2973 
Bill Johnson
CPHIMS FHIMSS FACHE
Senior manager First Consulting Group
E: [email protected]
W: www.fcg.com
Communications protocols consist of a set of rules that dictate how and when to send information, and what to do with it when it is received. They also address rules that determine how information gets to its intended receivers. These devices can be telephones, computers, or many different types of equipment. Internet Protocol’s (IP) widespread acceptance results from its simplicity and its ability to accommodate communications among different types of computing platforms. Healthcare is no exception – IP is ubiquitous in healthcare organisations.
Early in the history of computers, technicians realised that communications protocols were needed to facilitate exchange of data among computers. Early protocols were developed to allow large mainframe computers to communicate with smaller devices such as video display terminals and printers. They soon developed protocols to allow mainframe computers to talk to each other.
The 1970s and 80s brought on the microcomputer revolution and with it a need for these devices to talk to each other. Initially, people wanted to connect microcomputers together in an office to share data and printers. This resulted in the development of local area networks, or LANs, where microcomputers are connected to each other by wiring and equipment designed to route data among the computers. Several competing and mostly proprietary communications protocols were developed during this period. Realising the need for standardisation, the International Organisation for Standardisation (IOS) led an effort to develop a model for data communications. Their effort resulted in the development of a generic model that divided the data communications process into seven subprocesses or layers. This has become a widely accepted model and is called the open system interconnection or OSI model.
One of the layers of the OSI model is Layer 3, or the Network Layer, which is the portion of the communications process that establishes the pathway for routing data from one device to others. Layer 3 also includes addressing, error handling, congestion control and sequencing functions. Error handling consists of rules for restoring transmitted data that becomes corrupted or lost. Congestion control includes rules for sending data by alternate routes should one route become too filled with data. Sequencing rules allow data that is broken down into smaller units and transmitted to be correctly reassembled at its final destination. IP is a Layer 3 protocol that emerged in the 1990s as the dominant network layer protocol.
IP’s emergence in healthcare
The adoption of communications protocols in healthcare paralleled that of other industries. By the late 1990s, computer networks using IP had become dominant among healthcare organisations, primarily because Microsoft’s Windows operating system had become dominant. Windows, unlike its major competition, could use IP as its Layer 3 protocol. Facilitating communications among computers on a LAN is the primary role for IP in healthcare organisations today. In this respect, IP performs a valuable service – transmitting clinical, financial and administrative data among computing devices on healthcare organisations’ computer networks. In addition to this role, IP is expanding its usefulness within the healthcare industry.
Biomedical devices
Biomedical devices encompass a wide range of technologies that are intended to support delivery of healthcare. These devices typically contain some combination of the following: electronics,electro-mechanical components, mechanical components, hardware and software. They can be inserted or attached to patients and used to monitor clinical status or administer some form of treatment. Perhaps the most commonly known form of biomedical device is the electrocardiograph (ECG). ECGs have sensing devices that attach to patients and monitor heart rate. Most commonly, heart rate information is displayed by the ECG as a paper strip that shows the patient’s heart rate in a graph of a wave form. It is also becoming common to transmit heart rate information from the ECG device by networking technology to video monitors and computers.
The communication of ECG information represents one example of the beneficial role IP is playing in healthcare organisations. Increasingly, biomedical devices transmit their information at some point in the communications process through an IP-based network. When biomedical equipment manufacturers first began to display their devices’ information in a communications network, they often adopted their own proprietary protocols. These were designed to optimise transmission of their devices’ data. The downside to this is that typically each device needs its own network infrastructure that includes both wiring and transmission equipment.
Because most organisations implement IP as their Layer 3 protocol, we see increasing opportunities for biomedical equipment manufacturers to use data communications networks that already exist in most healthcare organisations to transmit biomedical information. What this means is that an ultrasound device’s information can be transmitted over the same network infrastructure as computer data. This reduces cabling and network equipment costs since one network can transmit multiple types of information.
Voice and data convergence
Just as an IP-based network can accommodate information from computers and biomedical devices, it can also transmit other forms of information, including information transmitted by human voice. Voice sounds can be digitised and then transmitted over data networks, which is the concept underlying voice over IP (VoIP). This concept is one of the hottest topics in the fields of data communications and telephony. The convergence of voice and data communications in essence will result in computers and telephones using the same communications networks. These networks will include LANs and wide area networks (WANs) that are IP-based. The internet is the best-known example of an IP-based WAN.
Many real world examples of voice-data convergence exist. In the USA, there are several vendors of internet-based telephony services. Customers can hook a telephone into their high-speed internet connection and talk to almost anyone else who has a telephone; the internet provides the communications network.
Many healthcare organisations take advantage of the voice-data convergence by connecting telephones to their computer communications networks. Several components are needed, including devices that translate telephones’ voice signals into data communications formats, as well as devices that connect the organisation’s computer network to the outside telephone system. If the organisation’s computer network has capability of accommodating wireless computers – which many do – wireless telephones can use this network as well.
A VoIP example
I have personal experience implementing VoIP technology as chief information officer of a small (86 inpatient beds) hospital in Virginia, US. When our hospital relocated two of its inpatient units from an older facility into a recently constructed building, we used the opportunity to evaluate VoIP. The immediate cause of our evaluation lay in communications problems caused by splitting one of the units between two different floors in the new building. Nursing supervisors, previously located in a single designated location, now became mobile as they travelled between the two floors. Staff began to complain that they were unable to reach these supervisors in a timely manner.
We evaluated a range of options to address the communications difficulties and decided that wireless VoIP cost the least. It could be implemented on our existing IP-based computer network with a minimal investment in network equipment and IP telephony software. We implemented the solution in less than three months, thereby resolving our supervisor communications problem. Additionally, we took this solution to the next level and subsequently decided to begin a strategic migration to VoIP for all our telephony needs – both wireless and wired. The hospital based its strategy on retaining its existing investments in its traditional analogue telephony hardware and its existing data communications network.
However, as its analogue telephony hardware reaches the end of its life expectancy, it will be replaced with VoIP technology. New telephones being installed use VoIP technology that is interfaced to the existing main telephone equipment based on older telephony technology. This equipment will eventually be replaced with equipment that is entirely VoIP-based.
Telehealth
“Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration.” The IP-based internet has become a major factor in telehealth, providing a low-cost medium for transporting medical information, images and other clinical data over long distances. Telehealth benefits healthcare organisations in many ways: continuing medical education can be provided using video conferencing; clinicians are able to provide diagnostic services to remote areas; and information from biomedical devices can be transmitted from patients’ homes to clinicians.
Future of IP in healthcare
IP will be around in healthcare for a long time because it will be around a long time in computer and voice communications. This protocol is widely entrenched and dominates among Network Layer protocols. Many forms of communications – data, voice and device – can use IP and other layers of the OSI model. This reduces overall communications costs for healthcare organisations. For this reason alone, we envision the expansion of IP in healthcare. Hospital management should be aware of IP and especially VoIP. This technology can bring substantial benefits to their organisations.
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References
- Johnson, W. Voice over IP: how computing technology is being used in mobile communications.J Healthcare Information Manage 2005;19:24-31.
- Available from: http://www.hrsa.gov
