A healthy outlook? - The downside to information-based healthcare
A healthy outlook? - The downside to information-based healthcare
Slow but steady movement towards shared electronic health care records is forcing healthcare providers to get their data management acts together. As David Braue reports, many health organisations are finding the going harder than they thought.
It's never easy to know how much storage is enough for a new application, but even the imaging experts at the Hunter Health Imaging Service (HHIS) were taken aback when their new medical imaging system quickly expanded to fill the two terabytes of disk space they had installed.
HHIS, a business unit of NSW's Hunter New England Area Health Service, serves a population of 840,000 people and processes over 175,000 digital radiology, ultrasound, MRI, angiography, nuclear medicine and CT scans annually. After an initial 2TB EMC Clariion disk array quickly filled up, HHIS recently added 4TB of StorageTek D280 disk storage.
The organisation has just added another 6TB of disk and will add a further 4TB by the end of the year, providing what it hopes will be enough headroom for growth-although the pending opening of new sites, such as a new Bone & Joint Building currently under construction at John Hunter Hospital in New Lambton, is likely to keep the pressure on. HHIS is also about to add a 34TB Kodak Long Term Storage EIM (Enterprise Information Management) system, including a StorageTek STK DTL-180 library, that will complement the existing StorageTek L-700 Tape Library to provide long-term archiving of critical health records.
Digital PACS (picture archiving and communications system) systems have revolutionised the delivery of healthcare delivery by providing immediate turnaround of high-quality medical imaging that can be accessed from a variety of locations. For HHIS, this flexibility has slashed radiology reporting time from nearly two weeks using film-based imaging, to just two days.
However, such benefits come at a price: with many images several megabytes in size and a single scan generating hundreds of images, information managers are climbing steep storage growth curves that have put the squeeze on enterprise backup and information management processes.
"It has caught us by surprise how quickly demand for the system has grown, and how quickly we've outgrown those initial storage requirements," says Joanne Horst, acting manager for operational support systems with HHIS, who estimates that the organisation's storage requirements will double by the end of 2006.
Information archipelago
Linking a broad range of patient records, which is critical to providing a single comprehensive view of a patient's medical history, has long been a goal of healthcare authorities convinced that easier access to a unified patient record will improve healthcare providers' access to critical information in a more timely fashion. However, attempts to bring order to patient records have proven even more complex as digital diagnostics join the continuing glut of paper-based patient records and blow out storage requirements by several orders of magnitude.
The sheer scale of the healthcare industry makes information consistency a real and ongoing problem throughout the sector, particularly since multiple healthcare providers typically have their own records of individual encounters with patients. Duplication of information is rife, and there is little quality control or consistency checking to eliminate inefficiency.
NSW Health, for one, estimates that its various healthcare organisations are managing more than 300 TB of data alone-and most of that is stuck in information silos spread across the state. GPs and other third parties would add even more to this amount, as do separate databases such as the maternal and neonatal system ObstetriX-a joint venture of Microsoft, Meridian Health Informatics and the NSW Health OBSTET Consortium that contains information about half of all babies born in NSW.
In another recent example, Melbourne's Peter MacCallum Cancer Centre recently worked with Global Health to launch a regional database consolidating information about familial breast cancer. Information in databases such as these may benefit small groups of researchers and clinicians, but lack of integration with patients' other healthcare records compromises the ability for clinicians to get a complete electronic view of a patient's history. Patients are often represented multiple times in different providers' databases, creating a nightmare of data inconsistency that has been compounded by the recent mergers among NSW health authorities.
Before healthcare providers can even hope to bridge these islands of information, they face major challenges in physically managing all the information they are creating. However, just managing the explosion of email and general administrative traffic has proven time-consuming enough, points out Simon Richardson, infrastructure services manager with Mercy Health & Aged Care, a Catholic community benefit organisation founded by the Sisters of Mercy to provide health, aged care and community services.
There, relatively predictable growth in patient treatment numbers has facilitated planning for growth in the 1.5TB of data in Mercy's patient information system. However, growth in unstructured data-Word documents and emails, in particular-has forced the organisation to replace its local server storage every 18 months. One site, Richardson says, took seven years to accumulate its first 15GB of data and had grown to 100GB six months later - despite Mercy's extensive use of content filters.
The growth has been so significant that Mercy is now in the process of reviewing its entire storage infrastructure to develop a more coherent archiving strategy for the future.
"In the last two years, we've noticed unprecedented growth in data and have started looking deeply into what sort of data has been stored," says Richardson. "There are a lot of duplicates, a lot of stuff that is extremely old, and stuff that hasn't been touched in years. There was no real strategy around how we archive it, how we need to keep it, and how important the information is. Everything was treated exactly the same."
Beginning in August, the healthcare organisation will start a process of consolidation that will see the use of server virtualisation to combine 54 current servers onto around 10 physical machines. An ongoing effort will see Mercy lay down clear policies on management and archiving of common information types, in an effort to rein in control of the organisation's data explosion and implement long-term ILM policies.
Real-time healthcare
For storage administrators, the confluence of exploding storage consumption and stricter requirements for patient record access has created an information train wreck in the making.
The need to get a better handle on all this information has made information lifecycle management (ILM)-that information-aging paradigm spruiked to private-sector companies by vendors casually throwing around words like 'governance' and 'compliance'-an essential capability for a healthcare sector that is still far from ready to embrace it.
Vendors are shouldering some of the responsibility for the beast their PACS systems have created. Kodak Health Imaging Group, for one, has supplemented its space-devouring imaging system with the ILM capabilities of its EIM application. As well as supporting conventional document files, EIM extends ILM policies to images. For example, a storage administrator can set the system to automatically recompress images to a much smaller size once a set period of time has passed and uncompressed images are unlikely to be needed.
ILM will be essential for individual healthcare organisations to support overreaching initiatives for providing electronic patient records. Slow but gradual progress towards unified healthcare record access, is pressuring healthcare providers to find a way to get patient data, organise it in a meaningful and consistent way, and keep it for longer than ever before.
No longer can out-of-date files be stored in a low-rent district and burned after the statute of limitations has run out; today's information-driven healthcare providers expect information immediately, no matter how old it may be. If unified electronic healthcare records become widespread, by extension it will be necessary to provide rapid online access to any supporting documents for those records. That means healthcare authorities will need to maintain massive historical archives of both data and image records on near-line storage that's readily available when needed.
Michael Hopmere, ANZ professional services manager with Kodak Health Group, has already seen the increase in demand for online healthcare information."We have gone from having small RAIDs [disk arrays] and large tape libraries [for backup] to having very large RAID and very small tape libraries," Hopmere says. "Waiting 24 hours for a film bag to arrive used to be acceptable, but now clinicians expect a sub-five second response time. That very much reflects the need for ILM."
Approaches to making this happen have varied considerably. In NSW, the Health Information Exchange has provided a common target for exchange of healthcare information, while the federal government's XML-driven HealthConnect project-which recently marked the successful completion of its pilot program-takes a different approach by building on the openEHR electronic health record standard to produce a record designed for portability between health authorities at different levels.
There are so many ways of looking at the electronic health record, and so many types of information to represent, that the Australian Institute of Health and Welfare recently launched its National Health Data Dictionary (http://meteor.aihw.gov.au), which contains thousands of healthcare-related metadata standards in an effort to bring consistency to discussions about representation of clinical information in electronic health records.
Slowly, slowly,
Whatever electronic records system is ultimately adopted, back-end processes will need to ensure timely access to a broad range of supporting diagnostics and other patient information. Recognising the changes that they must accommodate, and their more pressing risk of simply drowning in data, many hospitals are completely revisiting their plans for coping with storage growth. NSW Health, with its massive and distributed array data, will soon begin a governance and policy review of its Information Management Strategy in an effort to improve consistency and accessibility of healthcare information.
Change must be carefully managed though. At Melbourne Health, the eagerness of health executives to ditch paper-based patient results in favour of an electronic system drove Mary Wollmering, CIO of Melbourne Health Shared IT&T Services, to put on the brakes and create a dedicated Storage Archiving Committee (SAC) that is committed to exploring the implications of increasingly electronic healthcare information.
"You can't just [jump into electronic records]," says Wollmering. "You have to think about the cascading part of archiving, how frequently you have to retrieve information, and so on. I don't want my backup windows to creep into days as I have to back up more and more data. And that information has to be easily read wherever it goes, so it's absolutely essential that formats [such as HL7] are followed, that they're addressed centrally, and that everybody follows them."
The SAC, which is driven by heads of department as well as research centres and clinical users, was formed earlier this year and is meeting regularly to ensure that future healthcare information systems are rolled out in a methodical and accessible way. By putting responsibility in the hands of the business heads, Wollmering hopes the effort will position Melbourne Health to better cope with future systems rollouts and the demands of electronic patient records initiatives.
Even for a minute assuming that politicians can get past nagging privacy concerns and legislate for a unified electronic health record, can the healthcare community deliver and use it in a meaningful way? Greg King, marketing and communications director with healthcare systems supplier IBA Health, thinks so-eventually.
The key, he believes, is for health informaticians to remember that the healthcare system is a massive and complex supply chain-and that information management needs to be tightly wound around every link.
"The majority of effort has always been focused around the four walls of the hospital, but I'm not sure that's the right place," says King, who believes throwing millions at hospital IT staff to fix the problem is far from a complete solution. "The right place to start with is where healthcare starts, and that's out in primary healthcare with the GP. If we can develop the systems that enable health professionals to share the care, that will grow and populate the electronic records."
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