Storage gets a dose of medical data

By 2014, healthcare providers will be required to make every patient's medical information available electronically. While having all of a patient's data in one place will make it easier to diagnose and treat them, many medical IT departments don't have the IT infrastructure, storage and network bandwidth to accommodate these records.

The storage capacity needed for electronic medical records could be big ... real big.

"WITHIN 10 YEARS, every American must have a personal electronic medical record," said President George W. Bush in his State of the Union address on January 20, 2004. With that declaration, the federal government, led by Medicare and Medicaid, began the charge to electronic medical records (EMRs). The impact of EMR on IT, particularly storage, could be huge ... or not, depending on whom you ask.

"I don't think people are making special IT plans," says John Lightfoot, CTO at EMR technology vendor Orion Health Inc. "EMR requires about 2MB of data per patient on average. For 1 million patients, you're talking about 2TB of storage." At that rate, a neighborhood clinic could buy two 1TB disk drives at its local office-supply store, connect them to the server via the USB port for approximately $500 and support more patients than it would ever handle.

But other observers say EMR's impact on IT will be huge. "We are on the verge of a crisis," says Barry Runyon, research VP at Gartner Inc.'s healthcare provider practice in Tucson, AZ. He expects the healthcare industry to get hit by a data tsunami that many medical IT departments won't see coming. Many healthcare providers are a long way from having the IT infrastructure, storage and network bandwidth to accommodate the widespread use of EMR, says Runyon.

Complicating the problem is a considerable amount of confusion in the healthcare industry as to how encompassing a patient's EMR should be, what data it should include and how the EMR is designed. (A patient's healthcare record falls under the privacy protections specified by HIPAA.)

For example, should an EMR simply be a patient's clinical data record--the electronic equivalent of the paper chart that hangs at the foot of a hospital bed--or should it include every X-ray, CAT scan, EKG, diagnostic image and medical test? What about explanatory notes, documentation and copies of all emails? How about a DNA profile? Until questions like these are resolved, there's no telling how big an individual's EMR will be (2MB, 80MB or larger), and how much storage and IT resources will be required (see "How big can an EMR become?" below).

How big can an EMR become?
  • Less than 1MB for a relatively healthy adult patient

  • 1MB per page for scanned, paper-based data in TIFF format

  • 40MB without images for a patient with major medical issues

  • Approximately 300MB per image if picture archiving and communication system (PACS) images are included

  • 3GB minimum (no annotations) per patient if genome data is included

Some healthcare storage managers aren't waiting to find out. "We've had a fully implemented EMR for over a year," says David Whiles, director of information systems at Midland Memorial Hospital in Texas. But Whiles is a distinct minority. "Of the bigger hospitals, maybe 15% to 20% have an EMR," estimates Runyon.

Better patient care
There's little debate that over time an EMR will improve a patient's care and reduce costs. The EMR "saves money in two ways: by eliminating duplication [like duplicate tests and X-rays] and by preventing errors," says Terry Jacobs, director of electronic health records and emerging initiatives at Siemens Medical Solutions in Malvern, PA. With data in one place, healthcare providers can more easily spot potential problems and make healthcare decisions based on a variety of information and input from more people. Fred Trotter, a healthcare industry IT consultant at Houston-based SynSeer Inc., says EMRs improve the quality of care.

Take something as simple as allergies: Let's say you get sick in another city and the doctor there prescribes a drug for you. Neither the doctor nor the pharmacist filling the prescription will necessarily know what you're allergic to, and you could have a serious adverse reaction to the new prescription. "Allergies are part of your EMR, and you want that information to follow you wherever you go," says Trotter.

In other words, an EMR must become ubiquitous, and the industry has a long way to go before that happens. Gartner, in its latest EMR Magic Quadrant, reports that care delivery organizations are "pursuing clinical patient record (CPR) systems in record numbers." Yet at this point, the research firm notes, "fewer than 10% have fully implemented a CPR system." (See "Leading EMR vendors," PDF below)

Leading EMR vendors (PDF)

Click here for the Leading EMR vendors (PDF).

EMR storage challenges
Richard Eshbach is assistant VP/CIO at Mountain States Health Alliance (MSHA), a network of 14 hospitals based in Johnson City, TN. He says converting to EMRs will be "a big challenge both technically and to the workflow of the clinical staff." His hospital network is in the midst of a $38 million EMR initiative (see "Hospital EMR storage preferences," below).

Hospital EMR storage preferences
  1. Most use the same networked storage they use for their primary systems

  2. Hospitals that use DAS are moving to SANs for better backup and disaster recovery

  3. Popular SAN storage choices include EMC Corp. Symmetrix 3000/Symmetrix DMX, Hewlett-Packard Co. EVA and IBM Corp. DS4800

  4. Smaller hospitals and clinics often use storage from Dell Inc. or assorted NAS vendors

An EMR is made up of many different systems that each collect and store data. "There's no one system, no one application you can call EMR. You're talking about 150 to 200 applications" that each store data in their own way, says Jacobs at Siemens Medical Solutions. In addition, existing paper records need to be scanned into the EMR and stored as PDFs or TIFF images.

Midland Memorial Hospital uses OpenVista from Medsphere Systems Corp. for its EMR. Core patient data is stored directly and is also integrated with the hospital's other primary systems. Medical images are kept in a separate picture archiving and communication system (PACS). Midland's efficient OpenVista core EMR database uses just 80GB for its 400,000 patients and stores links to medical images residing in other systems. The core EMR is growing by approximately 10GB a year, reports the hospital's Whiles, and he has allocated about 1.5TB of the hospital's Hewlett-Packard (HP) Co. SAN storage to the EMR.

A bigger storage challenge is medical diagnostic imagining, which forms an increasingly critical part of an EMR. Healthcare providers have to figure out how to accommodate PACS data within an EMR--data that can eat up gigabytes of capacity for a single patient. "A typical PACS image runs about 300MB," says SynSeer's Trotter. And compressing those images isn't always an option, as diagnosticians need the highest resolution possible; physicians, however, will usually accept a lower resolution reference image.

At 300MB a pop, medical imaging storage adds up fast. According to the IBM Global Technology Outlook for 2005, by 2010 medical images will take up 30% of the world's storage. An EMR usually includes only links to a patient's images. "Imaging alone could require a hospital to add 1TB a year," says Gartner's Runyon.

The latest challenge is genome data. As the healthcare industry turns to genetic data to tailor specific treatments to individual patients, an EMR will need to contain an individual's personal genome data. "If a person's genome is going to be part of the treatment, then the EMR certainly has to have that data," says Vince Kuraitis, principal and founder of Better Health Technologies LLC, a Boise, ID, consulting firm.

According to the Human Genome Project (HGP), it takes 3GB to store a patient's entire genome. But there's a caveat, says HGP. This number "includes nucleotide sequence data only and does not include data annotations and other information that can be associated with sequence data ... These annotations associated with the sequence data will likely dwarf the amount of storage space actually taken up by the initial 3 billion nucleotide sequence." So, prepare to store more than 3GB of data.

"We don't include genome data, but we probably will in the future," says Bob Pappagianopoulos, corporate director, technical services and operations at Boston-based Partners HealthCare System Inc., which was founded by Massachusetts General Hospital and Brigham and Women's Hospital. Partners HealthCare System includes just about everything else in its EMR, such as links to images in multiple PACS. Its EMR contains about 40TB of data in a Cachet database stored on an EMC Corp. Symmetrix DMX.

In addition to preparing storage for EMR, the network may need an upgrade. "Many hospitals still use 100Mb/sec for the backbone," says Lightfoot at Orion Health. PACS usually gets Gigabit Ethernet (GbE), he notes, adding that 10GbE will probably become standard at large hospitals in the future.

Overcoming EMR challenges
With EMR data residing in multiple systems, one solution "is to use federated data," says Runyon. That allows a hospital to leave data where it sits and then pull required data together whenever it's needed using the Health Level 7 (HL7) protocol. Partners HealthCare System's Pappagianopoulos estimates their EMR system pulls data from as many as 200 applications.

As described by the HL7 committee, HL7 addresses the interface requirements of an entire healthcare organization by specifying a set of data exchange protocols that encompasses the requirements of installed hospital and departmental systems, some of which use mature technologies. The Continuity of Care Record (CCR) standard, based on XML, also aids data transportability and interchange, adds Shahid Shah, a healthcare IT consultant in Silver Spring, MD.

Another solution is to apply data-retention and lifecycle management practices to reduce the amount of EMR data kept online. "The healthcare industry doesn't apply retention policies in an organized way," says Gartner's Runyon. "Basically, they keep everything forever."

Partners HealthCare System, which installed its EMR system in 1998, retains data forever. "We don't purge any patient data. We periodically purge related non-patient data, such as schedules," says Pappagianopoulos. Partners has talked about a retention policy, but hasn't established the criteria.

Implementing EMR
MSHA's approach is to implement the EMR in stages; stage one was getting paper-based data into electronic form. "We started by scanning the paper during admission and after discharge into electronic form. We ended up with TIFF images, what I call a poor man's EMR," says Eshbach at MSHA. From there, the hospital can overlay notations and tags to the images. In this form, the patient's record runs less than 1MB per page.

MSHA moved rapidly beyond the first stage by incorporating its clinical data repository into the EMR. "That's the core of the EMR," says Eshbach. A dashboard was added to ensure relevant information jumped out, as well as drill-down capabilities to get more details. A clinical decision support system uses the data to suggest the next step in a patient's treatment. In subsequent stages, MSHA will integrate PACS and other systems.

Siemens Medical Solutions provides MSHA's EMR system. In 2004, MSHA acquired an EMC Symmetrix DMX for its EMR. It also uses EMC's Centera to store images and various EMC Clariion models for other data. Its total storage environment has grown to 60TB, which is backed up to tape using IBM Corp.'s Tivoli Storage Manager.

MSHA archives its patient records using the archiving tools of its radiology PACS system. Older images are migrated "from our faster, more costly EMC Symmetrix to a less-costly spinning disk [Centera]," says Eshbach. "We back up, but [we] don't archive to tape."

Fault tolerance and disaster recovery for EMRs are critical. Partners HealthCare System uses EMC's SRDF to replicate the EMR to a Symmetrix in another data center so "the data is always available," says Pappagianopoulos. The EMR is also backed up to tape and every medical department maintains a contingency plan to keep operating should EMR data ever not be available.

"This data is our highest level of criticality. We use a lot of belts and suspenders" to ensure availability, adds Pappagianopoulos.

Midland Memorial Hospital implemented an active-passive server cluster for fault tolerance using HP servers and a redundant HP SAN setup. It also deployed redundant switches on the front end of the server cluster so "there's no single point of failure," says the hospital's Whiles.

To ensure high availability, Midland Memorial Hospital maintains two data facilities approximately four miles apart and connected by a gigabit link. It backs up nightly to the second SAN and makes snapshots of core EMR components every 15 minutes; these are then sent to an offline server in case of a catastrophic failure. "We've been totally electronic for over a year," says Whiles.

By 2014, every healthcare provider will be under pressure to go completely electronic for the EMR. "EMR storage is like a smoldering virus," says Run-yon. And it's a virus IT doesn't want to let get out of control.

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