kA S E A R C H H E A L T H I T.

C O M E - B O O K
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

TIERED STORAGE
FOR HEALTH CARE
As the number of doctors and hospitals using electronic
health records and digital images grows, so will the
demands on storage. These strategies will help health
care IT professionals meet those storage needs.

Storage NHIN
Strategies STANDARDS
for Hospitals WILL EASE
Going Digital STORAGE
n BURDEN n

USING TIERED STORAGE,

SANS FOR IMAGES n

SAN Speed, Flexibility

Rule the Day n

1 Tiered Storage for Health Care A SearchHealthIT.com e-book

 k CHAPTER 1
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

STORAGE STRATEGIES
FOR GOING DIGITAL
Health care CIOs who need to upgrade or expand
Storage
Strategies for storage infrastructure have several options to consider.
Hospitals BY ELISABETH HORWITT
Going Digital

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

NHIN Standards
Will Ease
Storage Burdens

Using Tiered
Storage, Sans
for Images

SAN Speed,
Flexibility
Rule the Day
W HEN GREG JOHNSON
became chief tech-
nology officer four
years ago at the Vir-
ginia Common-
wealth University Health System,
VCUHS was, in some ways, a techno-
logical pioneer among health care
organizations. The system has used
electronic medical record (EMR)
software since the 1990s and com-
puterized physician order entry
(CPOE) software for another decade
before that, Johnson said.
Unfortunately, the organization’s
storage and backup systems were
anything but state of the art.
First, with no way to centrally man-
age the mixed bag of storage area
network (SAN)-attached, dedicated,
server-attached and network-
attached storage devices, the mem-
bers of VCHUS’ small IT staff spent
most of their time fighting fires and
“trying to get things to work together
that weren’t designed to,” Johnson
said. The setup was “wasteful, ineffi-
cient and ineffective,” he added. “We
were constantly losing data because
it wasn’t being backed up properly,
we had drive failures, you name it.
It was a disaster.”
In addition, backups were done on
two separate tape systems. Neither
worked very well, Johnson said. Data
archiving was outsourced to Iron
Mountain Inc., and it generally took
three to four days to locate and
restore requested files from tape.
The final nail in the coffin came
about two-and-a-half years ago, when
VCUHS was migrating applications

2 Tiered Storage for Health Care A SearchHealthIT.com e-book

 k STORAGE STRATEGIES FOR GOING DIGITAL
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
from the mainframe to Windows
servers. The Oracle Inc. database and
the Cerner Corp. EMR database had
to be backed up and synchronized
within the same two-hour window in
order to be reintegrated after the
transition. The restoration process
was supposed to take 25 hours. The
Storage first attempt failed at around 18
Strategies for
Hospitals hours; the second and third at 23
Going Digital hours. Upon discovering that one of
the tapes had bad media, the IT
group backed up both systems on the
NHIN Standards remaining drive, then spent an entire
Will Ease
Storage Burdens day manually synchronizing the two
databases. Total time: five days.
“Health care clinicians have zero
Using Tiered tolerance for downtime,” said John-
Storage, Sans
for Images son. “Imagine if we’d been recovering
an emergency production system.
The hospital would have been on
SAN Speed, downtime procedures for five days.
Flexibility
Rule the Day
We realized how vulnerable we were,
and started making major changes
[to the storage infrastructure].”
Many hospitals are now at the
point where VCUHS was four years
ago. The federal government is pres-
suring them to adopt electronic
health record (EHR) systems as
quickly as possible, offering mone-
tary incentives to those who can
prove the meaningful use of EHR
technology by 2015 and assessing
penalties to those who cannot. (Gen-
erally, an EHR system is set up to
share data with other systems, while
an EMR system is not.) However,
3 Tiered Storage for Health Care A SearchHealthIT.com e-book
budget-strapped hospitals are balk-
ing at the cost of such deployments,
according to Joe Flowers, a health
care analyst and futurist.
Like VCUHS’ Johnson, many IT
executives have realized that their
current storage and backup installa-
tions will need a serious upgrade, if
not a total revamp, in order to ade-
quately support the interoperability,
administrative and capacity demands
of their EMR and EHR systems.
BACK TO BASICS
VCUHS’ new storage strategy came
down to three basic elements—con-
solidation, standardization and cen-
tralization. “We realized we needed
centralized management in order to
ensure the integrity of all our sys-
tems,” Johnson said. “To accomplish
that, we needed to simplify and stan-
dardize” as much as possible on a
single vendor platform.
VCUHS replaced four legacy EMC
Corp. Clariion systems with two IBM
XIV virtual storage systems, one at
the primary site and one at the back-
up site. The XIV’s management soft-
ware works with IBM’s Tivoli Storage
Manager and SAN Volume Controller
to provide automated storage provi-
sioning and resource allocation.
Engineers no longer need to do ad-
ministrative chores such as format-
ting drives, partitioning and creating
logical unit numbers. The system is
 k STORAGE STRATEGIES FOR GOING DIGITAL
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
also extremely difficult to break,
Johnson said, because processes are
automatically reallocated across the
grid of drives when one fails.
Replacing two Clariion boxes with
a single XIV shrank the data center
floor footprint by 80%, and dropped
data center temperature by 6 degrees
Storage Fahrenheit, Johnson noted. Using
Strategies for
Hospitals SATA instead of high-end network
Going Digital drives has cut the cost of a terabyte
of data in half, he added.
In addition, IBM Virtual Tape
NHIN Standards Library replaced the old backup tape
Will Ease
Storage Burdens system as well as VCUHS’ archiving
arrangement with Iron Mountain.
“We can now restore a file in 30
Using Tiered seconds,” said Johnson.
Storage, Sans
for Images
STORAGE CHALLENGES—
SAN Speed, AND SOLUTIONS
Flexibility
Rule the Day
Unfortunately, many hospitals, par-
ticularly smaller ones, lack the inter-
nal resources to do a major upgrade
to high-end and leading-edge tech-
nology. There are ways around this
problem, however.
Johnson suggested taking advan-
tage of advanced computer-based
technologies by joining a health infor-
mation exchange, or HIE. These
groups bring together health care
organizations, generally in the same
geographic region, to share patient
information electronically, promote
continuity of care and sometimes
save costs by pooling IT resources.
4 Tiered Storage for Health Care A SearchHealthIT.com e-book
Some HIEs support configurations
in which one large health care organi-
zation hosts and administers patient
records on its EHR system, which
smaller hospitals and clinics access
remotely, usually via the Web. Mean-
while, the government’s Nationwide
Health Information Network (NHIN)
promotes the idea of having all U.S.
health care organizations share
patient records.
This brings up the question of
where the information will reside, and
who will be responsible for managing
it. Not surprisingly, major medical
organizations are leery of turning
over their patient records to another
provider, particularly a competitor.
This, in turn, raises another ques-
tion—how to track individual records
and ensure consistency across differ-
ent providers’ systems. Leading stor-
age vendors such as IBM and EMC,
and HIE software vendors such as
Axolotl Corp., Initiate Systems Inc.
and Wellogic provide middleware to
address these issues. Furthermore,
leading EMR and EHR vendors are
rallying around open source master
patient index and patient record loca-
tor software.
Hospitals in the process of revamp-
ing their storage infrastructures also
need to determine when and where
to move patient records that no
longer need to be accessed by clini-
cians in near-real time.
“Close to 80% of hospitals have a
 k STORAGE STRATEGIES FOR GOING DIGITAL
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
transactional clinical data repository
for capturing immediate patient
data,” said David Garets, executive
director of The Advisory Board Co.
Some hospitals also use the reposito-
ry for ad hoc querying, which can
lead to serious problems such as data
loss. Garets recommended installing
Storage a second tier to which data can be
Strategies for
Hospitals offloaded for ad hoc querying and
Going Digital reporting.
Another way to bring a major EMR
storage infrastructure revamp under
NHIN Standards budget is to turn it over to a Software
Will Ease
Storage Burdens as a Service (SaaS) provider. For
example, eClinicalWorks LLC and
PracticeFusion Inc. take care of stor-
Using Tiered ing and accessing records reliably
Storage, Sans
for Images and securely as part of their SaaS-
based EHR offerings.
SAN Speed,
Flexibility
Rule the Day
THE POLITICS OF STORAGE
Industry sources agree that hospital
departments can sometimes resem-
ble fiefdoms that are accustomed to
managing and purchasing their own
systems and do not appreciate inter-
ference from central IT departments.
This is particularly true of radiology
departments.
For instance, VCUHS has brought
nearly all departmental storage sys-
tems onto its SAN. Radiology
remains the holdout. As long as pic-
ture archiving and communications
systems stay isolated and propri-
etary, Johnson said, “IT administra-
5 Tiered Storage for Health Care A SearchHealthIT.com e-book
tors have limited visibility, particular-
ly when it comes to locating and
troubleshooting problems.”
Indeed, Flowers noted, hospital cli-
nicians and specialists across the
board tend to be “institutionally and
organically opposed” to the idea of
sharing “their” information with
someone outside their department
or, worse still, with another, possibly
competing hospital. They may have
valid security concerns, but quite
often it’s mainly a control issue.
Hospitals cannot afford to drag
their feet for long, experts agree. It’s
not just because noncompliance with
the Health Information Technology
for Economic and Clinical Health
(HITECH) Act will mean financial
penalties down the road. “How hospi-
tals store data is at the core of all the
changes health care will undergo dur-
ing the next few years, in order to
make patient care better, faster and
cheaper,” Flowers said.
To accomplish this, hospitals are
looking at major changes, not only to
their IT infrastructures but also to the
mind-set of their IT staffs and clinical
communities. Fortunately, the ongo-
ing development of NHIN standards
and the growth in SAN technology
adoption offer hospitals a useful
blueprint for starting this work. ■
Elisabeth Horwitt is a contributing writer
to SearchHealthIT.com. Write to her at
editor@searchhealthit.com.
 k CHAPTER 2
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

NHIN STANDARDS WILL

EASE STORAGE BURDEN
By letting providers exchange patient records and images
Storage
Strategies for electronically, Nationwide Health Information Network
Hospitals
Going Digital
data-sharing standards keep providers from filling file
cabinets. BY AL GALLANT
NHIN Standards ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Will Ease
Storage Burdens

Using Tiered

A
Storage, Sans
for Images con-
CCORDING TO A
gressional confer-
ence report released
SAN Speed, Feb. 12, 2009, the
Flexibility
Rule the Day Social Security
Administration (SSA) “has a vital
interest in exploring how health infor-
mation technology can be integrated
into the disability process through
the widespread adoption of electron-
ic medical records.” Congress may
not have known it at the time, but
Nationwide Health Information Net-
work (NHIN) standards are playing
an increasingly important role in the
way the SSA and other health care
providers share electronic health
records (EHRs). That, in turn, is
reducing the need to store hard
copies of images and paper records
for long periods of time.
As part of the HITECH Act, Congress
appropriated $1 billion to the SSA—
$500milliontoreplacethe30-year-old
SSA National Computer Center and
$500 million for health IT resources to
facilitate the adoption of EHR systems
in disability claims. Fifteen percent of
SocialSecuritytaxesareallocatedtodis-
abilityclaims,makingtheSSAoneofthe
largest disability insurers in the world,
as well as the keeper of the world’s
largest medical image repository.
In the past, when X-ray film was
lost or damaged there was no choice
but to duplicate the procedure; that
would delay the availability of infor-
mation and leave patients frustrated.
On the other hand, it is very difficult
to lose an image stored in a picture

6 Tiered Storage for Health Care A SearchHealthIT.com e-book

 k NHIN STANDARDS WILL EASE STORAGE BURDEN
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
archiving and communication system
(PACS). The image can be copied
and electronically transferred many
times without degradation. It can be
stored for minimal cost and is easily
retrievable. Transferring PACS images
through NHIN standards is, therefore,
an important step in lowering the
Storage cost of health services.
Strategies for
Hospitals To that end, for the past year the
Going Digital SSA has ran tests to obtain EHRs and
PACS images from sites in Virginia
and Massachusetts to process dis-
NHIN Standards ability claims through the NHIN. The
Will Ease
Storage Burdens SSA has found that disability claims
filed electronically take less time to
process than claims filed on paper.
Using Tiered The NHIN enables a common,
Storage, Sans
for Images Web-based platform for health infor-
mation exchange by providing the
services, protocols, standards, speci-
SAN Speed, fications and legal agreements for the
Flexibility
Rule the Day
secure transmission of health infor-
mation. The NHIN Workgroup, which
is part of the Health IT Policy Com-
mittee chaired by the Office of the
National Coordinator for Health IT
(ONC), is drafting recommendations
to extend the use of NHIN standards
for health information exchange.
The SSA announced on Feb. 1 the
extension of claims processing using
EHRs and NHIN standards to 15
organizations. These private groups
(see “Organizations Receiving SSA
Grants”) received a total of $17.4 mil-
lion in HITECH Act funds to set up
their systems.
7 Tiered Storage for Health Care A SearchHealthIT.com e-book
Michael J. Astrue, the commission-
er of Social Security, estimated that
more than 15 million paper request
packages are sent to health care
providers annually. Letting providers
use their own computer systems to
perform electronic transfers reduces
the amount of time it takes the
provider's staff to manually process
paper records. It also cuts the cost
and time it takes for the SSA to make
a decision about a disability claim.
STANDARDS OFFER KEY BENEFITS
The NHIN Workgroup has identified
several other benefits of using this
infrastructure for information
exchange:
■ Improved care quality
and lower health disparities.
■ Lower costs resulting from
inefficiency, errors, inappropriate
or duplicative care, and incomplete
information.
■ Improved coordination among
hospitals, laboratories, physician
offices and other entities.
■ Faster response to threats and
emergencies.
Through $560 million in HITECH
Act funding, the ONC worked with
19 other federal agencies to develop
open source software known as Con-
nect to help health care organizations
exchange information at the local and
 k NHIN STANDARDS WILL EASE STORAGE BURDEN
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

national levels using Health Level health-related missions, but it’s now
Seven International (HL7) and NHIN available to any organization for
standards. Connect was originally set health information exchanges that
up for federal agencies to support use national standards. In fact, the

Storage Organizations Receiving SSA Grants

Strategies for
Hospitals These 15 private groups received a total of $17.4 million in federal funds
Going Digital to set up claims processing systems using EMRs and NHIN standards.

NAME LOCATION AMOUNT

NHIN Standards
Will Ease California Regional Health Information San Francisco $1.625 million
Storage Burdens Organization

CareSpark Kingsport, Tenn. $1.363 million

Using Tiered Center for Healthy Communities, Dayton, Ohio $999,000
Storage, Sans
for Images Wright State University

Central Virginia Health Network/ Richmond, Va. $1.139 million

MedVirginia
SAN Speed,
Flexibility Community Health Information Collaborative Duluth, Minn. $977,000
Rule the Day
Douglas County Individual Practice Roseburg, Ore. $502,000
Association

EHR Doctors Inc. Pompano Beach, Fla. $1 million

HealthBridge Cincinnati $1.4 million

Lovelace Clinic Foundation Albuquerque, N.M. $1.083 million

Marshfield Clinic Research Foundation Marshfield, Wis. $998,000

Memorial Hospital of Gulfport Foundation Inc. Gulfport, Miss. $1.1 million

Oregon Community Health Information Portland, Ore. $284,000

Network Inc.

Regenstrief Institute Inc. Indianapolis $350,000

Science Applications International Corp. McLean, Va. $1.587 million

Southeastern Michigan Health Association Detroit $2.988 million

8 Tiered Storage for Health Care A SearchHealthIT.com e-book

 k NHIN STANDARDS WILL EASE STORAGE BURDEN
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
SSA is using Connect to exchange
data with the organizations listed
in “Organizations Receiving SSA
Grants.”
Connect uses the following compo-
nents to enable health care informa-
tion exchange:
Storage ■ The Core Services Gateway imple-
Strategies for
Hospitals ments NHIN Interface specifications
Going Digital and helps providers locate patients
at other organizations, request and
receive documents associated with
NHIN Standards the patient, and record the transac-
Will Ease
Storage Burdens tions for subsequent auditing. This
component also authenticates net-
work participants, authorizes the
Using Tiered release of medical information and
Storage, Sans
for Images tracks consumers' preferences for
sharing their information.
SAN Speed, ■ The Enterprise Service Compo-
Flexibility
Rule the Day
nents provide default implementa-
tions of enterprise components
required to support electronic health
information exchange. These include
a master patient index, XDS.b docu-
ment registry and repository, authori-
zation policy engine, consumer pref-
erences manager, and a HIPAA-
compliant audit log.
■The Universal Client Framework
contains applications that can be
adapted to create edge systems, ref-
erence systems, test systems or
demonstration systems on top of the
existing Connect platform.
9 Tiered Storage for Health Care A SearchHealthIT.com e-book
Connect is one of the smartest
initiatives to emerge from Wash-
ington. Usually, each government
agency develops its own gateway
in a nonpublic bubble, and the final
product is little more than a bunch
of nonfunctioning links. In this case,
however, 20 federal offices defined
their needs, jointly developed a sys-
tem through the Federal Health
Architecture, tested its connective
features and made it available for
any public health care organization
within a year's time.
As a result, every health care
organization in the nation now has
access to a system through which
medical information follows an indi-
vidual, clinicians can have readily
available medical data, and duplicate
medical procedures can be kept to a
minimum.
However, switching from paper to
digital files won’t solve your organi-
zation’s problems overnight. After
all, those digital files must be stored
as well—and, just like paper records,
digital images can quickly get out
of control if they are stored with no
clear plan in mind. The utilization
of tiered storage is one strategy that
should keep digital record and image
storage in check. ■
Al Gallant is director of technical services at Dart-
mouth-Hitchcock Medical Center in Lebanon, N.H.,
and a contributing writer to SearchHealthIT.com.
Write to him at editor@searchhealthit.com.
 A New Path For Your
Healthcare Data and Storage
Enabling Your IT With Healthcare Storage Virtualization—
Using Your Data, Your Storage, Your Way

Experience the difference that

Healthcare Storage Virtualization can make.
Visit us at www.BridgeHeadSoftware.com/HSV

or call us at USA +1.781.939.0780 | UK +44 (0) 1372 . 221950

If you’re faced with any of the following problems… …solve them with Healthcare Storage Virtualization (HSV)

∂ Controlling data management costs HSV creates a service platform for healthcare data, giving
∂ Keeping up with exponential growth you more choice, flexibility and control over the way data is
accessed, protected and managed. Ultimately, HSV lets you
∂ Digitizing paper records quickly enough break free from tactical decisions about storage and, instead,
∂ Enabling access to patient records provides a cost-effective and long-term strategy for managing
∂ Safeguarding privacy future data growth.
∂ Ensuring availability
Why BridgeHead Software?
∂ Migrating patient data Because over 1,000 hospitals use our software—so we
∂ Managing all types of data understand your data and we understand healthcare.

©2010 BridgeHead Software, Inc. All rights reserved. Other trademarks appearing in this document are the property of their respective owners.
 k CHAPTER 3
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

USING TIERED STORAGE,

SANS FOR IMAGES
Image and electronic health record data storage is a long-
Storage
Strategies for term problem for health care IT administrators. Tiered storage
Hospitals
Going Digital
and SANs can help prioritize management. BY AL GALLANT

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

NHIN Standards
Will Ease
Storage Burdens

Using Tiered
Storage, Sans
for Images

SAN Speed,
Flexibility
Rule the Day
I health
F YOU’RE A
care CIO trying to
understand your
organization’s future
storage require-
ments, you have to consider some
data points that CIOs in other indus-
tries would never worry about. For
example, what is the age of majority
in the states in which your organiza-
tion operates?
According to legal dictionaries, the
age of majority is set by statute as
the age a person first gains the legal
rights and responsibilities of an adult.
But for health care CIOs, it also
marks the end of the legally required
data retention period for patients
born in your facility.
The New Hampshire medical cen-
ter where I work services approxi-
mately 400 births each year. Some
of these births require extensive
medical imaging diagnostics such as
a computed tomography (CT) study.
Typical CT studies are made up of
256 slices, each a 500 KB image. A
single study would require 128 MB of
data storage. For a single infant born
in New Hampshire in 2009, this 128
MB would need to be retained until
seven years after the infant reaches
the age of majority, which is 18 in
New Hampshire. Therefore, as
required by the Health Insurance
Portability and Accountability Act
(HIPAA) and New Hampshire state
law, the image study must remain in
storage for 25 years. How many non-
health care CIOs do you know who
worry about storage requirements
out to 2035?

11 Tiered Storage for Health Care A SearchHealthIT.com e-book

 k USING TIERED STORAGE, SANS FOR IMAGES
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Now, take the same patient and
increase the electronic health record
(EHR) storage requirements for the
patient’s EHR, which could include
multiple diagnostic images, physician
orders, prescription lists, progress
notes, X-rays and MRI and lab results
for every clinical visit. All of a sudden,
Storage the EHR storage requirement is
Strategies for
Hospitals measured in gigabytes. Multiply this
Going Digital by the number of patients born each
year, and the number can quickly
move to terabytes.
NHIN Standards
Will Ease
For many health care institutions,
Storage Burdens that’s a long-term problem. My hos-
pital, for example, began with digital
storage of radiology images only.
Using Tiered Now we have image storage require-
Storage, Sans
for Images ments for cardiology, neurology, can-
cer, obstetrics, cosmetic surgery, the
spine center, orthopedics, the lab and
SAN Speed, the trauma center—with more and
Flexibility
Rule the Day
more departments requesting image
storage.
The largest image storage require-
ment that my institution manages is
for the neurology center. Our neurol-
ogy center has a process that syn-
chronizes patient video monitoring
with electroencephalography imag-
ing captures, allowing the neurologist
to study a patient’s physical symp-
toms as the EEG records neurological
events. Some of these studies use
continuous monitoring for up to four
days. These video images require
significant amounts of disk storage.
We are managing 8 terabytes (TB)
12 Tiered Storage for Health Care A SearchHealthIT.com e-book
of video storage for approximately
six to eight months of patient visits.
These types of health care video
and image storage requirements are
substantially different from the data
retention and storage requirements
for banking, tax returns and credit
cards records.
HEALTH CARE VIDEO
AND IMAGE STORAGE
REQUIREMENTS ARE
SUBSTANTIALLY DIFFER-
ENT FROM THE DATA
RETENTION AND STORAGE
REQUIREMENTS FOR
BANKING, TAX RETURNS
AND CREDIT CARDS
RECORDS.
So where does a health care CIO
keep all this storage? Three places:
tiered storage, tiered storage and
tiered storage. Image storage is static
storage. Once the image is captured,
it will not be modified. Typically, the
process is to capture the image on
tier 1 storage and keep it there tem-
porarily during clinical review. At
some point, usually within a month,
the images are moved to tier 2 stor-
age. After six months, the images
are then moved to tier 3 or higher
 k USING TIERED STORAGE, SANS FOR IMAGES
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
because future clinical review would
not require instantaneous access to
the medical images. We do this quar-
terly with scripts, so that it takes very
little staff time to do.
The example of tiered storage
below is based on RAID levels, per-
formance and cost. Definitions of
Storage tiered storage vary greatly from ven-
Strategies for
Hospitals dor to vendor and medical organiza-
Going Digital tion to medical organization, so
please do not take this example as
being strictly defined.
NHIN Standards
Will Ease
Storage Burdens ■ Tier 1: 15 K or greater, 146 GB
Fibre Channel (FC) disk with RAID
5 and shadowing (approximately
Using Tiered $15 per gigabyte).
Storage, Sans
for Images
■ Tier 2: 10 K, 300 GB FC disk
with RAID 5 and shadowing
SAN Speed, (approximately $10 per gigabyte).
Flexibility
Rule the Day
■ Tier 3: 10 K, 300 GB FC disk
with RAID 5 and no shadowing
(approximately $5 per gigabyte).
■Tier 4: 1 TB FATA disk with RAID
5 and no shadowing (approximately
$3 per gigabyte).
The most cost-effective way to
manage image storage is with an
enterprise storage area network
(SAN). Some image vendors, espe-
cially those that want to manage the
entire imaging system, will insist on a
13 Tiered Storage for Health Care A SearchHealthIT.com e-book
direct-attached storage array. They
do not want other applications to
affect their image systems and feel a
closed imaging system provides them
that level of risk assurance. Most
imaging vendors realize the invest-
ment a health care institution makes
in SAN technology and will work with
its information systems department
to use SAN storage. One of the
important things to remember when
working with image storage vendors
is that the Food and Drug Adminis-
tration (FDA) does not require an
approval process for disk storage for
medical images. If your vendor tries
to tell you the storage has to be FDA-
approved, feel free to show it the
actual regulation.
One last consideration is whether
to mix clinical and other data on the
same SAN. While some device and
medical application vendors will push
you away from that, the increasing
integration of health care data
demands at least some co-mingling.
The key is to always make sure your
storage for clinical data is delivering
the performance you need. As many
hospitals have discovered, SAN tech-
nology provides that desired per-
formance, even as record stores con-
tinue to grow. ■
Al Gallant is director of technical services at
Dartmouth-Hitchcock Medical Center in Lebanon,
N.H., and a contributing writer to SearchHealthIT.
com. Write to him at editor@searchhealthit.com.
 k CHAPTER 4
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

SAN SPEED, FLEXIBILITY

RULE THE DAY
As health care data proliferates, providers are turning
Storage
Strategies for to storage area network technology, which they find easy
Hospitals
Going Digital
to expand without compromising performance or breaking
the bank. BY STAN GIBSON
NHIN Standards ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Will Ease
Storage Burdens

Using Tiered

H
Storage, Sans
for Images stor-
EALTH RECORD
age needs are tax-
ing the ingenuity of
SAN Speed, health care IT pro-
Flexibility
Rule the Day fessionals faced with
their institutions’ ballooning quanti-
ties of data. Storage makes for a chal-
lenging conundrum. Data sets includ-
ing huge image files must be
available rapidly for a time, then
stored securely for years, all accord-
ing to HIPAA regulations. If that
weren’t enough, hospitals and med-
ical practices face tightening budgets
that rule out the easy answer, which
is to simply mount more and more
disk drives to handle their rapidly
proliferating data.
John Fagg, manager of storage
services at University of Utah Health
Care in Salt Lake City, said data at
his institution is “not quite doubling
every year, but [it's] close.”
For many hospitals, storage area
network (SAN) technology is the best
way to marry fast performance with
expandability. Utah Health Care, for
example, is relying on Fibre Channel
SANs and Brocade SAN switches to
handle its burgeoning data.
SAN technology is virtual storage,
which means the logical units of stor-
age are separated from the disk drive
arrays that physically store the data.
Logical units are allocated to different
applications but can be expanded
quickly across storage arrays, should
the need arise.
“You can grow a [logical unit] on
the fly and spread it across multiple

14 Tiered Storage for Health Care A SearchHealthIT.com e-book

 k SAN SPEED, FLEXIBILITY RULE THE DAY
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
RAID groups,” explained Jeffrey Had-
don, storage administrator at Utah
Health Care. Using the technique of
thin provisioning, it’s possible to
assign an application a 1 TB logical
unit that utilizes only 200 GB of disk.
“It’s easy to grow it in the back-
ground” as needed, without affecting
Storage end-user performance, he added.
Strategies for
Hospitals Despite the appeal of SAN technol-
Going Digital ogy, some medical software vendors
either do not support it or are reluc-
tant to do so, according to Steve
NHIN Standards Huffman, vice president and CIO of
Will Ease
Storage Burdens Memorial Health System in South
Bend, Ind.
“Some applications are still not on
Using Tiered our SAN. Some vendors say they’re
Storage, Sans
for Images not comfortable with the SAN envi-
ronment,” Huffman said. Nonethe-
less, he has implemented SAN-based
SAN Speed, health record storage wherever pos-
Flexibility
Rule the Day
sible and has moved a significant
portion of Memorial Health’s applica-
tions, including those from Cerner
Corp., Oracle Corp. and McKesson
Corp., to the SAN.
FIBRE CHANNEL SAN
CUTS DOWNTIME
Fibre Channel SAN technology, which
is ideal for connecting servers to
shared storage devices, has proved
its worth at Metro Health in Wy-
oming, Mich. “We have been a Fibre
Channel site for years,” said Aivars
Apsite, technology manager at Metro
15 Tiered Storage for Health Care A SearchHealthIT.com e-book
Health. “It’s very resilient. It doesn’t
really go down. It’s highly redundant
and failovers are seamless.”
The institution has redundant Fibre
Channel SANs in its primary data
center and its secondary data center,
located 12 miles away. The centers
are connected by redundant fiber
links, and data is mirrored.
The setup was tested when an
accident severed one of the fiber
links. On another occasion, a Fibre
Channel switch failed. “In both in-
stances, our Fibre Channel redundan-
cy worked flawlessly, and we never
incurred any downtime,” Apsite said.
The hospital recently completed a
major storage upgrade from 120 TB
to 254 TB using a Hewlett-Packard
Co. StorageWorks XP20000 series
disk array, with an HP StorageWorks
Enterprise Virtual Array 8400.
FLASH DRIVES
OFFER FAST RETRIEVAL
Although Fibre Channel SAN per-
formance suffices at many institu-
tions, Wausau, Wis.-based Aspirus,
a network of hospitals serving north-
ern Wisconsin, has turned to flash
memory to provide extremely fast
response time in its health record
storage system.
In Aspirus’ data center, EMC Corp.
enterprise flash drives are housed in
a Clariion CX4 Model 960, which is
known as “tier 0” in Aspirus’ tiered
 k SAN SPEED, FLEXIBILITY RULE THE DAY
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
storage architecture. That architec-
ture is fleshed out with iSCSI SANs at
tier 1, Serial Advanced Technology
Attachment, or SATA, drives at tier 2
and EMC Centera archival storage at
tier 3, which handles long-term stor-
age for its picture archiving and com-
munications system (PACS) from
Storage Sectra AB, cardiology images and
Strategies for
Hospitals video. (Remember that the defini-
Going Digital tions for storage tiers are not set in
stone.)
Aspirus’ Epic Systems Corp. soft-
NHIN Standards ware applications also are served by
Will Ease
Storage Burdens the EMC enterprise flash drives. Later
this year, Aspirus will add an Oracle
decision-support application that will
Using Tiered also store active data on the flash
Storage, Sans
for Images storage. “It gives physicians near-real
time retrieval,” said Tom Whalen,
server systems team leader at
SAN Speed, Aspirus. “We can serve more
Flexibility
Rule the Day
patients through the system. It both
increases volume and quality of clini-
cal care.”
Business applications, payroll,
enterprise resource planning and
high-speed reporting applications
also are on the tier 0 flash drives. In
all, Aspirus is storing about 4.5 TB of
data on flash memory, and may move
its Sectra AB PACS data to flash in
the future, according to Whalen.
ISCSI SAN: FLEXIBLE STORAGE
Like Aspirus, Community Health
Partnership Inc. in Eau Claire, Wis.,
16 Tiered Storage for Health Care A SearchHealthIT.com e-book
has implemented iSCSI SAN storage
technology. Community Health is
relying on Dell Inc. EqualLogic iSCSI
SANs for the bulk of its storage
needs, from active data to email
archiving. The speed, flexibility and
low cost of iSCSI give the health care
provider a one-size-fits-all approach
to health record storage.
“We can take any SAN and up-
grade the firmware easily. The PC
600 to the PS 6000—all the firm-
ware is the same,” said Andrew
Violet, systems engineer at Commu-
nity Health.
Community Health’s storage archi-
tecture consists of nine iSCSI SANs in
three groups of three, handling a total
of 90 TB of data. One group of high-
performance SANs handles active
data, working in tandem with another
local SAN. The third SAN group han-
dles backup at a remote site.
When it embarked on implement-
ing Allscripts-Misys Healthcare Solu-
tions Inc.’s EMR software, Communi-
ty Health considered adopting a Fibre
Channel SAN but found the higher
speed didn’t justify the steep addi-
tional cost. “Throughput is impor-
tant—but it’s not nearly as important
as the actual amount of data we can
store,” said Keith Grey, IT technical
services manager and security officer.
Staying with iSCSI allowed Com-
munity Health to implement All-
scripts’ EMR software by spending
only $65,000 for storage upgrades
 k SAN SPEED, FLEXIBILITY RULE THE DAY
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

instead of the $335,000 Fibre Chan-

nel would have required, Grey said.

DEDUPLICATION:
STORE DATA ONLY ONCE
Left unchecked, the sheer quantity Tiered Storage for Health Care
is produced by CIO/IT Strategy Media
of data in long-term archives could © 2010 by TechTarget.
Storage break the health record storage budg-
Strategies for
Hospitals ets of some organizations. To fight Jacqueline Biscobing
Going Digital back, many hospitals use data dedu- Managing Editor
plication technology to avoid storing Linda Koury
the same information many times— Art Director of Digital Content
NHIN Standards in some cases, tens or hundreds of
Will Ease Al Gallant, Stan Gibson, Elisabeth Horwitt
Storage Burdens identical instances. Contributing Writers
Utah Health Care is implement- Scot Petersen
ing both NetApp Inc. and EMC Data Editorial Director
Using Tiered Domain deduplication technology
Storage, Sans Brian Eastwood
for Images to justify storing the data on disk for Site Editor
longer periods, thereby assuring it
will be accessible faster than if it Anne Steciw
Assistant Site Editor
SAN Speed, were archived on tape. Deduplicated
Flexibility
Rule the Day
data is encrypted and transmitted Jean DerGurahian
to an off-site storage facility. Once News Writer
there, it is “un-deduplicated,” or Don Fluckinger
“rehydrated,” so the full record of all Features Writer
data instances can be stored for
Rachel Lebeaux
archival purposes on tape, Haddon Assistant Managing Editor
said.
Similarly, Community Health is FOR SALES INQUIRIES
Stephanie Corby
using VMware Inc.’s vSphere to per- Associate Publisher
form deduplication of the data within scorby@techtarget.com
its health record storage system, (617) 431-9354
Grey said. ■ TechTarget
275 Grove Street, Newton, MA 02466
Al Gallant is director of technical services at Dart- www.techtarget.com
mouth-Hitchcock Medical Center in Lebanon, N.H.,
©2010 TECHTARGET. ALL RIGHTS RESERVED.
and a contributing writer to SearchHealthIT.com.
Write to him at editor@searchhealthit.com.

17 Tiered Storage for Health Care A SearchHealthIT.com e-book

 k FROM OUR SPONSOR
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

q White paper: Disaster Recovery for Healthcare

q White paper: Healthcare Storage Virtualization

q Brochure: Healthcare Storage Virtualization

About BridgeHead Software:

BridgeHead Software, the Healthcare Storage Virtualization (HSV) company,

offers a scalable, future-proof platform to overcome rising data volumes and
increasing storage costs while delivering peace of mind around the access,
availability and protection of critical electronic patient data.

Trusted by more than 1,000 hospitals worldwide, BridgeHead Software solves

healthcare organizations’ backup, recovery and archiving challenges. Bridge-
Head’s HSV solutions are designed to operate with any hospital’s chosen soft-
ware applications and storage hardware, regardless of vendor. This presents
healthcare organizations with more choice, flexibility and control over the way
data is accessed, protected and managed. The net effect—better utilization of
hardware resources and, more importantly, the efficient distribution, availability
and use of vital healthcare data.

18 Tiered Storage for Health Care A SearchHealthIT.com e-book