Images & Information: Enterprise Storage Strategies

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Creating the right strategy for managing patient images and information is as unique as the data being managed. Five healthcare facilities tell why they've chosen a variety of approaches - from an enterprise approach with a storage area network and network attached storage to fixed content storage to a focus on disaster recovery and storage virtualization.

Enterprise-wide image and information storage is rapidly gaining traction in the healthcare arena. Hospitals and health networks have become data warehouses with more and larger files to be stored. Larger volume imaging studies in the radiology department such as CT and MR are driving storage needs with files up to one gigabyte, but cardiology and other 'ologies' as well as electronic health records (EHRs) and other healthcare datasets fuel storage needs, too. Many facilities cling to a departmental model with disparate silos of information running on distinct management protocols. This month, Health Imaging & IT explores the ins and outs of enterprise storage through five healthcare facilities that have tackled various aspects of the storage challenge.


The Pioneering Enterprise



Daniel Morreale, Chief Information Officer
North Bronx Healthcare Network, New York, N.Y.

North Bronx Healthcare Network (NBHN of New York City) consists of Jacobi Medical Center, North Bronx Hospital and affiliated community healthcare centers. NBHN relies on a variety of EMC Corp. storage solutions, including Centera content addressed storage (CAS), Symmetrix storage area network (SAN) and Celerra NS600 network attached storage (NAS), to comprise an enterprise model. Chief Information Officer Daniel Morreale conceived and oversaw the network's transition to an enterprise storage model.


Q: Why did you turn to the enterprise storage model? How did you approach the process? Why is enterprise storage a smart decision for healthcare facilities?

A: We approached enterprise storage almost out of desperation. Three years ago, a series of storage systems ran out of space. We had to scramble to buy storage for various systems - and financing storage on an unscheduled basis is tough. At that point, we realized an enterprise solution could better meet our needs.

We really did not know what we needed, so we hired a consultant to complete a storage assessment and provide guidance and education. It was no surprise that we needed everything - a SAN, NAS and an archive as well management.

Enterprise storage is proactive rather than reactive and simplifies management.

Q: How have your storage needs evolved over the last few years?

A: NBHN successfully built and deployed an EMR with imaging, and we store all transactions online. Consequently, our storage needs have increased logarithmically. The EMR consumed one terabyte of storage in its first seven years; in the last three years, storage needs for the EMR have doubled. In addition, NBHN is filmless, and we are seeing very rapid growth in image storage needs.

When we decided to consider an enterprise approach, we wanted to create an environment with a growth path. We knew our needs would continue to grow as we add functionality to the EMR. Cardiac cath is another major storage consumer with cath studies measuring up to one gigabyte. Other radiology devices, such as multislice CT scanners, need significant storage space. Finally, initiatives such as a teledermatology program will impact storage. After looking at all of these factors, we decided we wanted to deploy a model that could provide three to five years of storage.

Q: How have storage options changed in recent years? Have these impacted your approach?

A: Lifecycle data management - migrating data to less expensive storage models as it ages - is key. Our consultant revealed that 85 percent of the data we store is stagnant; it's not used after it's created, thus it does not require an expensive SAN.

We also wanted to get out of the tape back-up business. The odds of successfully restoring a clinical system from tape seem slim. Plus, it's a 30-year-old technology that can be replaced with tapeless solutions.

Q: What challenges have you faced in the enterprise storage arena? How have you overcome these?

A: We expected that back-up to disk would be a seamless process, however, it does require daily oversight. The IT staff is working to automate the process more.

Another challenge has been implementing lifecycle data management on clinical systems. We have not been able to move clinical systems to the lifecycle model because application software prevents it. The software needs to be updated to create synergy. We are encouraging vendors to move forward. It is a slow process, but eventually we will fully deploy the lifecycle model.

Q: How do you see your needs changing in the next three years? How are you preparing?

A: Staff is a primary need. When we installed the enterprise solution, we did not replace any staff that left. Currently, one FTE manages 180 terabytes of data. This is a somewhat precarious position, and we need a secondary back-up person. The skillset is critical. When you acquire advanced technology, you need to find a way to acquire the skillset to manage the technology in-house.

Another critical need to designing the system is acquiring high availability and high functionality.
    
Q: What advice can you offer for facilities considering an enterprise storage approach?

A: Enterprise storage does reduce costs, and it is effective and proactive. But it is best to move slowly and build a model that blends with your corporate culture. Design the model for long-term improvement, but implement it with short-term goals and steps. Choose the applications that fit best for initial conversion.



Moving Toward an Enterprise Approach


Mark Watson, IT Director, and Rick Bellott, Network Engineer
Susquehanna Health System, Williamsport, Pa.

Susquehanna Health System in Williamsport, Pa., is a 450-bed facility that sees storage, specifically access to relevant patient information, as a key component of its ability to provide high-quality, compassionate and cost-effective patient care. The system currently relies on Hewlett-Packard Xeon ProLiant servers, HP StorageWorks MSA 1000 and an HP tape library. The hospital is evaluating HP's BladeServer technology as an enterprise storage solution. Mark Watson is IT director, and Rick Bellott is network engineer.


Q: Why are you considering the enterprise storage model? Why is enterprise storage a smart decision for healthcare facilities?

A: Susquehanna Health System is evaluating the enterprise storage model. We currently rely on a network of 120 HP servers and NAS and SAN solutions. The storage footprint has become a challenge. We house two data centers that are busting at the seams. BladeServer technology offers size benefits. Forty-eight servers can fit in an area currently occupied by 20 servers. In addition to saving space, the technology may offer cost benefits. HP provides rapid deployment software and server management, so it takes less time to bring servers online. We're exploring the possibility of sharing storage among servers and applications, which could allow us to adjust storage on the fly without a major reorganization of servers.

Q: How have your storage needs evolved over the last few years?

A: Our first-generation storage solution placed all applications on a main frame with external storage. Next, the hospital migrated to the client server approach with separate, distributed servers and storage for each application. Client server architecture changed the way servers are deployed. We transitioned into a three-tiered storage system with more servers. Currently, we employ a combination approach with individual servers, external storage, SAN and NAS technology.

Q: How have storage options changed in recent years? Have these impacted your approach to storage?

A: Susquehanna Health System is an early adopter vs. a leading edge implementer of new technology. SAN technology has progressed to the mature point, where it is affordable, usable and ready for prime time.

Q: What challenges have you faced in the enterprise storage arena? How have you overcome these?

A: Managing the entire enterprise is a challenge. We need to analyze disk space and utilization and determine which servers need more space. We've faced some back up growing pains, too.

Q: How do you see your needs changing in the next three years? How are you preparing?

A: If BladeServer technology does not meet our needs, we expect to go back to the drawing board and assess the market from a cost and technology perspective and implement a semi-enterprise SAN large enough to handle medium-term needs.

Q: What advice can you offer for facilities considering an enterprise storage approach?

A: As you design the server environment, try to integrate as many as possible into the SAN. A SAN, rather than a distributed approach, provides true benefits in terms of resource allocation and management and cost efficiencies.



The Fixed Content Approach


Jorge M. Labrada
Radiology Information Systems Administrator
Mercy Hospital, Miami, Fla.

Mercy Hospital in Miami is a 500-bed acute care hospital with an imaging volume of 200,000 diagnostic studies annually. With imaging representing the lion's share of storage consumption, the hospital opted to implement the HP+Bycast Solution, which delivers enterprise storage for fixed content such as images, audio-video files and lab reports. The solution provides a fixed-content repository for radiology and cardiology PACS and a referring physician portal. Transactional data such as HIS/RIS databases are stored separately on a high-performance SAN. Jorge M. Labrada is radiology information systems administrator.


Q: How have your storage needs evolved over the last few years?

A: Our previous storage model consisted of an AIT tape jukebox with a disaster recovery copy sent offsite for storage. Seek and retrieve could take three to five minutes depending on image location. If a tape was lost or damaged, it could take three to six hours to restore the data.

Initially, the hospital required 1.5 terabytes of storage for three digital modalities - CT, nuclear medicine and ultrasound. The next phase entails employing Bycast for fixed radiology images, nuclear cardiology and echocardiography; and we plan to be 100 percent digital in 2006. With the addition of new modalities, our storage output will increase to three to five terabytes.

Q: What challenges have you faced in the enterprise storage arena? How have you overcome these?

A: One of the challenges we faced was converting from an obsolete, legacy PACS vendor to a new vendor with historical data held in a central repository. We turned to software vendors to develop programs to convert data to a format that could be retrieved in other systems, and thus ensure business continuity.

Q: How do you see your needs changing in the next three years? What factors influence these changes? How are you preparing?

A: Mercy Hospital plans to open new outpatient imaging centers, and physicians will need to access information across the enterprise. It will help if data are stored in a central location.

In addition, the hospital recently joined the Catholic Health East hospital system. The 31-hospital system is trying to centralize storage and may rely on our Bycast solution as a model for the entire system.



Meeting the Disaster Recovery Challenge


Micha Ronen, PACS Administrator,
Medical Imaging Services, Sun Health
Boswell Memorial Hospital, Sun City, Ariz.

Disaster recovery is a critical factor in the storage process. Most hospitals implement a single system and use off-site storage or DVD, but recovery can take hours to weeks.

Sun Health is a non-profit, community-owned network of healthcare services that operates the 343-bed Boswell Memorial Hospital and the 297-bed Del E. Webb Memorial Hospital in Arizona. The system is implementing the NetApp solution for disaster recovery; high availability deployment helps them comply with disaster recovery requirements. NetApp guarantees one hour recovery with no lost data. Micha Ronen is the chief architect.



Q: Can you provide an overview of your approach to disaster recovery? Why did you turn to the complete recovery model? How did you approach the process? Why is this a smart decision for healthcare facilities?

A: Sun Health operates two hospitals located about seven miles apart. Total imaging volume stands at 300,000 studies per year. When we implemented PACS, we opted for a complete disaster recovery solution rather than a high-availability alternative. The rationale was simple - if PACS manages the entire imaging department and it goes down, the hospital is out of business. If the disaster recovery solution takes one or more days, how does the hospital operate in the interim? Instead of conventional disaster recovery, Sun Health is implementing a NetApp system in each facility. The sites serve as each other's disaster recovery; if one site goes down, the other will take over.

Q: How have your storage needs evolved over the last few years?

A: Our storage needs continue to increase. Eighteen months ago, we calculated we would need 17 terabytes to hold 300,000 exams. When we add 64-slice CT later this year, we will need additional storage. There are demographic factors as well. Over the last three years, imaging utilization has increased 18 percent annually. That may be higher this year, which impacts our storage requirements.

Q: How have storage options changed in recent years? Have these impacted your approach to storage?

A: We purchased just half of the 17 terabytes when we purchased NetApp [technology]. That was a wise decision as price has dropped and performance has increased. For example, we'll replace 72 gigabyte drives with 300 gigabyte drives that are as fast as the 72 gigabyte drives. Not only are we buying more storage for less money, but upgrades are financed through the operational budget rather than as a capital expenditure, which is an advantage from the accounting standpoint.

Finally, equipment is smaller, so it consumes less hospital real estate.

Q: What challenges have you faced in the enterprise storage arena? How have you overcome these?

A: No matter when you hop on this train, there is always a faster train coming. But your vendors may not be ready for the next train. For example, I would have installed iScuzzy (Internet Small Computer System Interface) devices [to interface with servers] instead of fiber-channel, but our PACS vendor was not ready to interface with iScuzzy.
    
Q: How do you see your needs changing in the next three years? What factors influence these changes? How are you preparing?

A: Seventeen terabytes should last two years. During that time, the IS department will decide if it is going to implement enterprise storage for all other healthcare data. If that is the case, we will push images older than two years to that system. If not, we'll add a jukebox for images older than two years.

Also, we're evaluating the feasibility and benefits of adding echocardiography studies into NetApp. This is the preferred solution from the enterprise point of view, but there are some interface challenges. Five echo vendors claim they can interface with NetApp, but it is not a seamless, off-the-shelf, plug-and-play interface. Finally, in the next three years PACS will encompass other images such as ophthalmology photos and echocardiography results.



Choosing Storage Virtualization


William J. Roe, Manager of Server Services
Scott & White Memorial Hospital, Temple, Texas

Scott & White Memorial Hospital in Temple, Texas, manages more than 50 terabytes of disk storage across a mixed storage and server infrastructure of IBM and HP to support both its main hospital and 15 regional clinics. Scott & White has two IBM SAN Volume Controllers, helping the organization migrate storage from disk to disk without interruption and deliver seamless storage support. The hospital is evaluating IBM SAN File Systems as a solution to add flexibility to its existing file system. William J. Roe is manager of server services.

Q: Why did you turn to the enterprise storage model? Why is enterprise storage a smart decision for healthcare facilities?

A: A few years ago, we realized we would be hit with space, cooling and power limitations. We decided to decrease our storage footprint with IBM's virtualization solution. In addition to replacing the rack and stack model, this allows us to increase performance with tight integration among storage, servers and software.

We have a lot of direct-attached storage; about 40 to 50 percent of our total storage resides on direct-attached solutions. These are primarily Intel applications. In the UNIX arena, we have migrated to a storage area network (SAN) configuration.

We want to avoid the departmental silo approach. Managing from project to project is very inefficient for server management. A centralized storage structure is more efficient and gives us flexibility to move quickly for server and application upgrades.
    
Q: How do you approach enterprise storage decisions?

A: A long-term plan can help steer you toward the right decisions. A fair amount of policy comes into play in storage decision. You must determine the importance of a given application and whether or not it warrants the cost of a SAN implementation.

We rely on a three-year strategy that addresses storage needs and budget requirements; we look at the server inventory and new and sunsetting applications and build our budget strategy around applications to be deployed and technology refreshes. We will follow this strategy as we migrate Windows, NetWare and LINUX based applications onto the SAN.

Similarly, when the hospital's cardiology department implemented a new application with expandable, attached storage, we moved ahead with network-attached storage (NAS). This will allow us to avoid a migration down the road, and as other applications come online we can add to the NAS.

It's very important to have the storage vendor in the planning session to help in the overall strategic plan and the migration of data. With appropriate preparation, we have migrated applications with very little downtime.

Q: What challenges have you faced in the enterprise storage arena? How have you overcome these?

A: We've needed to work with some smaller, niche vendors to address the fear factor associated with unfamiliar hardware (virtualization of storage and servers.) Frequently smaller vendors have preconceived ideas of what the environment should be or propose an inflexible turn-key solution

Q: How will your needs change in the next three years? How are you preparing?

A: We need to try to control the growth of some systems. Large volumes pose archive challenges for some applications. The hospital is considering information lifecycle management as part of an overall solution. We have the space and types of storage media to implement a tiered storage strategy. We will continue to need to evaluate what needs to be moved to the SAN to simplify storage management and increase performance.