Business Cloud News
Chad Skidmore, director of network services at INHS

Chad Skidmore, director of network services at INHS

Across the United States, thanks in part to healthcare IT reform initiatives introduced under President Obama, healthcare organisations have flocked to adopt electronic health record (EHR) systems, integrating them into larger existing systems in order to improve patient care. Chad Skidmore, director at Inland Northwest Health Services (INHS), a healthcare-focused IT service provider, says increased uptake of EHR is also encouraging a broader shift to cloud services. But big legacy integration challenges remain and service providers and medical facilities will have to conquer them before the benefits of cloud can be fully realised.

Founded in 1994, INHS is a nonprofit corporation based in Spokane, Washington that delivers cloud-based healthcare services to about 40 hospitals and 750 physicians in the Pacific Northwest and beyond.

The company provides a comprehensive suite of services that cover the full spectrum of healthcare operations – hospital operations, admission of patients, pharmacy orders, lab services and patient clinical information handling, all delivered on Meditech, a cloud platform it hosts on heavily-virtualised IBM infrastructure.

“We’ve been long-time users of virtualisation for the compute side as well as storage,” Skidmore tells Business Cloud News. “We’ve been able to grow for a number of years without increasing datacentre space simply because of consolidation into a smaller footprint, both in terms of power, heat output and floorspace. From a raw systems perspective we don’t really see any big challenges anymore; we can leverage economies of scale and we worked closely with VMware to virtualise our infrastructure early on.”

Skidmore says demand for cloud-based EHR has increased over the past few years, particularly as the US federal government is in the process of implementing a number of healthcare modernisation initiatives. The Health Information Technology for Economic and Clinical Health (HITECH) Act, which was enacted as part of the 2009 stimulus package introduced by President Obama allocated roughly $26bn to promote and expend the adoption of health information technology.

But any patient-centric technology introduced into the US healthcare system is also subject to the Health Insurance Portability and Accountability (HIPAA) Act. Among other things the Act sets out policies, procedures and guidelines for maintaining the privacy and security of patient information, which is very important given the complex relationship between healthcare IT service providers, insurers and hospitals.

“These initiatives and policies are really driving what we’re seeing, which is an increased shift to cloud-delivered solutions,” Skidmore says, adding that the US regulatory environment can enable as well as prevent healthcare organisations from leveraging cloud-based solutions. “Some of the federal reimbursement models for smaller facilities allow them to be reimbursed for capital expenses but not operational expenses, which is a key challenge to overcome” given the nature of cloud-based solutions, he says.

Nevertheless, according to the US Office of the National Coordinator For Health Information Technology, adoption of EHR is on the rise – and has risen significantly since 2009. Between 2008 and 2009 adoption increased just 2.8 per cent among US hospitals. But between 2009 and 2012 adoption grew 61 per cent. 85 per cent of hospitals offering acute care now have at least basic EHR systems; close to one in five use more comprehensive systems like those on offer from INHS and Meditech, a six-fold increase in the past three years.

Skidmore says that the past 20 years has seen the healthcare IT service industry change significantly as more of these services become delivered via the cloud.  “As we’ve progressed and evolved our infrastructure we’ve moved from operating like an outsourced IT department for these hospitals and practices to architecting and engineering our systems to look a lot more like a service provider,” he says.

He continues: “EHR adoption is definitely leading to increased cloud adoption and confidence in those kinds of services but there are still key challenges to overcome,” Skidmore says.

“In the early days, most of the vendors were resistant to virtualisation. They thought it was some kind of black magic. And that created a situation where the early adopters in the healthcare space didn’t know how to architect and engineer a good virtualisation environment to deliver high performance, and so they had many bad experiences that set the tone for years.”

The other challenge is legacy. Many hospitals, medical facilities, and even the service providers catering to those in the US and internationally use legacy technologies like Mumps-derivative databases (which is both a language and a NoSQL database; Cache is actually a derivative technology), which has been around since the 1970s. The problem is that the explosion in patient data – whether discreet elements like heart rate and blood pressure or larger files like medical images and EKG strips – is creating integration challenges that Skidmore says will likely get worse as these technologies interface with increasingly modern architectures. Mumps databases simply don’t scale as well as more modern NoSQL database technologies, which is a huge challenge when I/O demands are high.

“The problem really becomes: How do we apply a modern infrastructure stack to these really old software problems that by and large scale vertically, not horizontally, or have very different demands on the manufacturer to configure the supporting storage system in a particular way? Or have very high disk I/O?” Skidmore says.

“A lot of our challenges revolve around disk I/O and follow that problem all the way up to the software. By today’s standards it’s generally poor and therefore demands more out of the storage infrastructure than a comparable piece of software – say, enterprise resource planning. We need to support disk storage in a manner that cloud isn’t today – a lot of cloud disk I/O is relatively slow by comparison with modern high speed SAN, but our modern applications demand modern high speed SAN,” he says.

“There’s a massive opportunity to get in and improve this,” he concludes.