Healthcare Wireless and Device Connectivity

Integra Systems and EPFL

We will be visiting www.epfl.ch and having meetings with a medical device start up incubated by EPFL. Integra Systems, Inc., has provided our expertise to EPFL on the behalf of this company.

Download EPFL-annual-report-2013

Download EY_EPFL_Entrepreneurship_event__flyer_-_16.09.14

Improvement of EMR Sign On Workflow

During an eight hour shift it is understood that a clinician may need to log into the EMR up to sometimes 68 times with his/her password? What if all you had to do was carry your BluStor card to eliminate the “manual log in”? Simply by biometric authentication, a random key generation, and wireless communications, you could dramatically improve work flow, improve security, and lower the hassle factor. It is possible now.

www.blustor.co

HIMSS Wireless Web Event Integra Systems and Motorola Solutions

Integra Systems, Inc. and Motorola Solutions will be conducting a web event in September. As the WLAN has evolved over the past decade plus, there are new requirements such as how the client device needs to perform in a mobile environment, the adoption of 802.11ac, and the convergence of Bluetooth 4.0 with the WLAN.

See the following link to the event:

http://www.himss.org/Events/EventDetail.aspx?ItemNumber=31243

Management of Alarm Fatigue from the Other End of the Spectrum

This blog will not delve into the ins and outs of the different ways of how to manage alarm fatigue as in accordance with the JCAHO NPSG announcement on June 25, 2013.
Much has been written about this and the awareness is front and center. It (JCAHO NPSG) is broken into the respective two phases, that is Phase I (beginning in June 2014) and Phase II, (beginning in January 2016). Education of those in the organization about alarm system management will also be required in January 2016.

Several patient monitoring companies are addressing this by collecting alarm information from patients from different physiological parameters and thus being able to create custom profiles for different types of patient populations. I commend these efforts as a great start and from what I have seen this has had excellent results…a significant reduction of false alarms. Actually it is creating the right predictive tools to understand perhaps what is going on before you have an alarm. That is what is ideal.

We envision that every medical device will have Bluetooth LE embedded in it. Follows the same process as WIFI over 14 years ago, but for different reasons.

What if you can have all your different patient profiles for all different type of unit settings loaded in a secure pass word smart card vault? Then when setting up your patient for monitoring this profile could be easily and by authentication to the user be loaded into the medical device. Would potentially decrease errors, improve productivity and work flow as well as create an audit trail.

Benefits of Smart Cards versus Magnetic Stripe Cards for Healthcare Applications

Smart cards have significant benefits versus magnetic stripe (“mag stripe”) cards for healthcare applications.

First, smart cards are highly secure and are used worldwide in applications where the security and privacy of information are critical requirements.

▪ Smart cards embedded with microprocessors can encrypt and securely store information, protecting the patient’s personal health information.

▪ Smart cards can allow access to stored information only to authorized users. For example, all or portions of the patient’s personal health information can be protected so that only authorized doctors, hospitals and medical staff can access it. The rules for accessing medical information can be enforced by the smart card, even when used offline.

▪ Smart cards support strong authentication for accessing personal health information. Patients and providers can use smart health ID cards as a second factor when logging in to access information. In addition, smart cards support personal identification numbers and biometrics (e.g., a fingerprint) to further protect access.

▪ Smart cards support digital signatures, which can be used to determine that the card was issued by a valid organization and that the data on the card has not been fraudulently altered since issuance.

▪ Smart cards use secure chip technology and are designed and manufactured with features that help to deter counterfeiting and thwart tampering.

▪ Smart cards can help to reduce healthcare fraud by providing strong identity authentication of patients and providers.
The use of secure smart chip technology, encryption and other cryptography measures makes it extremely difficult for unauthorized users to access or use information on a smart card or to create duplicate cards. These capabilities help to protect patients from identity theft, protect healthcare institutions from medical fraud, and help healthcare providers meet HIPAA privacy and security requirements.
Second, smart cards provide the capacity to store healthcare information on the card and the flexibility for securely adding information to a patient healthcare card after issuance.

For healthcare applications, this can deliver several benefits.

▪ Patient healthcare information and prescriptions can be stored on the card and updated after issuance, providing up-to-date information when a patient is receiving medical care from multiple providers or in an emergency situation.

▪ Multiple patient identification or patient record identification numbers can be written to the smart card, facilitating record exchange and assisting with coordination of care among multiple healthcare providers.

▪ Patient healthcare information can be written to and updated on the card by authorized healthcare providers, with updated information then available for both the patient and other healthcare providers (if authorized) to access.

Third, smart cards can support a wide variety of functions to improve healthcare provider and insurer processes, including:

▪ Quickly and accurately identifying patients, reducing medical identity theft and improving quality of care.

▪ Streamlining patient registration and patient information access at any points of care, reducing routine paperwork and eliminating errors.

▪ Supporting audit logging and remote access accountability.

▪ Enabling secure access to healthcare websites.

▪ Storing all necessary applications and information on the card, enabling offline access to critical healthcare information using portable readers.

Magnetic stripe cards, by contrast, have significant disadvantages for healthcare and other identity and payment applications.

▪ Magnetic stripe cards have minimal security. Because data is very easily read from and written to a magnetic stripe card, information can be easily stolen and a duplicate magnetic stripe card can be created. It is straightforward for a thief to “swipe” a magnetic stripe card and to collect all of the information from the card; the thief simply needs a magnetic stripe reader that has the ability to capture the information from the card (which all readers do). The thief can then either use that information directly or create a duplicate magnetic stripe card.

▪ Magnetic stripe cards store only a limited amount of data (less than 2 Kbytes) and are not updated after issuance, providing no ability to securely store or update healthcare information.

▪ Magnetic stripe cards support minimal functionality and require an online infrastructure to access healthcare applications and information.
Magnetic stripe cards have had a well-established position in the marketplace for over 30 years. However, many industries and government organizations recognize the limitations of magnetic stripe technology and are replacing magnetic stripe ID cards with smart cards.

For example, the global payments industry is migrating from magnetic stripe bank cards and infrastructure to smart payment cards based on the Europay MasterCard Visa (EMV) specification. Over 1.2 billion smart card-based credit and debit cards are now issued globally and 18.7 million point-of-sale terminals accept EMV cards. Eighty countries globally are in various stages of EMV chip migration, including Canada and countries in Europe, Latin America and Asia, with migration to EMV smart payment cards now starting in the U.S.

For legacy applications that are accessed with magnetic stripe cards, a smart healthcare card can incorporate a magnetic stripe to support legacy applications.
Table 1 summarizes the key differences between smart cards and magnetic stripe cards for healthcare applications.

As the costs for smart cards and smart card readers have dropped dramatically, and as the reader infrastructure is replaced or upgraded, smart card technology is poised to capture market share in financial services, personal identification and healthcare markets–where security, privacy and information portability are crucial.

BluStor www.blustor.co is the “smart card, smart storage, smart connectivity system”…the only technology platform in the industry that has the storage, capacity, and eliminates proprietary readers, while providing a multi-layered security strategy. Integra Systems, Inc. is partnering with BlueStor to develop leap frog next generation solutions in this space.

See attached a great article about BlueTooth LE. (June 2014)

Download BLE101-FINAL-053014

Bluetooth 4.0 Convergence and the Medical Device Space

Bluetooth LE or 4.0 is disruptive technology that will re-shape the medical device landscape. I really do not like the term of 4.0, because it tends to describe this as another evolution of BT. It is not a evolution, but in my opinion a revolution. It is my prediction that every medical device will eventually have this incorporated. The reason I am so bold to say this is that I was a senior systems analyst at the company that was the founding member of the WIFI Alliance in 1999. So I remember exactly when 802.11b came out. The rest what we say is history! I also as a research project with an infusion pump company that got bought out demonstrated for the first time the ability to control an infusion pump by a wireless fashion…long time ago, year 2001. This was "before the smart infusion pump...entered into the market"!

Bluetooth 4.0 just makes sense for a variety of connectivity reasons. Technology disruption becomes available in the enterprise, as is first enters into the consumer space. Bluetooth LE or 4.0 has been adopted by the IOS and Android platforms as well as being incorporated in virtual every smart phone and tablet device. Those companies that quickly embrace the technology as the path to competitive differentiation will be the winners.

For a small incremental cost Bluetooth 4.0 can be incorporated and while WIFI does have it’s specific niche, the ability of having the medical device adapt to different wireless application modalities has a use merit. Just think of the Smart Phone Use model.

Most of the WLAN players have or will be now incorporating Bluetooth 4.0 into their access points. So in essences what we now are creating is a real “personal area Bluetooth network” that can use the WLAN as the backhaul. With the potential of using the location capabilities of BTLE, we could have a very cost affordable and adaptable RTLS solution.

Business Insider magazine estimates that there are over 200 million iPhones and iPads currently deployed that are capable of acting as or receiving signals from iBeacons. Of course, once Android and other devices are added to the mix, the market potential grows even bigger; Analyst
ABI Research puts the space at $5 billion today, but predicts a rather modest Bluetooth Smart beacon deployment figure
of 20,000 by 2015. By 2018 however, ABI predict that over 800 million smartphones will be actively using indoor location for applications, making the technology as widespread in smartphones as GPS is today.

As for what this market will look like, ABI speculate that the development of technologies like sensor fusion for handsets will enable a whole new set of consumer applications. These potential applications will span ambient intelligence, social networking, corporate and enterprise, fitness and health, mobile advertising, and gaming.

Nordic Semiconductor has released a reference design for Bluetooth Smart beacons based on its nrF51822 System-on-Chip (SoC). The reference design allows beacons developed to Apple’s iBeaconTM standards, and proprietary smart beacon hardware for iOS and Android mobiles, to be developed quickly and easily.

Bluetooth Smart beacons are low-cost, low- power wireless transmitters that can advertise their location to Bluetooth Smart ready smartphones in close proximity.

Adding low power wireless connectivity to a product has become less of a challenge as chipmakers serve up proven silicon, reference designs, and development
kits. But designing an RF link from scratch is still far from a trivial exercise. Quick to spot
 an opportunity, commercial vendors now offer pre- engineered wireless solutions
in the form of modules. Such devices have been optimized
by the manufacturer to provide maximum range and bandwidth while meeting the regulatory requirements for operation in the Industrial, Scientific, Medical (ISM) 2.4-GHz band. Some are even delivered with certification proving they comply with a particular wireless standard.

The market is rapidly expanding: According to analyst IHS, worldwide revenue for the low-power wireless modules market will reach $1.40 billion this year, up a robust 14 percent from $1.23 billion in 2013. The company says this is the third consecutive year of double
digit expansion for the market.

IHS forecasts that the fastest- growing market for low-power wireless modules in the immediate future will be sports and fitness monitoring, with a compound annual growth rate (CAGR) of 49 percent.

The underlying growth in
 the application of wireless technologies in these markets will be the primary reason
for the increase in module shipments. However, a secondary reason for expansion is the high rate of adoption
of Bluetooth Smart, ANT+, EnOcean, RF4CE, and Z-Wave wireless technologies.

While these multivendor solutions are enjoying growth, low-power wireless technology is moving away from proprietary protocols, according to the company. Proprietary protocols made up 88 percent of module shipments in 2011, but will only account for about 50 percent by 2018. Key drivers for this trend are that customers are looking for interoperable communications across diverse systems, and want devices to communicate with mobile platforms like smartphones, tablet computers and laptops, without requiring dongles.

The ‘BlueTEG’ wristband sensor uses the temperature difference between the wearer’s skin and surrounding air to harvest enough energy to power the sensor’s systems. The device can measure parameters such as acceleration or ambient temperature and transmit the data to any Bluetooth Smart Ready smartphone, tablet, or computer.
Developed by the Fraunhofer Institute for Integrated Circuits IIS in Germany, the BlueTEG does not require a battery eliminating the need for it to be recharged or changed.
The BlueTEG is said to employ little more than a conventional thermogenerator and a special voltage converter developed by the Fraunhofer ISS, while being compatible with all types of body-worn wireless sensor systems and could even be integrated into multifunction GPS watches, for example.

Sensor Technology Changing the Medical Device Landscape

The CSPo1 developed by German startup Cosinuss is a sophisticated optical heart rate monitor that can transmit recorded data via either Bluetooth or ANT+. It also eliminates the need for a chest belt. Future versions will be able to measure core body temperature and with an addition of another LED and photodiode the the sensor pack blood oxygen saturation levels as well. Available Q4 of 2014 at around $208.00

Unique WLAN Design Healthcare Educational Event with Motorola

Integra Systems, Inc. in concert with www.motorolasolutions.com will be conducting a healthcare educational web based event in September 2014. This will be focused on the best of practice model for WLAN, WMAN, BYOD, LPBT, and the combined enterprise designs for healthcare mobility applications. This will also define the unique requirements to include wireless enabled medical applications at the real time application level. Stay tuned for further announcements.

Integra Systems Updated Web Site

We have officially updated our web site.
www.integrasystems.org

Smart Phones and Voice over IP WLAN

Integra Systems, Inc. has engineered some of the toughest environments for voice over IP. Not only do you have to the right signal strength but also the correct CCI. In reality the clients algorithms also dictate the quality of the ability to maintain a call while roaming.

Voice over WLAN Roaming

At its most basic level, roaming in an enterprise IEEE 802.11 network occurs when an IEEE 802.11 client changes its access point (AP) association from one AP to another AP within the same WLAN.
Roaming is a client decision. The client is responsible for deciding it needs to roam, and then detecting, evaluating, and roaming to an alternative AP.

Roaming is a client decision. WLAN standards bodies (such as the IEEE) and industry bodies (such as the Wi-Fi Alliance) do not specify when a client should roam, or how the client determines to which alternative AP it should roam. Each vendor's roaming algorithms are proprietary and are not generally published.

Client Roaming Decision
IEEE 802.11 clients typically decide to roam when the connection to the current AP becomes degraded. Roaming necessarily has some impact on client traffic because a client scans other IEEE 802.11 channels for alternative APs, re-associates, and authenticates to the new AP. Prior to roaming, a client may take some actions to improve its current connection without necessitating a roam:
• Data retries—The IEEE 802.11 MAC specifies a reliable transport. Every unicast frame sent between a wireless client and an AP is acknowledged at the MAC layer. The IEEE 802.11 standard specifies the protocol used to retry the transmission of data frames for which an acknowledgment was not successfully received.
• Data rate shifting—IEEE 802.11a, IEEE 802.11b, and IEEE 802.11g each support a variety of possible data rates. The data rates supported for a given frequency band (such as 2.4GHz or 5GHZ) are configured on the WCS/WLC and are pushed down to the APs using that frequency band. Each AP in a given WLAN then advertises the supported data rates in its beacons. When a client or AP detects that a wireless connection is becoming degraded, it can change to a lower supported transmission rate (lower transmission rates generally provide superior transmission reliability).
Although the roaming algorithms differ for each vendor or driver version (and potentially for different device-types from a single vendor), there are some common situations that typically cause a roam to occur:
• Maximum data retry count is exceeded—Excessive numbers of data retries are a common roam trigger.
• Low received signal strength indicator (RSSI)—A client device can decide to roam when the receive signal strength drops below a threshold. This roam trigger does not require active client traffic in order to induce a roam.
• Low signal to noise ratio (SNR)—A client device can decide to roam when the difference between the receive signal strength and the noise floor drops below a threshold. This roam trigger does not require active client traffic in order to induce a roam.
• Proprietary load balancing schemes—Some wireless implementations have schemes where clients roam in order to more evenly balance client traffic across multiple APs. This is one case where the roam may be triggered by a decision in the WLAN infrastructure and communicated to the client via vendor-specific protocols.
• Scan threshold—The minimum RSSI that is allowed before the client should roam to a better AP. When the RSSI drops below the specified value, the client must be able to roam to a better AP within the specified transition time. This parameter also provides a power-save method to minimize the time that the client spends in active or passive scanning. For example, the client can scan slowly when the RSSI is above the threshold and scan more rapidly when below the threshold.
• Transition time—The maximum time allowed for the client to detect a suitable neighboring AP to roam to and to complete the roam, whenever the RSSI from the client's associated AP is below the scan threshold. The scan threshold and transition time parameters guarantee a minimum level of client roaming performance. Together with the highest expected client speed and roaming hysteresis, these parameters make it possible to design a WLAN network that supports roaming simply by ensuring a certain minimum overlap distance between APs.
• Minimum RSSI field—A value for the minimum RSSI required for the client to associate to an AP.
• Hysteresis—A value to indicate how much greater the signal strength of a neighboring AP must be in order for the client to roam to that AP. This parameter is intended to reduce the amount of roaming between APs if the client is physically located on or near the border between two APs.
Roaming Selection of a New AP
Channel Scanning
Wireless clients learn about available APs by scanning other IEEE 802.11 channels for available APs on the same WLAN/SSID. Scanning other IEEE 802.11 channels can be performed actively or passively as follows:
• Active scan—Active scanning occurs when the client changes its IEEE 802.11 radio to the channel being scanned, broadcasts a probe request, and then waits to hear any probe responses (or periodic beacons) from APs on that channel (with a matching SSID). The IEEE 802.11 standards do not specify how long the client should wait, but 10 ms is a representative period. The probe-request frames used in an active scan are one of two types:
– Directed probe—The client sends a probe request with a specific destination SSID; only APs with a matching SSID will reply with a probe response
– Broadcast probe—The client sends a broadcast SSID (actually a null SSID) in the probe request; all APs receiving the probe-request will respond, with a probe-response for each SSID they support.
• Passive scan—Passive scanning is performed by simply changing the clients IEEE 802.11 radio to the channel being scanned and waiting for a periodic beacon from any APs on that channel. By default, APs send beacons every 100 ms. Because it may take 100 ms to hear a periodic beacon broadcast, most clients prefer an active scan.
During a channel scan, the client is unable to transmit or receive client data traffic. There are a number of approaches clients take to minimize this impact to client data traffic:
• Background scanning—Clients may scan available channels before they need to roam. This allows them to build-up knowledge of the RF environment and available APs so they may roam faster if it becomes necessary. Impact to client traffic can be minimized by only scanning when the client is not actively transmitting data, or by periodically scanning only a single alternate channel at a time (scanning a single channel incurs minimal data loss)
• On-roam scanning—In contrast with background, on-roam scanning occurs after a roam has been determined necessary. Each vendor/device may implement its own algorithms to minimize the roam latency and the impact to data traffic. For example, some clients might only scan the non-overlapping channels.
Typical Scanning Behavior
Although most client roaming algorithms are proprietary, it is possible to generalize the typical behavior.
Typical wireless client roam behavior consists of the following activities:
• On-roam scanning—This ensures clients have the most up-to-date information at the time of the roam.
• Active scan—An active scan is preferred over a passive scan, due to lower latency when roaming.
There are some informational attributes that may be used to dynamically alter the roam algorithm:
• Client data type—For example, voice call in progress
• Background scan information—Obtained during routine periodic background scans
Ways in which attributes can be used to alter the scan algorithm include:
• Scan a subset of channels—For example, information from the background scan can be used to determine which channels are being used by APs in the vicinity.
• Terminate the scan early—For example, if a voice call is in progress, the first acceptable AP might be used instead of waiting to discover all APs on all channels.
• Change scan timers—For example, if a voice call is in progress, the time spent waiting for probe responses might be shortened during an active scan.