Point of Care Data Networking by Kevin Breneman and Keith Ensor of Wellspan Networking and Telecommunications Keith Ensor email: [email protected]@wellspan.org

Point of Care Data Networking

by Kevin Breneman and Keith Ensorof

Wellspan Networking and Telecommunications

Keith Ensor email: [email protected] Breneman email:

[email protected]

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

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

page 4

Wellspan Glucose System Components 1st Level

Lifescan meter Lifescan IR docking station Lantronix mss100 terminal server

House wiring / interconnect

Catalyst 5500 Ethernet switch

decre

asin

g u

ser

exposu

re

page 5

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

use

r exposu

re

page 6

Point of Care Data Networking Glucose TestingDocking 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. Tip: -UPGRADE AC brick if

you have Lantronix REGAL’s

-Tape power couplers

page 7

Wellspan Glucose System Components

Lifescan meter1. Handheld, self powered,

Lifescan glucose meter “mini”-computer

2. Touch screen user interface Input/Output

3. Strip sensor i/o port4. Bar code reader i/o port5. 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 symbologies54

7

31

2

6

page 8


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

page 9

Tip: ECHO test if it’s alive and on-line. from your desktop pc issue the command: ping 192.168.236.104


UTP rj45 Ethernet presentation

Status LED’s

AC power adapter connect

Lantronix terminal server

RS232 standard “db25” presentation serial data communications connector with rj11 adapter

page 10


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 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:

Structured house wiring. UTPUnshielded Twisted Pair with rj45 jack presentation

page 11


Network switch with fiber uplink

House wiring

Networkports

MID level network connectivity

Wellspan network closet 0666th flr main bldg

telephoneports

page 12

Wellspan Glucose System ComponentsTop level network connectivity

Distribution Router #1

CORE Router

Distribution Router #2

Hospital 6th flr idf 66meter location

7th flr & POC dept idf 79LIFESCAN Server location Hospital Data Center idf

159Cerner LIS location

Access layer

Distribution layer

Corelayer

Tip: check the path. from your desktop pc issue the

command: tracert 192.168.236.104

page 13

QDXI

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

CERNER

Eclipsys

Lifescan Workstation and iSTAT CDS

page 14


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

RouterEthernet Hub

SUPER DOOPER

HOST

Glucose Server & Data Collector

page 15


Glucose Meter A w/IR linking

Ethernet Switch #1

POC dock

Lab Info System


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)


POC dock Ethernet Terminal Server

2

Ethernet Switch #2

Ethernet Switch #4

Fiber links

UTP links

serial links


Ethernet Switch #3

1

2

3

4

Subnet 3Subnet 4

Subnet 2

Subnet 1

Host AAA

Laser A

page 16



POC dock


Ethernet Switch

Ethernet Area/Core

Router

Ethernet Area/Core Router

Lab Info

System

Registration System

Ethernet Switch (#2 & #4) w/ VIRTUAL capability


Ethernet Switch #3


POC dock


Ethernet Switch #1

32&4 1

Interface engine (Cloverleaf)

5

67

page 17

Point of Care Data NetworkingiSTAT 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 workstationScripted CDS to Cerner interface

Cloverleaf NOT used!!!! NON - HL7Likely Low Cost but LOW TECH….only works to Cerner. Un-expandableLooks like a user logged in on the system. Subject to Cerner changes!!uses a VT420 dumb terminal style of login and script to upload dataNOT interfaced to Eclipsys interfaced billing/registration system

page 18

Component FunctionsGlucose 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

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.

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 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

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 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.

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

6

5

1

4

3

2

6

5

1

4

3

2

QDXIFull Mesh

Hub and Spok

e

versus

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.

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?

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

08-00-2b-01-af-19 hex 0000 1000 0000 0000 0010 1011 0000 0001 1010 1111 0001 1001 binary equiv

8,796,814,552,857 decimal equiv

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: 192.168.236.104 Above in binary is 1100 0000 1010 1000 1110 1100 0110 1000

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: 192.168.0.0 thru 192.168.255.255 first dot boundary (/24 bit) 172.16.0.0 thru 172.31.255.255 second dot boundary (/16 bit) 10.0.0.0 thru 10.255.255.255 (/8 bit)

page 27

IP addressing/subnet masking

Example: 192.168.236.104 Above in binary is: 1100 0000 1010 1000 1110 1100 0110 1000

Mask 255.255.255.0 1111 1111 1111 1111 1111 1111 0000 0000 The above 32 bit mask allows 224 bits for network and 28 bits for host

numbers

MASK Value Typical masks are :

255.255.255.0 - allows last byte to be all host numbers 28 = 255 (actually 256-1)

255.255.0.0 - allows last 2 bytes to be for host numbers 216 = 65,535 255.0.0.0 - allows last 3 bytes to be for host numbers 224 = 16,777,215

BUT they can be on a NON-classful boundary 255.255.255.240 - 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.

page 28

IP addressing/gateway

Example: 192.168.236.104 Above in binary is: 1100 0000 1010 1000 1110 1100 0110 1000

Gateway: 192.168.236.253 Above in binary is: 1100 0000 1010 1000 1110 1100 1111 1101

Mask 255.255.255.0 1111 1111 1111 1111 1111 1111 0000 0000

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!!!

Host portion

Network portion

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 192.168.236.253

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 www.google.com which really is 64.233.167.99

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!

page 30

Wellspan Glucose System Networking

Glucose ServerData CollectorIP: 10.2.1.1Gateway: 10.16.9.1Mask: 255.0.0.0


POC dock


IP: 192.168.236.104Gateway:

192.168.236.1Mask: 255.255.255.0

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 telnetTip:

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.

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.

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. Here’s 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:135 0.0.0.0:0 LISTENING TCP lfs_datalink:135 0.0.0.0:0 LISTENING TCP lfs_datalink:1027 0.0.0.0:0 LISTENING TCP lfs_datalink:1029 0.0.0.0:0 LISTENING .. . TCP lfs_datalink:137 0.0.0.0:0 LISTENING TCP lfs_datalink:138 0.0.0.0:0 LISTENING TCP lfs_datalink:nbsession 0.0.0.0:0 LISTENING . . . . TCP lfs_datalink:4760 192.168.16.3:3001 ESTABLISHED TCP lfs_datalink:4762 172.20.150.13:3001 ESTABLISHED

. . TCP lfs_datalink:4780 192.168.236.103:3001 ESTABLISHED TCP lfs_datalink:4781 192.168.236.103:telnet TIME_WAIT TCP lfs_datalink:4782 192.168.157.12:3001 ESTABLISHED TCP lfs_datalink:4783 192.168.157.12:telnet TIME_WAIT .

Tip:

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 /email 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

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

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.

page 37

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?

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 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-youQuestions

Keith Ensor [email protected]

Kevin [email protected]




EXTRA CREDIT

page 41

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 192.168.22.8 So you do a ping to 192.16.22.8

---- 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!!!

page 42

PING example - success

What’s a ping display look like when it is successful?

page 43

PING example - failure

What’s a ping display look like when it fails?

page 44

Trace route example (tracert)

Note tracert (and ping) commands are case sensitive.

Two techniques shown

Standard trace with name lookup

tracert 192.168.236.104

What’s a tracert display look like?

Modified trace with resolve of names disabled tracert –d 192.168.236.104

page 45

Futures

IP version 6 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

page 46


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|199912271408|CHARRIS|ADTÂ04|1817457|D|2.3| EVN|A04|199912271408|||CHARRIS PID||0493575^^^2ÎD 1|454721||DOE^JOHN^^^^|DOE^JOHN^^^^|19480203|M||B|254 E238ST^ÊUCLIDÔH^44123ÛSA||(216)731-4359|||M|NON|400003403~1129086|999-| NK1||CONROY^MARI^^^^|SPO||(216)731-4359||EC||||||||||||||||||||||||||| PV1||O|168 ~219~C~PMA^^^^^^^^^||||277ÂLLEN FADZL^BONNIE^^^^|||||||||| ||2688684|||||||||||||||||||||||||199912271408||||||002376853

HL7 messages are ASCII messages and the standard requires that they be "human readable". The | (pipe characters) are considered readable

page 47

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!!!!



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:0830-0900 registration0900-1000- networking lecture (keith &kev)1000-1015- break1015-1130 networking lecture &questions (keith &kev)1130-1330- lunch & vendor fair1330-1430- barcoding lecture

Conference chairperson/contact:Beverly McAllister, MS, MT(ASCP)SCLaboratory Operations ManagerEphrata Community Hospital169 Martin AveEphrata, PA. 17522Phone: 717-738-6527Fax: 717-738-6533

What presenter(s) will provide: Final version of presentation

emailed 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.

Documents

Point of Care Data Networking by Kevin Breneman and Keith Ensor of Wellspan Networking and Telecommunications Keith Ensor email: [email protected]@wellspan.org