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(HealthNewsDigest.com) – There’s little debate among healthcare policymakers that electronic patient records improve health care quality and reduce costs. The Obama Administration agreed so much that it put $18 billion into the American Reinvestment and Recovery Act of 2009 (aka the stimulus bill) to promote “meaningful use” of electronic health records (EHR).
EHR systems are the new axis that health care will turn on. Consolidating all of a patient’s information – medical history, prescriptions, test results, allergies, images – in widely accessible electronic repositories will increase efficiency by orders of magnitude over today’s paper-based systems. For example, clinicians won’t have to order duplicate tests because they can’t get the results of previous tests, or another MRI because the original films are shelved in a remote facility. With an EHR system, that information is digitized and accessible through handheld devices and wireless networks.
The “meaningful use” proviso is meant to ensure that only medical establishments serious about using EHR systems to improve care and cut costs are eligible for federal money, and that their systems are up to technical standards. But “meaningful use” is also an implicit warning to anyone who goes ahead with an EHR implementation. An EHR system is only meaningful if you can use it. Medical IT carries different expectations than standard business IT, and foremost among them is availability. Unlike most business IT systems, which can tolerate some unscheduled downtime, EHR systems have to run constantly.
“Behind the flash of hand-held prescribing tools, wireless tablets in the operating room, and remote radiology viewing, these systems demand a backend infrastructure of application servers, database servers, physician portals, patient web sites, real-time claims gateways, secure access points for clinical information exchange, and hundreds of other potential services,” Forrester Consulting wrote in its Feb. 2010 report “Server Availability Trends In The Time Of Electronic Health Records.”
Despite that need, healthcare technology vendors treat EHR systems like any application. They talk about functionality interoperability, security and application performance, but not about the highly reliable hardware foundation that ensures critical EHR applications will be available. The non-profit group that certifies EHR applications compliant with federal regulation also makes no reference to uptime metrics.
Where does this leave healthcare IT professionals? Without an advocate to help them meet a need they know exists, according to Forrester. The company found that “fewer than half of IT professionals think that their server infrastructure is ready to meet the current and future needs of their institutions. Overall, healthcare IT professionals are aware that the old service levels that supported administrative and billing systems will not be sufficient to meet the needs of the digital health era.”
For EHR to deliver the quality and improvements and cost reductions its advocates promise, some of the focus has to shift away from software and onto hardware – specifically, uptime. If vendors and policy makers don’t face uptime requirements now, they’re going to face them later when a lot of the money is doled out and the mistakes are made. Unless they want to be one of those mistakes, healthcare IT managers have to be ready to force the uptime issue with vendors.
Higher than usual stakes
The stakes are higher in medical IT than they are in other industries that rely on IT to support vital processes. If the inventory system in a regional distribution center crashes, users cuss and might fall behind in their work while they’re waiting for it to recover, but the actual financial damage is small. Most companies assume some system downtime – in fact, accept it as inevitable, which practically ensures downtime will happen eventually – and factor it into their overhead costs. Healthcare providers can’t do that because their overhead cost is ultimately human. When an emergency room physician needs to know an unconscious accident victim’s medical history, time matters. Waiting for a backup server to kick in or an application reboot to finish make a difference in patient care.
Government and the healthcare technology vendors have entrusted the Certification Commission for Health Information Technology (CCHIT), a five-year-old Chicago-based nonprofit, with developing standards for EHR application functionality, interoperability, security, and compliance with Federal standards. Performance and availability, however, don’t come up. EHR vendors talk about application performance, but not hardware performance. The network infrastructures they recommend to support EHR implementations could just as easily support a regular office workgroup LAN because it doesn’t include any reliability technology.
Healthcare IT professionals currently maintain application uptime by employing combinations of clusters, redundant servers, mirroring, fault-tolerant hardware, and physically swapping in standby servers. According to the Forrester Consulting report, however, lack of a cohesive availability plans limits their effectiveness:
These strategies aren’t working so well. Three-quarters of respondents experienced downtime related to a server failure during that past two years. And these weren’t blips. Sixty-eight percent had an impact on clinical activities and greater than half affected administrative processes. Rarely was there no impact. And recovery times were typically measured in hours. Only 1 percent of server outages were resolved within five minutes. Providers’ strategies for swapping servers and manual failovers are not medical grade.
Planning for reliability
Although healthcare IT managers know what they need for successful EHR implementations, they have limited options for getting it. Compared to their opposite numbers in other industries, healthcare IT professionals have very little money to spend on availability solutions.
Fault tolerant servers provide the highest levels of availability, which is why their purchase price will be slightly higher than less-capable conventional servers. The configuration complexity required to make clustered servers highly available puts their price on par with fault-tolerant systems, yet they are less reliable and more difficult to operate and maintain. ROI is best measured against the cost of downtime in terms of patient safety, lost productivity, financial consequences, exposure to litigation, or general disruption.
Then there’s virtualization, which comes up as a panacea for just about everything that ails IT these days and in some cases does fit the bill. Instead of one server running one application, virtualization software enables many applications to run on a single physical server, with each application having its own operating system and share of processing resources running in a virtual machine created by the virtualization software. This technology allows many workloads to be consolidated on far fewer physical servers, thereby eliminating the associated cost of electricity, cooling, system management, maintenance, staffing, and rack space. Also, IT can put several virtual machines supporting the same application on one server to act as backups if an application goes down.
But even virtualization has its weak spots. Consolidating five, ten or 15 server workloads onto a single server introduces single points of failure into the IT infrastructure. In a virtualized environment, if the physical server fails it brings down many applications, not just one like in a conventional environment. Virtual machines are a cost-effective alternative to back up physical servers, but they don’t provide uninterrupted availability. It can take anywhere from a few minutes to an hour to bring a new virtual machine online to replace a crashed one, which isn’t much better than a conventional backup server. Even though the application comes back up, the healthcare provider at the other end can’t do his/her job during the failover period. The same goes with clusters. The applications in a clustered environment recover, but the time to recovery is what causes problems for the users.
Combining virtualization with fault tolerant hardware has many advantages. The fault tolerant server is significantly less likely to crash than a conventional server; the difference between the 99 percent availability a conventional server provides and the 99.999 percent that a fault tolerant server provides is the difference between weeks and minutes of unscheduled downtime per year. Fault tolerance essentially eliminates the server as being a a single source of failure, and reduces reliance on virtual machines as backups.
The fault tolerant-virtualization option should be part of a broader availability strategy that encompasses, hardware, software and network infrastructures. Not every application requires the performance assurance of fault tolerance. Healthcare IT managers need to start with a serious audit of their service obligations, and include clinical personnel in the discussion, to decide which applications need continuous availability. That process will determine whether EHR systems deliver the care quality improvements and financial savings their advocates promise.
When the business world adopted information technology, it quickly learned how important reliability is. The best feature sets and fastest throughputs are useless if the applications run on hardware infrastructures that can’t provide the requisite uptime. Most business processes are forgiving of a few minutes of downtime per month, but the healthcare industry can’t be. The brief outage that is an annoyance in retail is a crisis for healthcare facilities that use EHR systems. When vendors and healthcare IT managers talk about “meaningful use” of EHR systems, uptime and application availability have to be part of the conversation. Otherwise, “meaningful use” is meaningless. Stratus Technologies
(Roy Sanford is chief marketing officer at Maynard, Mass.-based Stratus Technologies.)
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