To save money and avoid server sprawl while managing systems centrally, the hospital went with a VMware virtualized server environment. The hospital also chose Stratus Medical Grade ftServer and ftScalable Storage for the core of the cloud infrastructure to provide the required uptime to serve the various physician practices.
"Had we not done server virtualization and some other things, our costs would have been higher, but even still, it was higher than we'd projected," Crowley said.
"It's one thing when I can send out an e-mail in our hospital saying we're going to be down for maintenance today, but now we're answering to all these other clinics," Laforge added. "We had to look at ourselves as a SaaS provider. The hardware fault tolerance of the Stratus equipment combined with VMware gave the kind of uptime we felt we needed to provide."
The hospital has four virtualized servers and one server for vCenter, which cost several hundred thousand dollars in hardware alone.
Crowley and LaForge are still working on integrating the hospital's laboratory and radiology departments with the EHR system, but the technology has been available to the rest of the hospital and to affiliated and nonaffiliated physician practices since May. Nonaffiliated practices have their own discrete database instances, but all of them pay the hospital for the service based on a chargeback model.
"From that perspective, it's a SaaS model to them," LaForge said.
In some cases, regional hospitals with large IT shops have opted to build out their data center infrastructure in order to host affiliated and nonaffiliated hospitals in their areas. As IDC's Hanover puts it, "IT often is not a core competency for hospitals and physician practices." Moreover, a small clinic isn't likely to keep good IT personnel around for long, she added.
The system at University of Pittsburgh Medical Center (UPMC) is a good example of shared EHR services. UPMC is an $8 billion integrated global health enterprise headquartered in Pittsburgh, and it's one of the leading nonprofit health systems in the country.
For all intents and purposes, UPMC runs a private cloud. All healthcare, financial and administrative applications run in a shared environment.
Paul Sikora, vice president of IT at UPMC, said his hospital shares its data center with 27 other hospitals in the region, including Children's Hospital of Pittsburgh, which opted to run its EHR applications on discrete servers in UPMC's facility.
In 2009, the Healthcare Information and Management Systems Society honored Children's Hospital with its HIMSS Analytics Stage 7 award in recognition of the fact that the hospital had an advanced patient record environment. "One reason they were able to do it is they didn't have to worry about infrastructure," Sikora said.
UPMC, which itself won an HIMSS Analytics Stage 7 award this year began to rip and replace its outdated data center infrastructure five years ago at an unspecified cost of millions of dollars -- and it was worth every penny, said Sikora. An IDC evaluation of UPMC showed that the hospital avoided $80 million in expenditures that it would have incurred if it had stuck with its legacy infrastructure, Sikora said.
Apart from the $80 million in cost savings, Sikora said he was also able to avoid the need to build a new $85 million data center in order to keep up with server sprawl.
"A lot of that savings was because of the virtualization we rolled out," he said. "When you can pack 24 rows of servers [we formerly had] in to one server rack, that's savings. When you cut 100 Unix servers down to 14, that's savings." UPMC runs its new virtualized environment at one-fifth the cost of its legacy data center, he added.
UPMC runs 1,300 Windows virtual machines on 22 physical servers, allowing it to add capacity for hosted hospitals in hours through strokes on a keyboard instead of building out additional infrastructure. And I/O loads are matched with the most cost-effective computer service in the environment.
UPMC not only virtualized its servers with VMware; it also virtualized its storage with IBM's SAN volume controller appliance, which sits in front of storage arrays and makes them appear to application servers as a single pool of available capacity.
"When you get all of your enterprise systems in a standardized environment, you can start to manage it differently. You start to see load characteristics ... and then you can determine that you can take this data and put it on Tier 3 storage with a lower cost," he said.
UPMC, which has an IT staff of 197 people who support 4,000 physicians, began its data center consolidation and upgrade in 2005, long before the government began formulating its requirements for meaningful use. Sikora said the technical complexity behind EHRs just from an infrastructure standpoint is "enormous." A midsize hospital starting up an EMR project could devote more than half its effort just to getting the new infrastructure operational. "And that hinders the ability to do the task at hand, which is the health record itself," he said.
"What we do is very scalable. Any number of community hospitals could share in an environment like ours," he said. "I think if the government were to fund some type of regional data centers, it's probably money better spent than giving hospitals money to figure out how to do it."
In order to justify the cost of an in-house, client/server EHR model, physicians should tackle EHR projects in groups of three or more, according to Bell.
IDC's Hanover recommends that, before rolling out an EHR system, physicians and clinics should first perform a gap analysis to determine what they currently have and what they still need in order to roll out the new system. They should consider what technology will be required to support their service goals, and they should take into account both near-term and long-term meaningful use requirements as well as their the future patient care goals. Only after doing all of that should they put together a request for proposals for vendors.
Gartner's Handler suggests that healthcare providers should also consider processes and protocols -- in other words, they should figure out how to standardize technology rollouts from physician practice to physician practice and hospital to hospital in a group. Also, they should consider whether they need functions such as order sets as part of a computerized physician order entry system with prefilled ordering templates.
The Office of the National Coordinator has established 66 Regional Extension Centers, or RECs, throughput the U.S. for the explicit purpose of helping physician practices and rural clinics roll out EHRs.
RECs were created last year under the Health Information Technology Economic and Clinical Health (HITECH) Act. For the most part, the RECs don't provide healthcare providers with any funds, but they do offer training and technical assistance in rolling out computer systems. Each REC has 10 to 30 employees, depending on the size of the region in which it operates.
The U.S. government also issued $144 million in grants to create college courses to train people and help fill an estimated 50,000 jobs needed to assist doctors and hospitals as they roll out EHRs. However, none of that money covers the cost of EHR hardware and software -- the most basic costs associated with health IT.
Another reason to wait
Bell said physician practices and clinics that haven't begun implementing EHRs may get a system that truly suits their needs -- and meets federal meaningful use criteria -- later on.
By waiting until 2012 or 2013, healthcare facilities can ensure that they are preparing to meet both Phase 1 and Phase 2 meaningful use requirements.
"The very first step that needs to happen, which frankly many physician offices skip, is the business plan. Why are you doing this? Be very clear about your revenue stream now, your revenue stream after you adopt," Bell said. "Ask if this is the time to go forward with an EHR, or should you watch and wait a little more?"
If you ask Crowley, however, there are worthwhile benefits to implementing an EHR long before the government's deadline.
"We're definitely pleased we did it, and we can see the light at the end of the tunnel. I think we'll be ecstatic once a whole year goes by and everybody's much more comfortable with it," Crowley said. "In terms of patient safety ... we've taken a huge leap forward."
Lucas Mearian covers storage, disaster recovery and business continuity, financial services infrastructure and health care IT for Computerworld. Follow Lucas on Twitter at Twitter @lucasmearian. His e-mail address is email@example.com.
This story, "When and how to deploy e-health records tech" was originally published by Computerworld.