Februaury 2008

Architecting Health Network – Building a Foundation for Health Connectivity : Michael Gill, Cisco Internet Business Solutions Group

Forget most of what you know about using the Internet. Think instead about communities and families living across a region, and imagine how electronic healthcare services would support them.

Today, the focus is increasingly on understanding the dynamics across multiple health agencies and developing an architectural information and communications technology (ICT) response. In this context, ICT architecture refers to the process of determining the principal design attributes associated with connecting people, entities, and services in a planned manner in order to optimize delivery, cost, and scalability. Significant activity is occurring in many regions and countries. The capability of ICT to be transformative1, particularly in terms of system efficiency, is not disputed2 and often claims to provide tangible benefits in specific areas such as health.3

In the European Commission report (titled ‘National Strategy for e-Health’) an evaluation of 10 e-health case studies yielded the observation that – “given the right approach, context, and implementation process, ICT-based solutions can indeed improve the quality, access and efficiency of healthcare provision”. However, realisation of actual and tangible benefits happen only after couple of years. In this context, it may be worthwhile to highlight a study by RAND Corporation, which modelled the impact of EMR adoption in United States and found the potential benefit in monetary terms to be as much as US$ 77 billion per year.4

People live in places and move across geographic areas. In doing so, they tend to form identifiable communities. Mixed in among these communities are general practitioners, specialists, pathologists, radiologists, elder-care facilities, community health services and hospitals. People needing care regularly move through a geographic area seeking support and treatment. Patients are discharged from hospitals, sometimes requiring ongoing care from a general practitioner. Elderly patients and/or chronic-care patients may move between facilities and may require a wide variety of medical providers over extended periods.

It has been observed that most health activity happens in the community, and not in the hospital. Health systems tend to be acute-centric and as such, ignore the burden of care required in a community setting, particularly for chronic-care patients. When primary care fails, the demand increases on ambulatory system, such as outpatient care. This increase can cause failures in the outpatient system, resulting in more hospital admissions.

This scenario is the foundation for two emerging concepts. The first is that health-related information and services need to be available and accessible throughout a region and across all patient and health provider segments, if quality, safety, and inclusivity have to be equitable. Information availability and accessibility are directly tied to significant, positive and improved health outcomes.5 The second concept is that a systemic failure in one part of the health system can have major ramifications on other parts of the system. This is because costs tend to be high in the hospital and low in the community and systemic failures magnify cost, often exponentially. Put another way, errors and mismanagement cost much more to recover at the hospital end than at the community end of the care spectrum, yet relatively little effort is expended to improve community care. Think of it this way – an inpatient admission represents a failure of ambulatory management.

Patients and their families “move” through regional, state or national health systems. The efficiency and effectiveness of their “journey” bear directly on improved health outcomes. This is, for example, reflected in a reduction in waiting time for emergency treatment or surgery, or in reduced admission rates for diabetes sufferers because of improved case management. This journey also impacts how families and individuals seek medical support, particularly in chronic-care areas. Mental health is typical among these.

The fundamental proposition is that providers and patients need to connect in a timely and appropriate manner. That connection via electronic means is the primary opportunity given the principles of a patient’s journey, which can start at his or her home, neighbourhood or village � through the system. Only when one is connected reliably and securely can the exchange of information and electronic services take place. Clearly, there is an underlying point here of empowerment and patient-centricity. On the provider side, the implication is that communication is a catalyst for collaboration � the more interactive the nature of connection, the higher the probability of successful collaboration actually taking place. In other words, providers can obtain and exchange information and services at the point of care in order to reduce errors, create faster flow-through, improve patient satisfaction and, in short, help ensure better healthcare. The following examples illustrate this point.

Unlike a banking or government general services network, connectivity in health usually occurs among multiple, autonomous provider entities. This situation introduces a huge set of complexities not addressed in simpler networks found in banking and transportation. Connectivity in healthcare is fundamentally of a higher order than any other network configuration due to the need to develop design and governance responses compliant with local
ownership requirements. In addition, the amount of data transmitted, such as data from radiology images, far exceeds that of bank transactions. Furthermore, the level of security required is variable, and the ability of the network to deliver services and information at the point of care can often have severe physical consequences for the patient if a network failure occurs. Another point of differentiation is that many of the provider entities have already developed electronic responses to varying degrees of maturity and sophistication, and may have upward of 400 old and new applications that need to function and exchange information.

Reliance on the Internet without a critical assessment of user needs, security,6 and service reliability is akin to sailing without a compass. The volume of medical reference material, the size and complexity of CAT (computerized axial tomography) scans and X-ray images, the move to video-based consultations, and the need to preserve confidentiality are all factors that have to be taken into account to find new approaches to healthcare delivery. The health industry is required to know that the information has been sent and received, is free from computer viruses, and is intact, irrespective of its complexity or volume, particularly in crisis health environments. General practitioners require secure e-mail, automatic hospital discharge summaries and the ability to access the latest patient condition information quickly. Such service guarantees are not possible across the Internet.

There is no guarantee that the e-mail you sent to a family member overseas will actually arrive. This is simply not good enough for critical health information. And if we introduce telemedicine or general practitioner-to-medical-specialist video conferencing across a region, for instance, the volume of video-based traffic could exceed the connection capacity normally available for the Internet. At a system level, national health monitoring for conditions such as arthritis, and for access to databases and financial information, is increasingly required in real time to aid planning and insurance outcomes.

Currently, it is not possible to add features onto pre-existing, older networks. The ability to scale from a few ad-hoc, video-based conferences among clinical practitioners to multipoint conferences on a regular basis needs to be designed into the network from the start. Such a network architecture response takes into account the quality of service requirements in a scaled system so that consistency and quality are evident across the entire geography and the entire electronic network as well.

Security for networked communications is complex. The model adopted in the financial services sector tends to resemble a “fortress” orientation where all access points are limited and access is restricted, irrespective of need. For the healthcare industry, such a model will not work because of the numerous, autonomous provider entities. Access to the electronic assets of a health system would be based on communities of interest and on the need to connect to a service or database. For example, general practitioners may require their own electronic community with its own access control in the form of passwords and authentication, or hospitals may require quite a different model with access gateways between general and specialist hospitals. And, elder-care facilities and medical specialists may require their own electronic community that interconnects with selected providers such as pathologists and pharmacists. In other words, security in health is multi-layered and should be built on a foundation of double redundancy and virtual private networks.

Modern network technology design is moving in such a way that many intelligent functions can be performed by the network itself. Such functions include virus detection and denial of service attacks, combining messages, and thorough data packet inspection. These developments imply that the provision of network-based electronic services in healthcare is much more than simply providing connectivity. Managing compliance with a specified security policy probably needs to be centrally managed. The security model deployed in healthcare is much more akin to that of an airport where “passengers” are allowed access to different areas based on their needs.

In the current health sector, which is a mix of public and private providers, the transmission of messages, services, and images is done through a series of networks, some of which are interconnected.

Establishing national health connectivity will likely lay the foundations for building connectivity in other service areas such as education, public safety, and regional economic development. Much of this thinking is currently encapsulated in policy developments around deploying national broadband. While this is useful, the national development of a health-sector response suggests building regional points-of-presence7 where other services, such as education, are also aggregated. This, in turn, suggests architecting for more than health services; it suggests providing partitioned capacity for other services, which may, from a health sector perspective, reduce costs of infrastructure development and increase political support.

The foundations for health connectivity include the following:

  • Requiring connection to all providers
  • Providing access and gateways for patients
  • Recognising that an area-based health strategy is more desirable than simply focusing on the transfer of acute and emergency-care information
  • Understanding the patient’s journey through the system, and his or her information requirements
  • Connecting and communicating to promote team-based clinical problem solving and, thus, changing work practices


1. The Indian Government plans to install online and video-based kiosks in 100,000 villages, providing agriculture purchase services, education, and health support services.

2. “e-Government Strategy”, page 6, Australian Government Information Management Office, March 2006.

3. “National Strategy for e-Health,” page 2, Ministry of Health and Social Affairs; “New Zealand Health Information Strategy,” page 34, Ministry of Health, August 2005; “eHealth Is Worth It” study, European Commission, September 2006.

4. “The RAND Study of Potential Costs and Benefits of Electronic Medical Record System,” Richard Hillestad, Ph.D., RAND Corporation, September 21, 2005.

5. Public Services Summit @ Nobel Week, December 2006. Tele-dermatology pilots in Norway observed a 40 percent decline in face-to-face specialist consultations. In New Zealand, chronic-care telehealth services achieved a 60 percent decline in hospital admissions.

6. “Symantec Internet Security Threat Report,” Symantec Corp., January 2006. According to the report, there were 6,110 “denial-of-service” attacks per day from January 1 to June 30, 2006. And, Web application vulnerabilities made up 69 percent of all vulnerabilities.

7. Points-of-presence (PoP) are geographically dispersed access points for subscriber connection, consisting of Layer 1, Layer 2, or IP access transport services sourced from commercial telecommunications carriers, and providing firewall, encryption, IP VPN termination, and other services.

network for healthcare

Jagdish Mahapatra
Vice President � Sales
Cisco Systems (India)

Cisco has announced the roll-out of its Medical Grade Network (MGN) offerings in India, targeting the domestic healthcare service providers. What is the technology framework and solution architecture of MGN?

With the roll out of Cisco Medical-Grade Network we look forward to build awareness amongst hospitals and healthcare practitioners of the benefits of technology in the sector through our partners and healthcare seminars across the nation.

The Cisco MGN creates the foundation technology from which information can be disseminated within the hospital or healthcare system. By interconnecting independent healthcare entities that are now technology-enabled by the Cisco MGN, Cisco supports the transformation of healthcare with the connected healthcare ecosystem.

This Network helps create collaborative relationships among all members of the connected healthcare ecosystem, enabling a connected healthcare community through interoperable processes, technology, and people to provide ‘anywhere, anytime’ information.
The Network provides an optimized framework for the healthcare industry by meeting healthcare’s unique needs for interoperability, security, availability, productivity and flexibility. Recognizing that every healthcare institution has different needs�whether it is a hospital, a clinic, or an academic facility� the Cisco Medical-Grade Network provides a framework that defines network strategies and policies that are purpose-built for each environment. By building networks within the organization that meet these needs, the stage has been set to expand the organization’s reach into the connected healthcare ecosystem.

What business critical advantages will MGN bring in and how does it promise to enhance service quality and operational efficiency of service providers?

Cisco’s MGN solution will enable healthcare organisations to enhance patient safety with more timely and accurate results and protection of patient data, as also to improve patient satisfaction by reducing wait times and stream line patient care process. It will also help optimize technology investments by fully integrating with existing systems and applications and minimize the risk of costly downtime through self healing capabilities.

The Cisco Medical-Grade Network provides the advanced technologies and infrastructure one needs to support their business capabilities and meet their business objectives. The Network is an emerging, health industry-specific architecture that defines an optimally performing healthcare network based on four key factors:

  • Resilience – High-quality health services depend on uninterrupted access to clinical systems and data. With a focus on maintaining continuous uptime, the Network optimizes the accessibility and transmission of vital-often lifesaving-information, to and from the point of care.
  • Protection – Fully embedded network wide security enables the Network to provide comprehensive protection of information and applications through the use of identity authentication tools, firewalls, intrusion detection systems (IDSs), and self-healing capabilities.
  • Responsiveness – Doctors and other medical personnel can access information at any time, from any location, through wireless-enabled and remote-ready applications and devices. A VLAN “guest network” enables business partners and other non-employees to gain secure network access.
  • Interaction – By converging voice, video, and data on a single system and dynamically connecting in-house and remote medical staff to one another, the Network strengthens communication among care-givers and allows for higher-quality patient care.

While the benefits of connectivity may be different for each segment of the health community, the benefits to the patient are the same: the delivery of safe, affordable, and accessible healthcare. In the end, it is simply about connecting people to enable access to critical health information anywhere and at any time.

Since western markets are considerably advanced than India’s, their level of technological maturity is quite understandably higher. What has been your experience with deploying MGN and similar solutions for providers in advanced economies?

Adoption of technology by the healthcare sector has changed its dynamics across the world. With the advent of Internet technologies and rapid access to information; management and delivery of healthcare information has emerged as an issue of prime concern. Collaboration of technology, telecommunication and information has given rise to innovative practices such as e-health. These practices have opened up opportunities to provide healthcare facilities to patients better, faster, at lower costs and higher levels of convenience.

IT adoption among healthcare institutions in India is still comparatively low as compared to developed economies (average IT expenditure of large hospitals is still at 2% of annual turnover in India). In this scenario, how do you strategise to market high-end solutions like MGN? Do you have plans for offering shared services infrastructure for SME players?

In India the overall healthcare market is booming. A CII-McKinsey study reveals that the total healthcare market in the country could increase to US$ 53-73 billion (6.2-8.5 per cent of GDP) in the next five years.

Currently, India’s domestic consumption of healthcare services is low but is expected to increase as the economy develops. The organised healthcare industry in India is still in its nascent stages and will take another couple of years to start taking shape.

The growth in the organized sector, from IT product/solutions vendor point of view, has created a need for provisioning specialized solutions to these players. Cisco has designed its Medical Grade Network (MGN), as an architecture that offers all these critical features that the healthcare sector demands for.

Cisco, has identified this space as one of the key growth areas for networking based on the plans that both national and international healthcare service providers have for India. Over the next couple of years Cisco will be strengthening its position in this market.

Cisco has also introduced its innovative ‘HealthPresence Pod’ in India. Can you elaborate on the Pod and how can it benefit healthcare providers in delivering services?

As part of its healthcare strategy, Cisco has piloted a HealthPresence Pod which can help the hospitals to take their service delivery closer to the patients. Using the Pod, the government’s public health clinics too can offer healthcare services to patients residing in remote locations. Designed by Cisco’s team in Australia, HealthPresence Pod is currently deployed in Bangalore as a pilot.

The Pod may be installed at any public space such as a mall or an airport or a railway station. A patient may walk into the Pod, video-conference with his doctor, plug in basic records such as EMR, and seek his/her advice. This way, the patient is not required to go to the hospital or the clinic which may be a few kilometres away from his house.

The Pod can thus bring convenience to the patients and also extend the service delivery points of private sector hospitals and government’s PHCs. As an extension of this concept, this Pod may even be set up inside a van. The Mobile HealthPresence Pod can then reach to patients residing across a wide geography, revisiting the same locations periodically. Cisco will further develop the solution taking inputs from hospital customers in India and carry out the deployments through partners. The fees charged for these services will be determined by hospitals and PHCs. Once deployed, Cisco’s role will be only maintenance and support.

What is the business volume you are expecting from the Indian healthcare market over the long term? What is the expectation from South and South-East Asia as a whole?

At this point, Cisco is working with its partners to build awareness for the benefits of putting in place a robust communication and information network, which will provide the foundations for advanced healthcare solutions.

It would be premature to peg a figure to the volume of business expected, but given that healthcare consumption as a proportion of average household consumption is expected to triple from 4% (1995) to 13% (2025), Cisco believes that the sector is on the verge of major growth and we are positioning ourselves to take advantage of this.

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