workshop - mobile health clinics associationmhca annual meeting 2012 charlotte nc wireless router...

Workshop Mobile Communications: Ch ll & S l ti

September 22, 2012 Charlotte, NC

Mobile Communications Challenges and Solutions

MHCA Workshop

PRESENTERS

• Jerry McLarty, Ph.D. – Workshop Moderator – LSU Health Sciences Center ([email protected])

• Neil Shah, Roni Zeiger, M.D. – Hobnob, Inc.

• Andy Willet – NetMotion Wireless, Inc.

MHCA Annual Meeting 2012 Charlotte NC

Agenda • Introduction and Overview

– Challenges – Brief Introduction to the technology – Options

• Satellite Technology • Cellular Technology • Software Technology • Summary • Q & A Session


Disclosures • I have no financial conflicts or commercial interests in

anything discussed in this workshop. The conclusions and recommendations are my own.

• Note: three presenters are associated with commercial hardware/software/service providers

• Their presentations are meant to be educational, not promotional

• They were selected because their products/services address significant issues in mobile communications

• Neither MHCA nor the moderator endorse the products discussed over any competing products in the industry


Introduction

• When we leave home base: – We can take our medical technology and expertise

with us – We can generate our own power

• But, we lose our connection to land-line telephones, access to the internet, access to databases and other computer resources

• The purpose of this workshop is to discuss various options a mobile operator may use to address the loss of connectivity


• Voice Communications • Internet Communications

– forms, registration, databases, resources • Image transmissions

Delivery of these capabilities can be complicated in the

health industry by the need to protect patient privacy (HIPAA)

Identifiable patient information must be encrypted (coded) such that if anyone intercepts the transmission they could not read it


Privacy protection brings additional problems

• One common method of privacy protection is called VPN (a virtual private network). This methodology can slow down transmission time considerably and can lead to time delays (to be discussed later). These time delays can cause loss of connection, often requiring reconnection and re-entering data and losing time.


Typical Mobile Unit Equipment

• One or more computer terminals • Cell phone • Mammogram or other specialized machines

• The goal is to connect all these devices to the

Internet.


8 Methods of Digital Communication for a Mobile unit.


1. Plug-in directly to a local broadband connection


Usually, this is the fastest, most reliable connection, if you can get it.

External Ethernet Jack on our mammogram vehicle.

2. Connect Each Onboard Device to a Local Wi-Fi Hotspot via Wireless Cards


Wireless Router

DSL, Fiber-optic or other broadband Internet connection

Requires a Wi-Fi hotspot at each remote site. Speed is O.K. for voice, and low-speed computer connections for devices with wireless capability. Typically too slow for uploading Images. Security may be an issue on a public hotspot. Dropped Calls may be an issue with secure communications.

3. Connect Each Onboard Device to the Internet via Cellular Connection


Cellular Provider Broadband

Internet Connection

Each device has it’s own Aircard to connect To the internet via an Cellular Provider

Speed is limited to the speed of a single cellular carrier. Limited by availability of cellular coverage. Usually too slow for transmission of large images. Dropped calls may be an issue with secure communications.

4. Connect all onboard devices via wireless to a mobile hotspot or Mi-Fi


Onboard MiFi or Mobile Hotspot

Cellular Provider

Internet

Bandwidth is shared by all devices. May be sufficient for low-speed applications but upload speed is limited. Restricted to a single cellular provider, different remote locations may have different carriers. Dropped calls may be an issue with secure communications.

5. Use a Wireless Bridge to Link the Onboard Network to a Broadband Network


Onboard Network

Broadband Internet

Matching High-Speed Wireless Routers and Antennas

Works well for all applications including image transmission. However, requires a matching wireless router and external antenna with internet connection at each remote site.

Statewide Fiberoptic Network

Matching Wireless Ethernet Routers

LSU Health Sciences Center

Bridging Example: real-time reading of mammograms

6. Use a Wi-Fi Hotspot Device That Can Use Multiple Cellular Carriers


Onboard Wi-Fi

Hotspot /Router

Cellular Company

Cellular Company

Cellular Company

Cellular Company

Onboard Network and/or Wireless Devices

Broadband Internet

Chooses best cell signal. Can combine multiple carriers to get a high upload bandwidth. Depending upon availability and quality of cellular signals, works well for all applications including sending images.

7. Satellite-Based System


Internet

Sometimes the only option when cellular connection is not possible. Used for voice, computer data, images. Upload speeds can be slow and expensive. Latency (which can cause dropped calls) may be an issue.

8. Combination System

• Some mobile operators use combinations of wireless bridges, cellular-based systems and satellite systems, some even with automatic selection of the best available method.

• Expensive • Complicated, require customized design and

implementation and expert monitoring during use. Most mobile operators don’t have their own dedicated communications engineer.


Communications Primer

• Bits, Bytes, data transfer speeds, image sizes, uploads, downloads, latency


Terminology 101


Upload

Download

For most systems downloading (receiving data) is faster than Uploading (sending data)

Bits and Bytes

• A bit is a single binary number, with possible values of 0,1. All digital systems work with bits.

• To make characters, symbols and decimal numbers

out of bits takes a collection of 8 bits. This is called a byte. For example, the letter “A” is represented digitally by the 8-bit byte 01000001.

• Bits are designated with lowercase b, bytes with an upper case B.


Typical Satellite Transfer Speed

• $600/month service plan • Download speed 1500 Kbps (receiving) • Upload speed 512 Kbps (sending)

• How long would it take, theoretically, to

upload a typical set of mammogram images, say 100MB?


512,000 bits per second

100,000,000 Bytes

How long would it take to upload?

• 100 MB = 100 Mega Bytes = 100,000,000 Bytes • 512 Kbps = 512 Kilo bits per second

= 512,000 bits per second = 512,000/8 = 64,000 bytes per second

100,000,000 Bytes = 1,562.5 seconds 64,000 Bytes per second

= 26.04 minutes to send one patient

set of mammograms!


• For most of us, 26 minutes per patient images would not be practical.

• This is a theoretical maximum upload speed, in practice you cannot even do this well, there are delays in the system due to distances, routing, encryption, firewalls, security checks, etc.

• Solution: a more expensive, higher speed satellite service. Typical costs for higher speed run $5,000 per month and can send 100MB images in approximately 5 minutes.


Note:

• This doesn’t mean satellite systems are impractical for mobile health operators. Satellite speeds are satisfactory for voice, patient registrations, determination of insurance coverage and other non-image based applications. Many mobile operators use it just for these kind of applications, and pay $500-$600 per month for this service.


Another image time example:

• AT&T claims its average 3G cellular user gets 0.71 Mbps upload speed.

• .71 Mbps /8 = .089 MBps

• 100MB image/.089MBps = 1124 seconds =18 minutes

So you wouldn’t want to send images Over a single cellular carrier either.


6. Use a Wi-Fi Hotspot Device That Can Use Multiple Cellular Carriers


Onboard Wi-Fi

Hotspot /Router

Cellular Company

Cellular Company

Cellular Company

Cellular Company

Onboard Network and/or Wireless Devices

Broadband Internet

The router device can break the signal into packets and divide them among the various carriers, getting a higher upload speed than is possible with only one cellular connection.

Combining Multiple Cellular Carriers

• From the AT&T example, with 4 cell devices combining bandwidth 0.71 Mbps X 4 = 2.84 Mbps.

• This could upload the 100MByte image in 4.5 minutes, a much more manageable time.

Actual uploads of 100MB images in 2 minutes or less are possible with this cellular technology.

• This depends upon having good cellular connections, rural areas often don’t have this fast service available.


How does this technology work?

• By dividing the signal, e.g. image, into many small packets (IP packets) and routing the packets through different cellular carriers. The internet knows how the put them back together on the receiving end.

• With this technology, the upload speed could exceed the download speed.


IP (internet Protocol) Packet Structure


Note how much of a Packet is used up with Housekeeping stuff. This is why you can Never approach the Actual bit-rate with your data. The Internet has to Have this extra information to know how to route things around the internet and put them back together at the destination.

VPN (Virtual Private Network) • VPN is a means of secure data transmission

– Adds and extra layer to the IP packets – Requires more coordination between sender and

receiver – Encrypts the message

• VPN is sensitive to signal delay, even a half second delay can cause a link to be dropped

• VPN adds to the overhead of sending information and can significantly reduce bit rates

• Can be accomplished by software or hardware


VOIP (Voice over Internet Protocol)

• Special considerations are required to make telephone calls from a mobile unit via the internet

• Can be done with a computer and a microphone (also video camera)

• Can be done with a special phone that plugs into the onboard network somehow.

• Requires an account with a third party, e.g. Skype, Vonage to make the phone connection


Latency - an enemy of effective communications

• Network news example • This same delay of signal (latency) happens with virtually all

communications devices, including satellite and cellular systems. Geosynchronous satellites have the highest latency.

• VPN is especially sensitive to latency: if one end of the conversation doesn’t hear back from the other end of the conversation within a certain period of time, VPN will break the connection as part of its intruder protection algorithm.

• This causes wasted time re-establishing connections, logging back into data systems and often starting over and entering the same data again.


End of Primer


Discussion of three communications approaches: I. Satellite-based Systems II. Cellular-Based Systems III. Software-enhanced Systems


I. Satellite-Based System

• Systems • Antennas • Antenna height – folding antennas • Advantages • Limitations • Charges


Two Kinds of Satellite Service: BGAN and VSAT

• BGAN is short for Broadband Global Area Network. This network is comprised of three satellites in stationary orbit around the planet so that no matter your location, you may connect with one of the satellites. Made primarily for outdoors. – Pro: High speeds are feasible with BGAN

– Con: The price is much higher that for traditional dish antenna

systems. Latency is also high with BGAN.

– BGAN Not typically used for mobile health clinics in this country


BGAN Terminal and Phone


These are designed for outdoor use. Rooftop antennas are available.

VSAT

• VSAT A very small aperture terminal (VSAT) is a two-way satellite ground station with a dish antenna that is smaller than 3 meters.

• This is the satellite system most often used on mobile health clinics.


http://en.wikipedia.org/wiki/Satellite

http://en.wikipedia.org/wiki/Ground_station

http://en.wikipedia.org/wiki/Satellite_dish

VSAT System


Geosynchronous Satellite

Hub

Mobile Clinic

Internet

VSAT (Continued)

• Pro: – Available almost everywhere with an unobstructed

view of the sky – Can be used for voice, data, images

• Con: – Relatively expensive

• Equipment and Installation • Monthly Usage Fee

– Requires outside dish antenna – Slow upload speed – Subject to rain fade-out


Typical Satellite Monthly Cost


To upload a 100MB image at 512 Kbps would take at least 26 minutes.

Cost

• Costs and plans vary considerably between satellite companies. True story: one mobile clinic provider went from $15,000 per month to $5,000 by switching satellite companies.

• Many mobile clinics don’t send images and are satisfied using the cheaper $500-$600 monthly plans.

• You may have to pay extra for voice capability


Antenna Height Problem


Minimum vehicle clearance of 13’6” is required. Rooftop mounts may take up an extra foot of height, even when stowed away. A foldable side mount is possible:

Another antenna option


II. Cellular-Based Solution

• A single cellular system, e.g. aircard on your laptop, is probably not sufficiently reliable for VPN communications. The next speakers will discuss a means of combining multiple cellular to improve reliability and bandwidth.

• Neil Shah, Roni Zeiger, M.D. – Hobnob, Inc.


September 22, 2012

MHCA Forum Mobile Clinic Connectivity Issues

The Problem? Mobile clinics cannot effectively access EMR systems, email, and other programs while in the vehicle.

• Clinicians missing key data from records such as medication list, allergies, immunizations

• Proper diagnosis may be delayed • Treatment plan may be incomplete or even harmful

( ( Quality of Care ) )

( ( Patient and Staff Satisfaction ) )

• Staff (over)time to complete charting and other tasks when back on network • Unnecessary tests or follow-up visits due to incomplete information during

patient visit • An evolving EMR system

( ( Additional Costs ) )

• Patients know they're getting lower quality care if records aren't available • Staff frustrated by inability to provide best care and extra time required when

back online

Possible Solutions? Mobile clinics cannot effectively access EMR systems, email, and other programs while in the vehicle.

Smart phone applications (apps) available to access select EMR systems remotely, but usually with limited functionality and at slower speeds

( ( Smart Phones ) )

Can give good internet access in some locations, but connections can be spotty. May not work in different locations, and subject to congestion.

( ( USB Data Air Cards / “MiFi” Hotspots ) )

Great for very remote locations, but incredibly expensive and provides limited bandwidth.

( ( Satellite) )

? Not providing the best available care to patients. ( ( Do Nothing) )

Reliability What happens if you use a solution that is not reliable?

• What would happen in urgent or emergency situations? • Are your needs time sensitive?

• Will your organization still be HITECH compliant?

( ( Is 90% Good Enough?) )

• Do you need to support several uses from several users like credit card processing, EMR, and Email?

• How many users need to be supported?

( ( What are your needs? ) )

• For every hour that your network is down, how much money is your organization wasting?

• If you had a reliable network that you didn’t have to think about, how much more productive would your staff be?

( ( What is the value of time?) )

A Unique Solution Take the possible solutions and combine them so that you’re ALWAYS on!

Hobnob allows your staff to type up to speed in the EMR system even when the network is busy with data-intensive applications such as mobile mammography.

( ( Quality ) )

+ + = + Always-on, always fast!

combines multiple network carriers into an “always on, always-fast” network that supports your mobile

x

Why Hobnob? Hobnob is a next-gen mobile broadband offering that combines multiple network carriers into an “always-fast, always-on” network experience.

Hobnob ensures that your staff get the fastest keystroke response possible even when the network is busy with data intensive transactions with the

reliability of several networks combined.

( ( Quality ) )

Experience next-gen mobile broadband performance today: Hobnob technology amplifies the latest 4G LTE and HSPA+ networks into a “5G” class network.

( ( Innovation ) )

Experience the stability of a fully monitored and managed network and the jaw-dropping responsiveness of a world-class support team.

( ( Customer Service ) )

How Much Better Is Hobnob? Hobnob combines all available carriers into a next-gen “5G” class network

Experience the power of combining

all available networks. No

matter where you go, Hobnob dramatically

outperforms the competition.

( ( Unique ) )

Solutions Hobnob provides solutions for individuals, small teams, and large groups who are constantly on the go

Hobnob’s flagship managed router that allows large numbers of data intensive users to work productively in moving vehicles for a mobile

office environment.

Hobnob’s latest innovation provides multiple carrier mobile data- now in your laptop to take

with you wherever you go.

Hobnob 4000 Routers

Hobnob NetAmp Software

How Hobnob’s Routers Work

Customer Satisfaction Customers are thrilled with the unparalleled support with Hobnob products And services. Applications for medical systems include:

( ( F100 Technology Companies) ) ( ( Educational Institutions) )

( ( Philanthropic Based Organizations)

)

( ( Railway Networks) ) ( ( Construction Companies) )

( ( VC-backed Startups) ) ( ( Celebrities ) )

( ( Employee Shuttles) )

( ( Ambulances) ) ( ( Field Research) )

( ( Mobile Teams) ) ( (Remote Location Offices) )

( ( Medical Mobile Clinics) )

Hobnob 4000 Technical Specs The Hobnob 4000 managed router solution is designed for large-capacity mobile offices, ideal for mobile medical clinics, employee shuttles, transport vehicles, railways, and more!

• Supports up to 128 parallel carriers (broadband, WiFi, BGAN and VSat ) • GPS support including recording and storage infrastructure with route management • Supports LTE, HSPA, HSPA+, EV-DO, 802.11 and more. • Supports the following protocols/standards:

VLANs/802.1q, QOS: Traffic Prioritization, Traffic Shaping, Scheduling, and Congestion avoidance algorithms, Remote management capabilities (SSH, Telnet, HTTP, HTTPS, SNMP), DHCP, DNS/DDNS, NAT, Firewall, Tunneling protocols (GRE, IPSEC, PPTP), Routing (OSPF, BGP, static)

• WiFi Capabilities: 802.11 a/b/g, 802.11n 2.4 GHz and 5 GHz Up to 8 radios supported, Multiple SSIDs on each radio

• Authentication: 802.1x support, EAP-MD5, EAP-TLS, and PEAP-TTLS, WPA2, IEEE 802.11i Encryption with AES, Captive portal, Dynamic RF/channel selection, interference detection/mitigation, quality statistics tracking and reporting, public IP infrastructure

How Hobnob’s NetAmp Works

NetAmp Technical Specs Multiple carrier mobile data now in your laptop for individuals or small teams located in remote areas or are doing time sensitive activities.

• Supports up to 3 parallel carriers (broadband, WiFi, BGAN and VSat) • Basic GPS support • Supports LTE, HSPA, HSPA+, EV-DO, 802.11 and more. • Supports the following protocols/standards:

VLANs/802.1q, QOS: Traffic Prioritization, Traffic Shaping, Scheduling, and Congestion avoidance algorithms, Remote management capabilities (SSH, Telnet, HTTP, HTTPS, SNMP), DHCP, DNS/DDNS, NAT, Firewall, Tunneling protocols (GRE, IPSEC, PPTP), Routing (OSPF, BGP, static)

• WiFi Capabilities: 802.11 a/b/g, 802.11n 2.4 GHz and 5 GHz • Authentication: 802.1x support, EAP-MD5, EAP-TLS, and PEAP-TTLS, WPA2,

IEEE 802.11i Encryption with AES, Captive portal, Dynamic RF/channel selection, interference detection/mitigation, quality statistics tracking and reporting, public IP infrastructure

NetAmp Personal

NetAmp Plus

NetAmp Team

NetAmp Premium

NetAmp Platinum

Max Number of Simultaneous Users

1 3 5 7 15

Number of Total Carriers Supported

2 2 2 2 3

Hotspot Capability

GPS Support

WiFi Amplification

Reporting System

Hobnob Uberhub Support

License Pools

NetAmp Packages

An optional GPS TMS system can be added on to NetAmp Team Packages and above


III. Software-enhanced Solutions

• Maintaining constant communications is difficult when signals fade, cell towers or satellites get busy, when latency and other issues cause VPN to drop a link. The next presenter will discuss a software approach to this problem.

Mobile Health Clinics Association Presentation

September 2012

Andy Willet , NetMotion Wireless, Inc.

Introduction and Full Disclosure • NetMotion Wireless

– Based in Seattle, WA – Software provider focused on

challenges of mobile field workers and wireless

• Andy Willett

– 11 years at NetMotion Wireless – 11 years at AT&T Wireless and Sprint

Wireless

66

48%

11%

11%

7%

3%

20%

NMW Customers

Gov’t Telecom/Cable

Utilities/Energy

Other Comm’l

Healthcare

Insurance

Presenter

Presentation Notes

Mobility XE meets customers’ needs and, as a result, we have built an impressive base of more than 1,600 world-class customers in Canada and the United States, some of whom you see here. These are great customers, whose ongoing needs kept us growing robustly through one of the worst recessions in decades. This represents license sales for a cumulative total of more than 460,000 individual users, 89 per cent of them are under continuing maintenance contracts. Customers like us and our surveys say that 97 per cent of them would recommend us to others.

Mobile Deployment Challenges

67

1

Security

2

Usability (Connectivity)

3

Visibility and Control

It’s Secure, But…..

• How do I keep secure, but also….. – Combine multiple networks – Use available bandwidth intelligently – Minimize disruptions due to connectivity challenges – Easy to use

68

VPN Technology • SSL VPNs – Application Layer

VPNs – High in the stack – No visibility into the network – Poor performance over slower

connections • IPSec VPNs – Network Layer VPNs

– Low in the stack – No visibility into applications

• Mobile VPNs – Transport Layer VPNs – Transport Layer Application Level

Proxy – UDP vs. TCP

69

MOBILE VPN TECHNOLOGY

Mobile VPN Server

WWW Enterprise WAN Home WiFi

WiFi Hotspot

1. Operates as a Service 2. Security 3. Application and Network Session Persistence 4. InterNetwork Roaming 5. Intelligent Network Optimizations 6. Intelligent Network Selection

70

Summary – Mobile VPNs • Same (or better) security • Architected for wireless and

mobility • Not well known – but very

mature technology • Multiple vendors

71

Workshop Summary

Note: the opinions expressed are my own. Most of the commercial product features discussed are also available in products from other vendors. (JM)

So, what should I use on my mobile vehicle?

• It depends: – What is available at your remote sites

• Cellular carriers – which ones, how strong are the signals

• Are your sites fixed or do they change rapidly • Are there broadband connections locally available

– Do you need to send images or not • If so, how long can you wait to send them

– How much can you afford to spend


• Decide what your needs are • Investigate what’s available at your remote sites • Consult with an expert before committing to an

approach –it will save money in the long run • Some vehicles have an aluminum skin, radio signals are

attenuated by the metal walls. This may require external antennas to overcome.

• Compare different vendors prices before signing an agreement

• Make sure your system has (and will work with) VPN or other privacy/encryption tools.


Dropped Connections:

• If you generally have good signal strength (either cellular or satellite) but experience frequent dropped connections due to delay or interference

• Consider a product like the NetMotion Wireless VPN software


Cellular-based System

• If you have good cellular service at your sites, this may be the most cost-effective solution.

• Depending upon a single aircard system is risky, VPN can cause frequent dropped connections. Large image transfers are not practical with only one carrier.

• Image transmission are possible if multiple cellular signals can be combined using a router device or special software.


You Might Try This First! • One manufacturer* has a software to combine or choose among

three cellular carriers (e.g. AT&T, Verizon, Sprint) • It operates like a MiFi, a wireless hotspot onboard your vehicle,

with the added bonus of using one or more of up to three different carriers. So, if one carrier is weak in a location, chances are that one of the other two won’t be.

• Combining two or more carriers can greatly increase the upload speed.

• The software fits on a laptop. • I haven’t used it, but it may be a good thing to try before investing

in other more expensive solutions.

*Hobnob, Inc. NetAmp software. There may be other companies with products that do the same thing, but I am not aware of them.

Satellite System

• If all else fails, a satellite system can be used. • The equipment is expensive. • Upload speeds are slow, sending images is

impractical unless cost is not a factor • Many mobile clinics are satisfied not to send

images and just use it for voice, internet usage, patient registration, etc.


If cost and technical expertise is not a limitation consider using several or all

of the methods discussed.


Hardwired or Wireless Bridge System

• If all your sites have broadband available (for example in fixed rural clinics), consider a hardwired or bridged solution.

• This is potentially the most reliable, fastest method (unless the broadband devices are slow, e.g. DSL)


My experience (JM):

• In Louisiana, not all cellular carriers are available in many locations. AT&T may work great at one site and not be available at all at the next site. 4G service is rarely available.

• In our situation we chose to use one of the hardware devices that combines cellular carriers, we currently have 5 different aircards plugged into our router, but Verizon and AT&T are the most commonly used.

• This solution works well in 19 of 20 locations, the one bad location

has very weak 2G and 3G service. We are considering a bridging system at that location.

• As 4G service becomes available in more locations, the cellular solution should become more and more cost-effective.



Questions?

workshop - mobile health clinics associationmhca annual meeting 2012 charlotte nc wireless router...

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