The rapid evolution of health care IT means that you probably will migrate or upgrade your health care wide area...
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networks (WANs) in the coming years, if you haven't already.
Three years ago, the majority of WAN connections running at my health care organization were point-to-point T1 lines that were fairly expensive for 1.2 Mbps of bandwidth. These connections couldn't handle voice and data transmissions concurrently, nor could they support video or many complex image transmissions. We had a few 5 Mb and 10 Mb Asynchronous Transfer Mode (ATM) connections; these were more expensive than T1 lines, but they allowed more imaging transfer and better application connectivity.
Our institution needed high-bandwidth connections to converge voice, data, a picture archiving and communication system (PACS) and video. We use the WAN connections to service data connections to clinical and business servers, and for voice traffic to our main office phone switch.
We migrated key T1 WANs to ATM WAN connections to meet the clinical demand for computer services for regional clinics. Now we are migrating many of these ATM connections to Ethernet Private Line (EPL) connections using such telecommunication companies as AT&T, Verizon Communications Inc. and FairPoint Communications Inc.
In addition, we use two separate Internet service providers (ISPs) that deliver 1 Gb EPL connections to local clinics within five miles of the main campus. Two years ago, the bandwidth of our organization's core network was 1 Gb. Being able to have a WAN bandwidth of 1 Gb at an affordable price allows us to provide more clinical services to these local clinics than we could just a short time ago. We use redundant connections where possible, as well as where they're clinically required. Cost is the biggest restriction on redundant 1 Gb EPL connections.
Health care WAN connections typically support an electronic health record (EHR) system and associated clinical systems, such as a PACS and one for labs, as well as core business functions. Ours provides service to about 3,000 concurrent clinical users during core clinic hours -- 7 a.m. to 9 p.m. We transfer lab orders, images and prescriptions; and update EHR systems heavily during this 14-hour window. We do not run quality of service on the WAN during core clinic hours, but we are looking seriously at doing so for such clinical applications as EHRs and PACS. We closely monitor and modify our WAN connections to provide the best performance.
Consider WAN optimization for efficient connections
One way to make a WAN connection more efficient is to implement a WAN optimization or deduplication system. A few vendors provide WAN optimization tools, including Cisco Systems Inc., Juniper Networks Inc., Blue Coat Systems Inc., Silver Peak Systems Inc. and Riverbed Technology Inc. Some tools are appliance-based, and others are software-based.
I believe appliances are the best choice, simply because they are designed to enhance throughput at full bandwidth speeds, and little to no overhead is used in the optimization process. Cisco, Blue Coat and Riverbed offer proven products that address WAN optimization quite readily. Meanwhile, data deduplication technology within WAN optimization products, though fairly new, is becoming more robust and comes in time to meet health care institutions' requirements for WAN connections.
WAN optimization is becoming very important to health care institutions, primarily because they no longer work in an isolated environment. Affiliated institutions require fast, secure WAN connectivity. Emergency response and trauma centers need to provide critical clinical data to affiliates quickly and accurately through the WAN.
Pay attention to ISP, VPN connections
The Internet connection is one of the most important WAN connections a health care CIO needs to pay attention to. Previously just a connection for reference information and for sending and receiving email, the Internet now is a critical path for WAN services to and from every kind of health care organization in the world, from health care libraries to biomedical device vendors.
WAN optimization is becoming very important to health care institutions, primarily because they no longer work in isolated environments.
To provide high availability to Internet connections, we use two nonaffiliated ISPs. We make sure they don't route through the same T1 networks. This way we are pretty much assured that if one ISP has a routing problem, the other will not have it as well. We route our ISP connections through different building access conduits.
We also make sure that the connections don't share the same public access to and from the building. I remember a case where a hospital touted its redundant ISP services, only to discover that its ISP vendors shared a single telephone pole on the street. It was only when a truck took out the telephone pole that hospital staff members realized they didn't have the redundancy they thought they had.
Our dual-path ISP connections service more than 35 vendor virtual private network (VPN) point-to-point connections. These VPN connections are for such basic health care business functions as medical record dictation, pharmacy services, lab services, biomedical systems management and billing services.
Overall, WAN connections have become a lifeline for small clinics and medical specialty services. For most of these facilities, we use point-to-point VPN connections over our redundant Internet connections. The clinics connect to the Internet through cable companies, telephone companies providing DSL, and even cell phones with Wi-Fi. From there, we set up the VPN connections, giving the clinics access to our medical services, EHR systems, lab services, pharmacy and PACS. This allows the clinics to have services that would be too costly for them to host or manage themselves.
Al Gallant is the director of technical services at Dartmouth Hitchcock Medical Center in Lebanon, N.H.
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