Most CIOs have had to deal with rogue business units - parts of the organisation that, for one reason or another, can stave off any attempt to modernise, standardise or stabilise its idiosyncratic IT systems, but still need solid data connections to the parent company.
Hospital CIOs have to deal with hundreds of those units every day - connecting doctors' offices that are fiercely independent, too small to hire IT specialists, and are unlikely to put IT upgrades high on the priority list.
Beth Israel Deaconess (BID) Medical Center, a teaching hospital of the Havard Medical School in the US started solving that problem two years ago - long before the American Recovery and Reinvestment Act (ARRA) promised the industry $19 billion to pay for a large scale migration to electronic health records.
Trying to match pay-for-performance plans that require much more detailed and realtime documentation than the hospital's existing systems, BID rolled out an electronic health records and practice management system to the 175 or so practices it owns directly.
That covered 300 of its core physician network, but not the 900 that work out of more than 300 practices affiliated with BID, but which are owned and operated independently. The largest employs 14 doctors and about 60 staff.
"Most of them are basically work 10 hours a day, see 40 patients a day and don't have time to load the latest Microsoft patch or deal with a corruption with MySQL, let alone build a new system," Gillis says.
"They can't afford a lot of IT and, really, they're not that interested in it," Gillis says. "But you can't have electronic health record systems (EHR) without a practice-management system and a billing system and most of these offices are small enough that they get along without one."
EHR is a requirement for membership in the Beth Israel Deaconness Physicians Organisation - the internal group that provides administrative, clinical and technical support for doctors' offices.
EHS is also a requirement if practices are going to apply for the $40,000 per physician that's available to fund the systems, let alone whatever pay-for-performance, documentation, automation and other requirements come out of any federal healthcare reform bill.
EHR is more than just a way to make it easier to ship medical records from one office to another, according to Leo Carpio, vice president for the Health Care IT & Services practice of equity research firm Caris & Co.
Medical practices have to hire several times the number of employees they normally would, just to handle the paperwork required for them to be paid by either Medicaid or private insurance companies, Carpio says.
Not being able to connect specific electronic records to billing statements and invoicing systems holds the whole industry back by slowing the flow of payments for services through administrative friction, not one related to either the quality or type of care, or regulation of the industry, he says. EHR is not a panacea. "I'm really concerned when I hear people talking about EHR as a way to rescue healthcare," according to Carl Labbadia, director of Information Systems at Grove Hill Medical Center in central Connecticut.
"IT can do a lot of good for patients and a lot for administration," he says. "People may be putting too much reliance on it, though.
Building the system ahead of time and hoping the affiliates would sign up was a multimillion-dollar risk in an industry with a history of rejecting IT that doesn't suit its needs.
Because they're independent, BID had to build a system that would work with even less effort and cost than the one it build for the internally owned practices, and demonstrate that it worked before any of the affiliates would sign up.
"We could have gone with a classic environment - server clusters and building arrays for storage; the problem was that we'd have to build it for the largest load we'd ever need and we had no guarantee anyone would use it," Gillis says.
The software is a set of EHR and practice-management applications from eClinicalWorks, which licensed the software to BID, but also provides it as a hosted service.
Physician offices access the cloud using a normal PC with a thin-client connector that provides encryption, authentication and connectivity to the cloud. "They get a new appliance that front-ends this whole thing for us and can light up a practice with no hardware except what's talking to the virtual desktops," Gillis says. "There's still a client on the device, so it's not fully a Web app. But you can get directly to the EHR without messing around with a terminal-services app."
The cloud infrastructure is a set of VMware ESX servers running on half a dozen Hewlett-Packard servers - a number that can change with relatively little effort.
Making adjustments to virtual servers rather than physical saved BID $300,000 late in the project, when eClinicalWorks added more muscle to its SSL encryption and put an unacceptable strain on the existing servers. Gillis spent about $20,000 on hardware upgrades and additional VMware licenses, rather than the $325,000 he would have had to spend for new servers in a purely physical server cluster.
It also makes capacity planning a lot easier because it's possible to swap out servers or storage or increase capacity to match seasonal spikes without, essentially, even telling the applications it's happening, he says.
Because of the need for security, privacy, access to data in exam rooms and support for increasingly technical medical-support systems, healthcare has been in the forefront of virtualization for years, according to Jack Santos, executive strategist for consultancy The Burton Group, a former CIO for two hospitals and senior IT executive for insurers and other healthcare companies.
"Hospitals automated the backoffice years ago, but then they kind of slowed up," Santos says. "They're way behind the curve in automation at the healthcare level. Running EHR on virtual servers is good if there's an access issue, but it's not a leading-edge kind of thing. You can do most of that with Citrix, and you can hardly walk into a practice that doesn't have a Wyse or other kind of terminal and has everything remoted to it."