LHSC and St. Joseph’s see benefits transferring EHR to the cloud

Once the groundwork was laid at London Health Sciences Centre and St. Joseph’s Health Care London, migrating their core IT systems to the cloud was instantaneous. “It was like a NASA launch,” said Glen Kearns, integrated vice-president of diagnostic services and CIO at the two organizations. It literally occurred with the flick of a switch. “Dave was the maker of the switch.”

The Dave in question is David Schned, integrated director of infrastructure technology. And the switch in question moved the shared, Cerner health information system of LHSC and St. Joseph’s Hospital, along with nine partner hospitals in southwestern Ontario, from in-house data centres to a cloud-based environment managed by Cerner Canada.

London Health Sciences accomplished the transition to the cloud in June.

“We’re a multi-campus, multi-hospital organization,” said Schned. The original solution not only serviced LHSC and St. Joseph’s, but also supported the patient record needs of associated hospitals over “a good chunk of southwestern Ontario.” Schned and Andrew Mes, integrated director, clinical informatics and clinical corporate solutions, provided the strategic leadership for the move to the cloud and started the planning in the Spring of 2013.

“We still have two data centres in the city of London, with other solutions supporting the organization for the business of treating patients,” said Kearns.

The transition of the patient record system to the cloud was LHSC’s first foray into exploring the viability of cloud-based solutions. “Taking our most relied-upon systems (and putting them into a cloud environment) says to us that for all other solutions, this is absolutely possible and sets us on a path to lay out that plan. We’re leveraging access to those systems through those new data centres in a way that we basically look at as Software-as-a-Service.”

The move sets the groundwork not only for the near future, with significant cost savings and other important benefits, but for future applications that require massive computing resources for analytics and personalized medicine.

A new approach: It is a new approach for delivering health information systems for Cerner Canada, said company president Jim Shave.

“This is our first in Canada, whereby Cerner has struck a relationship with a healthcare client to take over the data centre responsibilities for all of their clinical information systems,” Shave said. “In the States, we’ve been doing it for at least a dozen years.” Cerner has its own data centres in the U.S., and 450 hospitals work on the model that Cerner Canada replicated for LHSC and St. Joseph’s.

“The traditional obstacle in Canada has been that we can’t take advantage of those centres because we can’t have cross-border storage of patient information and communication,” Shave said.

He explained that for Canada, “We did not build a data centre. We acquired capacity through two robust, industrial-strength centres that were already here in Canada,” from providers Q9 (a BCE company) and Sunguard. “Each is served by redundant telecommunications paths, and we have two of everything.” That supports the disaster recovery element of a healthcare provider’s strategy, something Shave said is underserved in the Canadian market.

Cerner Canada has aspired for some time to bring this model to market, Shave said, because dependence on electronic patient records increases with the adoption of new technologies. “The more sophisticated these clients get, in term of their IT adoption, the more there’s a reliance on this technology to be available 24/7 with little to no outages, because there’s no paper to go back to,” Shave said.

Shave characterizes LHSC’s and St. Joseph’s infrastructure as a private cloud. Unlike a public cloud environment – think Amazon, or, on a simpler, Software-as-a-Service level, Google Apps – private clouds don’t share physical hardware among clients. (Hybrid clouds are growing in popularity, wherein some data and applications exist on a private cloud, while others are in a public cloud environment; it’s particularly suitable for operations that have to scale to meet peak demands.)

Risk and reward: And the move to a cloud-based infrastructure can be resource-intensive. LHSC and St. Joseph’s “flip of the switch” masks a huge effort, internally and externally, to make the transition. Two project leads – Nicole Arsenault on the technical side, and Dorothy Seiler on the applications and integration side – led 106 staff from 22 separate work teams across 394 separate work streams on the project, which consumed almost 11,000 IT hours.

Moving from a concurrent user model to a 15,000-unique-user model – where the hospital pays licenses for the number of users who have access, rather than the number of users on the system at any given time – has avoided $2 million in one-time and ongoing costs.

Not only that, but data, applications and user volumes are 100 percent recoverable in the event of a system failure, and transaction time has dropped 40 percent to an average of 0.31 seconds. “That is really significant when you look at the number of transactions that occur on a monthly basis” – about 85 million – said Schned.

The redundancy of the previous infrastructure had the ability to support 50 percent of LHSC’s and St. Joseph’s capacity and usability of services in the event of a catastrophic event. “In the new environment, the new infrastructure, we basically increased that to 100 per cent,” said Schned. “Our business continuity plan is by far improved.”

The business argument: Robert Fox is the director of healthcare transformation for networking giant Cisco Systems Inc.’s Canadian operations. He stresses he’s not a technical guy; he came to Cisco after 20 years of working on capital expenditures – infrastructure, equipment, technology, and construction of facilities – at St. Michael’s Hospital in Toronto, while consulting at other Greater Toronto Area (GTA) hospitals.

He said he’s seen the business arguments, and tried to make them, for moving critical health information systems to a cloud environment. (Cisco is the primary provider of “self-healing fibre ring” connectivity for LHSC, said Schned.)

“I’ve always asked why we can’t move to a cloud environment,” Fox said. “As the head of planning, development and capital, I was responsible for facilities, so I obviously wanted that real estate that the data centres all took up.” Data centres don’t cope well in a basement, where flooding and facilities issues happen. There was friction with the IT department, who wanted to take over higher levels of the hospital – levels Fox felt would be better used for patient care.

Fox’s pitch to move to the cloud encountered the same resistance as it would at any enterprise. “The No. 1 thing you’re going to get is around patient privacy, data security. And then the other discussions are around data sovereignty. All of that is always going to come up.”

But deeper in the decision-making matrix, said Fox, is a fundamental question: Does it work?

“Hospitals have always generally been conservative organizations,” Fox said. Risk-taking with patient outcomes is not an option, so a CIO who proposes something radically new takes on the risk if anything goes wrong. It’s a common discussion in a healthcare environment, whether it be IT, housekeeping, security, or facilities management – who is best equipped to manage, the hospital or an outsourced provider with subject-matter expertise and economies of scale? “That can create a value proposition in my mind for moving these services out of the hospital,” Fox said.

Another issue is the ownership of the system, Fox said. Public sector contracts have to demonstrate the best value for taxpayers. In an open, competitive bidding market, it’s rare for a contract to last more than five years, Fox said. What happens to the data and applications and systems if a contract changes hands? That’s a big deal, said Fox, and it adds another element of risk.

The Internet of Things: The benefits don’t stop there, for the individual healthcare provider or the industry as a whole, said Cisco’s Fox. “I think in the healthcare sector we want to make sure that healthcare continues to partner with industry to create the best outcome for patient care.

Industry has got fantastic innovation and inventions that have been created by significant investment in R&D, and working with other hospitals. Let’s say we create a solution with Hospital A. Hospitals B through Z should also benefit from any of the discoveries or developments that we’ve created.”

Hospitals also must recognize the sea change coming with new connected devices and networking technologies, Fox said. “The Internet of Healthcare Things is really going to become more pervasive as time goes on.”

Startups and established companies are developing devices, therapeutics, wearables and sensors that can connect the patient to the cloud. That data flows into an analytics engine that can create workflow designs that optimize the care hospitals provide.

All this data traffic will create a need for better connectivity and scalable processing. How big does an IT department have to get to cope? Given the explosion of patient information systems, is a hospital the right environment to manage it? Doesn’t partnering with private sector providers make more sense?

Those analytics are on the radar for LHSC and St. Joseph’s. In addition to short-term goals of improving user experience, disaster recovery and cost avoidance, the hospitals are positioning themselves to leverage advanced analytics and mobile functionality as a more long-term goal, said Kearns. By pooling anonymized data with other health organizations, analytics can drive better clinical outcomes. And there’s a major move to drive information into clinicians’ hands wherever they are through whatever device they have.

“We have to integrate that into our strategy at every opportunity, and this was a thoughtful way to build it right into our infrastructure potential to move down that path,” said Schned.

Analytics ties directly to the mobile movement. “We do have a vision as an organization to be able to provide real-time information and solutions at the bedside, at the point-of-care, that allow our providers to be predictive and proactive in terms of managing the health of our patients,” said Kearns.

For that to work, patient data has to be consistent and completely electronic. While in the U.S., where healthcare organizations are much larger, there’s a critical mass large enough to support that. By contrast, Canada’s smaller healthcare organizations need to pool data on a consistent platform, Kearns said.

Standardization: At virtualization technology vendor VMware Canada, health industry leader Dave Pattenden sees a trend toward common platforms that could be better served with cloud computing.

“In terms of the benefits of cloud, we see it helping with consolidation in terms of some of the shared services that are being created across the country,” Pattenden said. “We’re seeing regionalization out west, and we’re seeing benefits in jurisdictions like Ontario. (Cloud computing) really helps take the cost out of their operating model, and helps extend their existing applications and their new applications out to mobile devices.”

For his part, Fox said his utopian ideal is the ability to connect stakeholders in the healthcare system, whether it’s clinician-to-clinician or a telehealthcare environment, where remote patients are connected to medical care. “It’s an incredibly complex endeavour … having a commonality of service across the healthcare system would only make us more able to achieve that goal.

“Access and connecting healthcare clinicians across the system is absolutely critical, and the more accessible information is, by having computing power available from anywhere, is an enabler to that goal.”