In the last decade, the use and application of wireless technologies in healthcare has grown exponentially. Analysts at Gartner predict that the annual market for wireless solutions in healthcare will reach $1.7 billion by 2014. Additionally, an estimated 500 million users are expected to use wireless health and wellness applications by 2015. The meteoric growth of mHealth – the use of mobile communication technology to deliver healthcare services – is stark testimony to the value of employing wireless in healthcare.
Wireless in healthcare is driving a high degree of disruptive innovation, supplanting and replacing traditional methods for the delivery of healthcare services. Key underlying trends include real-time and virtual access to enterprise clinical systems via web-based portals, wireless point of care (both workflows and process), outreach and extension of clinical operations (i.e., remote medication compliance), wireless medical imaging (via DICOM and ePACS), the medical home (i.e., in-situ care and primary triage) and (chronic) disease and wellness management.
Today’s wireless systems offer sophisticated security and privacy controls (necessary for HIPAA compliance), bandwidth throttling and segmentation of services and are interoperable with IP-based electronic data interchange (EDI) systems. Powerful new capabilities to deliver real-time, contextual care at the point and time of care are possible that were not previously cost-effective or practical when used in a rich device ecosystem that includes smartphones, tablets and application-specific low-cost M2M devices, healthcare IT systems (i.e., electronic medical records or EMRs) and database analytics (i.e., medical informatics).
It's not surprising that leading healthcare organization are quickly adopting wireless communications. Indeed, the U.S. remote patient monitoring market is expected to reach $4.2 billion by 2018, and more than 3 million patients will be monitored over cellular networks by 2016 (iData Research, 2012, Juniper Research, 2012). Wireless spending in healthcare in the United States will rise from $9.1 billion in 2012 to an estimated $14.4 billion by 2017 (Insight Research, 2012).
Thoughtful consideration must be given to the technology acquisition process of wireless systems and services, and how best to address the needs of the HCO. To this end, we have identified the top seven critical wireless issues that healthcare CTOs should be considering.
1. Have you defined a wireless ecosystem strategy that considers all of the components that will impact success or failure?
Of fundamental importance to the HCO is determining how to use wireless to improve clinical operations and excellence safely and effectively. Using a systems approach will help to navigate through the fog of complexity and risk. In defining the strategy, the CTO must consider a broad point of view to ensure organizational alignment:
- What are the pertinent goals and measurable objectives of the organization?
- What are the different possible users and their use cases?
- What are the dependencies? Are service level agreements required? If so, what are the on-going operations, maintenance and administration hurdles?
- What are device and wireless network lifecycles?
- What are the total costs of ownership for budgeting?
- What are the impacts in terms of people, process and technology and how can they be used to maximize project success?
- What are the assessment and acceptance criteria, and what partners and collaborators should be involved throughout the process?
2. Does the wireless strategy consider the emerging impacts and changes around “licensed wireless solutions” from carriers?
Renewed interest in the application and use of licensed wireless solutions from wireless carriers is burgeoning, especially with the advent of small cells as a compliment to distributed antenna solutions. With 4G LTE, cellular technology is finally able to offer a viable broadband alternative to Wi-Fi in terms of throughput (i.e., >10Mbps), while addressing many of the Wi-Fi capacity and scaling issues. Consequently, a cohesive wireless strategy should consider licensed wireless offerings from the wireless carriers.
There are number of reasons for this, especially when considering the benefits and use cases that licensed wireless can address. First, cellular technology is provided in licensed spectrum, and therefore is inherently secure and private from jamming and interference. Second, cellular coverage is relatively pervasive outside of venues, and demand for coverage inside healthcare facilities is growing as consumers and caregivers alike come to expect reliable and ubiquitous wireless services. Finally, the use of cellular in healthcare provides a means to address data offload of constrained Wi-Fi resources. This alleviates bandwidth, scaling and load balancing issues associated with having just Wi-Fi for voice and data services. Also, device manufacturers of tablets and smartphones support both Wi-Fi and cellular. Hence, supporting both modalities provides wireless services to a broad spectrum of users, including first responders.
3. What is your strategy for leveraging Wi-Fi in 2013? Is it being used to enhance your licensed wireless to support BYOD initiatives?
Technical advances in Wi-Fi continue to demonstrate its efficacy in healthcare settings, making a Wi-Fi leverage strategy critical. For example, discrete Wi-Fi designs offer a rich mosaic of devices for wireless point of care, and new evolutions of the standard (i.e., 802.11n) provide throughputs on the order of 300Mbps. Also, Wi-Fi is relatively easy to deploy and is inexpensive. The locality of Wi-Fi is especially attractive, enabling HCOs to precisely define coverage and quality of service. The greatest challenge of Wi-Fi is that service is offered in unlicensed spectrum, meaning that it is susceptible to interference and jamming. Additionally, HCOs are grappling with ROI and other cost-benefit matters associated with increasing the quantity of supported access points. This includes attendant security vulnerabilities, interference and frequency planning, not to mention denial of service (DoS) attacks (whether intended or unintended), as is the case with Bring Your Own Network (BYON). Furthermore, as HCOs transition to 802.11n, the number of access points necessary to support BYOD voice and video conference capabilities is increasing at an accelerated rate. This is placing even further constraints on HCO IT budgets. For example, some HCOs claim a minimum of a 2x Access Point (AP) density rate to maintain coverage and capacity levels with increasing application loading.
One strategy for leveraging Wi-Fi is to consider a duality approach that employs both licensed wireless and Wi-Fi. This approach is strategic because it achieves a synthesized wireless services offering that can be applied across the HCO’s healthcare continuum via localized offloading of data transactions (through small cells), and it supports BYOD and BYON in a robust and highly-available manner.
4. Has near field communication been effectively integrated? Does it take advantage of machine-to-machine, medical telemetry and biosensors?
Wireless connectivity solutions may be broadly classified into macro network (i.e., cellular LTE), micro network (i.e., small cell) and near field network (i.e., Zigbee and sometimes Bluetooth). The latter is increasingly relevant in healthcare settings as a critical component of mHealth and wireless point-of-care applications. Near-field communications is most commonly implemented via M2M, and it is attractive for a number of reasons. First, the cost profile, form factor and battery life (not less than two years) of M2M optimized for Zigbee communications is very appealing, especially for wearable devices used for patient monitoring, disease management and MU compliance metrics (i.e., hand-washing stations for clinicians). Second, M2M communications are secure and private, and inherently resistant to macro interference given their short range. Lastly, M2M lends itself exceeding well to integration with cellular networks from a wireless backhaul perspective. In this scenario, M2M communications are multi-hop: the first leg is to a network gateway via near-field transport (i.e., Zigbee). The second leg is from the gateway to a data via cellular backhaul. With these benefits in mind, it's no wonder that Zigbee is the fastest growing wireless modality in healthcare, engendering wireless point-of-care that is supplanting traditional Wi-Fi.
5. Is there a realistic strategy for solving wireless integration issues?
Complex integration issues include network functionality, maintainability and operability and feature attention to security, privacy, regulatory requirements, identification management and device management. Security and privacy considerations are de facto requirements for compliance to HIPAA. Compliance with IEC 80001 for medical device interoperability and FDA medical device data systems (MDDS) are increasingly important. Specifically, how the wireless network is designed (including the types of technology) and managed has a direct bearing on the safety and effectiveness of medical devices that use the network. According to the FDA, key issues include loss of data, data interchange incompatibilities (i.e., signaling), corrupted data (i.e., data errors), incorrect data transmission (i.e., service incompatibilities) and unauthorized access to data (i.e., theft or interception of data). The latter is particularly acute regarding identity management in a BYOD paradigm, especially given recently strengthened rules and regulations around distribution of controlled substances under new HIPAA mandates. Fortunately, wireless device management via the network has emerged as a compliment to mobile device management for a defense in depth approach to this challenge.
6. Given competing priorities, what return will an investment in wireless produce?
Total cost of ownership must be considered as well as monetization strategies of the investment made in wireless systems. This requires an understanding of capital expenditures and operational expenditures, and choosing the right balance between the two. A key aspect of this requires an understanding of wireless technology lifecycles and wireless archetypes in terms of their scalability (to eliminate fork-lift upgrades), extensibility and interoperability, including support of cloud-based computing. The latter is highly significant for mHealth given an industry predilection for using distributed computing resources outside the four walls of the HCO to collect, extract, transform and load data elements into the EMR located under the HCOs controlled domain.
Other considerations include determining who pays for wireless services and relative remuneration (i.e., the HCO pays entirely or amounts are apportioned to certain users), and control and management of personal versus organizational use of wireless services (especially given BYOD). Lastly, TCO should explore different management options of wireless such as HCO managed, carrier managed, or third-party managed with performance SLAs. As the complexity of wireless in clinical operations increases, third-party management is increasingly attractive to HCOs in order to achieve excellence in operation without having to staff specialized, full time equivalent resources that are dedicated to wireless systems.
7. What type of operational strategy is required to adequately support the plan?
Technology acquisition follows a lifecycle process. Concept exploration followed by scoping and high-level requirements definition is part of an on-going systematic process underpinning an effective operations strategy. This ensures that the wireless solution sets remain viable in terms of their benefits to the HCO and its stakeholders. Questions to consider include how on-going developments in the wireless landscape will be handled, what future technologies are of consideration and why, and how will wireless bandwidth, spectrum and use be managed?
Clearly, advances in technology devices and wireless networking options are contributing to the meteoric rise of the use of wireless in healthcare. Naturally, this will continue to increase as mHealth modalities prove to add the value that the HCO and its stakeholders expect. Development of a wireless strategy that includes a framework for identifying the tactical operational steps is essential for proper execution, reducing risk and achieving wireless infrastructure excellence. Understanding the critical wireless issues outlined will provide an excellent foundation for developing a wireless strategy that meets the challenges and opportunities that lie ahead.
Eric B. Abbott, MMI, MBA, MS, is director of product management and Tormod Larsen is vice president and chief technology officer for ExteNet Systems, Inc. ExteNet Systems designs, builds, owns and operates distributed networks in key strategic markets for use by wireless carriers and venue owners.
