w/o impact. Active Connections Proto Local Address Foreign Address State TCP lfs_datalink: :0 LISTENING TCP lfs_datalink: :0 LISTENING TCP lfs_datalink: :0 LISTENING... TCP lfs_datalink: :0 LISTENING TCP lfs_datalink: :0 LISTENING TCP lfs_datalink:nbsession :0 LISTENING. TCP lfs_datalink: :3001 ESTABLISHED TCP lfs_datalink: :3001 ESTABLISHED. TCP lfs_datalink: :3001 ESTABLISHED TCP lfs_datalink: :telnet TIME_WAIT TCP lfs_datalink: :3001 ESTABLISHED TCP lfs_datalink: :telnet TIME_WAIT. Tip:

35 page 35 Wireless adoption Current capabilities 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

36 page 36 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 Wheres 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.

37 page 37 What might POC users be asking of POC vendors for future product considerations give thought from a Networking perspective. Does the vendors devices allow you to use existing network resources. You may already own terminal servers? Why buy more? We shouldnt 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?

38 page 38 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 dont 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 itll be buried in charts and you can be assured of failures. If it didnt require tools to install it then it wont 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 youve assured continued meter reliability. If it breaks youll get the blame so why not get the credit.

39 Point of Care Data Networking Thank-you Questions Keith Ensor Kevin Breneman

40 Point of Care Data Networking Keith Ensor Kevin Breneman EXTRA CREDIT

41 page 41 BEST PRACTICES: DNS Domain Name System Whats 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 cant 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 cant 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!!!

42 page 42 PING example - success Whats a ping display look like when it is successful?

43 page 43 PING example - failure Whats a ping display look like when it fails?

44 page 44 Trace route example (tracert) Note tracert (and ping) commands are case sensitive. Two techniques shown Standard trace with name lookup tracert Whats a tracert display look like? Modified trace with resolve of names disabled tracert –d

45 page 45 Futures IP version 6 Huge address space 128 bits of addressing capacity 3.40 X 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

46 page 46 Wellspan Glucose System Components 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|ADT^A 04| |D|2.3| EVN|A04| |||CHARRIS PID|| ^^^2^ID 1|454721||DOE^JOHN^^^^|DOE^JOHN^^^^| |M||B|254 E238ST^^EUCLID^OH^44123^USA||(216) |||M|NON| ~ |999-| NK1||CONROY^MARI^^^^|SPO||(216) ||EC||||||||||||||||||||||||||| PV1||O|168 ~219~C~PMA^^^^^^^^^||||277^ALLEN FADZL^BONNIE^^^^|||||||||| || ||||||||||||||||||||||||| |||||| HL7 messages are ASCII messages and the standard requires that they be "human readable". The | (pipe characters) are considered readable

47 page 47 Security Planning and Considerations Three As 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

48 Point of Care Data Networking THATs ALL FOLKS!!!! REALLY!!!! Keith Ensor Kevin Breneman

49 page 49 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.

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