B e t t e r P a t i e n t C a r e : V i r t u a l l y T h e r e

Autora: Judy Hanover  August 2010

This IDC Health Insights White Paper identifies the key benefits from desktop virtualization in the clinical environment and presents case studies from three hospitals that are early adopters of desktop virtualization in the clinical environment. The landscape for U.S. providers has been altered by two laws, the American Recovery and Reinvestment Act (ARRA) of 2009 and the Patient Protection and Affordable Care Act (PPACA) of 2010. These laws have created unprecedented incentives for the adoption of clinical technology and new goals for delivering higher-quality care to more Americans at lower cost. This will require providers to adopt new technologies rapidly and at the same time streamline their processes, cut costs, and improve quality. To do this, providers will be forced to examine all areas of their business and technology infrastructure. One of the key technologies that IDC Health Insights has identified for making provider IT departments more efficient and helping to meet these goals is virtualization. The return on investment (ROI) for provider organizations has been well documented for server and desktop  virtualization, but the clinical benefits that arise from the virtualization  of the clinical desktop have only recently begun to be discussed.
The research for this white paper included detailed interviews with IT  departments at three hospitals that are early adopters of desktop  virtualization for clinical applications. The observed clinical benefits  from desktop virtualization in these organizations include:

● Improving efficiency in the IT department, enabling the delivery of higher service levels, better uptime, and higher availability and performance of clinical applications while maintaining staff levels

● Driving adoption of clinical applications by improving the usability and performance of legacy clinical applications

● Supporting provider mobility with wireless access, thin-client hardware options, single sign-on, and session virtualization

In the rapidly changing environment created by the new incentives and regulations, IT efficiency and agility are critical to success for provider


I N   T H I S   W H I T E   P A P E R

This White Paper is presented by IDC Health Insights and sponsored by VMware. The objectives were to gain insights into:

● The decision-making process for investment in desktop virtualization of clinical application by hospitals

● The IT and clinical benefits experienced by three provider organizations that invested in VMware desktop virtualization solutions

● The importance of desktop virtualization in unleashing the value of electronic medical record (EMR) and other clinical applications

To meet these objectives, IDC Health Insights conducted three indepth interviews with provider organizations that have adopted desktop virtualization of clinical applications in the 2009–2010 time frame; the interviews were conducted in March–June 2010.

S I T U A T I O N   O V E R V I  E W

As the healthcare industry seeks to implement and drive widespread adoption of clinical computing, performance and accessibility of applications for clinicians are critical. In the hospital environment, solutions like desktop virtualization are increasingly playing a role in bridging the gap between available resources and satisfaction of enduser requirements.
Incentives created by ARRA and the additional goals of PPACA are resulting in a surge of new EMR and computerized physician order entry (CPOE) system implementations, alongside expanded adoption of existing clinical information systems, analytics, and revenue cycle solutions. The growth in adoption of clinical information systems will result in a proliferation of point-of-care computing, dramatically increasing the number of client machines that need to be supported by  IT organizations.
Client or desktop virtualization provides a tool that can help provider IT organizations to:

● Deliver enhanced performance, uptime, and availability to providers using clinical applications

● Drive efficiencies and improve service provided by IT staff
implementing, managing, and maintaining clinical systems
● Improve accessibility and productivity for mobile users of clinical
applications in complex care settings
● Create a foundation of a private cloud internally, virtualizing
servers, applications, networking, desktops, and applications
● Manage healthcare information technology (HIT) efficiently by
centralizing services in a single datacenter, thereby freeing up
resources that were devoted to catering to individual endpoint
devices
● Increase security by controlling information and keeping data off
endpoint devices
● Lower operating expenses by redirecting IT resources from help
desk calls to support new projects, EMR, and additional desktops for
clinical applications — all without increasing staff
S O L  U T I O N   D E S C R I  P T I O N
Current commercially available software products encompass three
types of virtualization: server virtualization, application virtualization,
and, most recently, client or desktop virtualization. This white paper
focuses on the features and benefits associated with virtualization of
the client.
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Client or desktop virtualization is a datacenter-centric computing
model that borrows from the traditional thin-client model but is
designed to give system administrators and end users the best of both
worlds: enabling system administrators to host and centrally manage
virtual and/or physical desktop machines in the datacenter while
giving end users the traditional PC desktop experience to which they
have become accustomed.
In virtualized client environments, the software image of a physical
desktop PC is replaced by a virtual PC running on a server. Each user
accesses a unique virtual PC, complete with its own virtual CPU,
RAM, and hard disk. Virtual PCs run concurrently on top of the
virtualization layer provided by the hypervisor software, which also
controls the computing resources (mainly CPU and RAM) allocated to
the virtual PCs. Although multiple virtual PCs typically run on a single
server, the crash of a single virtual PC is unlikely to cause other virtual
PCs on the same server to crash. Users access datacenter resources via
thin-client or full-client workstations.

Application virtualization separates applications from the underlying
operating system and packages them with a virtual operating system in
a completely isolated container. This allows users to run applications
on the same desktop that may have conflicted before or run
applications that use different Windows operating systems side by side
on a single desktop. Applications can be virtualized and delivered into
virtual desktops or traditional desktops.
V M w a r e   S o l u t i o  n   D e s c r i p t i o n
VMware provides a number of solutions to accomplish virtualization
implementations at the hospitals we spoke with. The VMware products
in use include:
● VMware View provides a centralized virtual desktop and
distributed virtual desktop that allow remote and local management
of fully virtualized desktops.
● VMware ThinApp is a key component of VMware View and is also
available as a standalone solution. This solution provides application
virtualization to simplify application delivery and management.
The three hospitals discussed in this study are using VMware View
and ThinApp to deliver client virtualization solutions.
B E N E F I  T S
Enterprises have discovered that the use of virtualization to support
desktop workloads, like the use of virtualization in support of
traditional server workloads, creates a range of significant benefits.
These benefits include improved IT management efficiency, improved
price efficiencies, and improved functional capabilities. The key IT
benefits associated with desktop virtualization in the healthcare
industry fall into the following areas:
● Enablement of thin clients. Because little computational execution
occurs at the edge in a desktop virtualization environment, the
computing architecture becomes less reliant upon the horsepower in
endpoint devices. This creates an opportunity for IT to significantly
drive down the cost of endpoint hardware either by extending the
life span of existing PCs by repurposing them as client endpoints or
by replacing aging PCs with a thin-client device, which typically
operates across a life span twice that of a standard PC.
● Improved data security. The ability to move data from the edge
of the IT environment into the datacenter inherently reduces the
security risks to an IT organization. Centralization of data access
can mitigate the risk of data leakage and theft and simplify
compliance procedures.

● Simplified data backup. Because centralized virtual desktops
reside entirely within the datacenter, it is easier to ensure full
compliance with backup policies. Furthermore, depending on how
the platform is architected, the use of consolidated images and
delta files may further simplify the abstraction and collection of
important data, thereby simplifying backup processes.
● Simplified disaster recovery.  Virtual machines (VMs)
significantly simplify disaster recovery because central IT staff can
easily revert virtual desktops back to their last known good states.
Thus, IT no longer needs to provide spare endpoints that are up to
date with the latest image.
● Time to deployment.  In particular, when thin clients are used
within a virtualized architecture, the process around deployment is
significantly simplified because nothing is installed on the
endpoint device.
● Simplified PC maintenance.  When used appropriately, virtual
desktops can be far easier to maintain than traditional PCs. Because
of the unique characteristics of virtual machines, it can become quite
simple to patch applications, provision/deprovision users, migrate to
new operating systems, and perform auditing duties.
● Flexibility of access. Because corporate desktop environments are
centralized, access to them can be provided to users who do not
have access to their own PCs, in situations where users need secure
access to clinical systems while working from home, on hospital
floors, in acute care environments, or in other remote situations.
This is particularly important for mobile caregivers who work in or
move between hospitals, ambulatory care environments, and other
settings.
● Simplified application delivery and management. Applications
virtualized into single image executables can be centrally managed
and delivered to many endpoint devices. Application virtualization
also minimizes application testing and help desk support because
the application is completely isolated from the operating system,
ensuring the same application behavior independent of the
operating system configurations.
While IT improvements are certainly impressive in their own right,
enhancing the quality of care and patient safety is a top priority for the
healthcare industry. Desktop virtualization can be a critical component
of strategies to achieve these goals and deliver clinical benefits in
healthcare. The clinical benefits seen by the three organizations we
spoke with are discussed in the case studies presented in the following
section.

D  e s  k t  o p   V  i  r  t  u a l  i  z  a t  i  o n   a t   T h r  e  e   H e a l  t  h c  a r  e  O r  g a n i  z  a t  i  o n s  Case Study #1: University of Toledo

The University of Toledo (UT) went through a profound change four years ago when a 20,000-student university merged with a 300-bed teaching hospital. The opportunities presented by such a merger seemed endless. But with those opportunities came challenges; merging cultures, departments, and of course, technology was no easy task. There are more than 10,000 Windows desktops in the combined institution and over a dozen Information Technology support groups managing them. Josh Spencer, Team Lead for the Desktop Development group in Information Technology, provides desktop administration support such as application packaging, imaging, and desktop automation for more than half of these PCs. He identified a common challenge that plagues each of these groups: "maintaining stable desktop images and keeping them updated with the ever-changing software suites." A variety of methods have traditionally been used at UT, ranging from group policies to scripting upgrade routines to "sneakernet." According to Spencer, "This is particularly challenging because unlike some industries which require a handful of applications to do business, the IT groups at UT have to support hundreds of software titles." Any number and combination of applications might be required in student labs, in clinics, and in training rooms. The sheer number of applications and computers makes it difficult to keep the images current. The endless varieties of software combinations introduce instability. Spencer's team has implemented VMware View and ThinApp in both clinical and academic environments to address these challenges.


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 Over the years, the Desktop Development group has implemented a variety of application packaging technologies in an attempt to reduce the age-old problem of dll and registry conflicts. While incremental improvements have been realized, the group has found that these technologies all fall short, causing a great deal of administrative overhead to manage application conflicts and a loss of productivity for end users.  About three years ago, the group decided to try application virtualization using VMware ThinApp. This technology has two key components that made it a success: application isolation, which improved desktop stability, and application streaming, which reduced administrative overhead and increased uptime. According to Spencer, "Application isolation not only allows us to segregate the application and all of its dlls; we can actually include all supporting applications in the virtual 'bubble.' This concept introduces a level of stability never before attainable in our desktop environment."  Today, the Desktop Development group has approximately40 virtualized applications in production, the majority of which are in the clinical environment. The clinical staff at the UT Medical Center use applications such as McKesson Star Navigator and Care Manager and Allscripts Vision. These applications have all been virtualized and are streamed to thousands of physical and virtual desktops throughout the institution. "We started with our most complex and problematic applications and saw the benefits of application virtualization immediately," said Spencer. Applications such as Allscripts Vision require a specific set of prerequisite software such as Java, .NET framework, and IBM Informix Connect. Managing each of these applications independently and ensuring that they remained at the appropriate level to support Allscripts Vision proved to be a challenge. Spencer noted, "We simply put all the prerequisite software in the bubble with [Allscripts] Vision, and we don't have to worry about what is or isn't on the host; the application just works." Another improvement in stability comes from the fact that once virtualized, applications that would normally require local administrative privileges to function can run as a standard user. Spencer's team is now deploying clinical desktops with restricted privileges, preventing unauthorized changes and improving uptime.
Administrative overhead for deploying and upgrading applications has been reduced dramatically through the use of virtualized applications.
Rather than using traditional install/upgrade methods, Spencer's team is streaming applications from a central server. This method reduces the need to make changes on the endpoint computers. Spencer said, "We no longer have to write a scripted upgrade routine for our applications. We simply update an executable on the central share and the work is done.
We've seen our failure rates for an application upgrade drop from 5% to nothing; people sometimes don't even know we've done anything."
Clinical applications that have been altered by application packaging of any kind are usually not supported. Spencer's team made the decision that the benefits from repackaging outweighed the risk of diminished support from vendors and uses a traditionally installed version of the application when contacting suport.


B e n  e f  i t s   o f   D  e  s k t  o p   V i  r t  u a  l i z  a t  i  o n  

The University of Toledo used VMware View to build a private cloud infrastructure, providing students with on-campus and off-campus access to hundreds of virtual machines in dozens of unique configurations. Last year the university decided to implement 300 new virtual machines along with thin-client devices as part of an electronic medical record initiative in the Medical Center hospital. A variety of factors were involved in the decision, and several technological solutions were considered. In the end,Prior to the implementation there were approximately 600 PCs in the UT Medical Center hospital. The Horizon Electronic Documentation project required an additional 300 PCs to provide bedside patient care.
The work of deploying and managing these devices had to be done with no additional staff. Spencer's team worked with Clinical Informatics, Hospital Client Services, Server Administration, Network Engineering, and other IT groups to design a system that met the needs of the clinicians and that could be supported with existing human resources.
Wyse thin-client devices with custom XP embedded images were deployed to wall-mounted arms in patient rooms, desktops in nursing units, and mobile carts. Barcode scanners were attached to most devices for use in bedside drug administration. The thin-client devices were programmed to connect only to the VMware View servers.
The benefits realized from virtualizing the desktop environment at the University of Toledo Medical Center include:

● Removal of data from the endpoint device. Traditional desktop PCs allow end users to store sensitive information on the local drive, creating a potential risk in the case of theft. The thinclient/View model keeps all data in the datacenter and prevents anything from being stored locally.

● Reduced administrative overhead. Because applications on the virtual machines have been virtualized, allowing for more restrictive local privileges, desktop stability is greatly improved.

On the occasion that a VM does need to be reimaged, the use of VMware snapshots has reduced what takes more than an hour with a traditional PC to less than five minutes. "Our technicians can simply use the Virtual Center console to revert a VM to the snapshot taken when it was created. In a matter of minutes, the clinician is back up and running," said Spencer.

● Lower-cost endpoint devices. Thin clients are a fraction of the cost of a typical PC and have a longer life expectancy.

● Energy savings. Spencer reported that an internal power study shows a considerable reduction in energy consumption for thin clients and supporting back-end infrastructure compared with traditional PCs currently used in the hospital.

For the IT team at the University of Toledo, key learnings have included understanding how clinicians work, how they want to work, and what they need to be successful and then balancing all of that information with HIPAA requirements and the internal resources available to provide support.

Case Study #2: Overlake Hospital Medical Center Overlake Hospital Medical Center is a nonprofit community medical center that includes a 337-bed hospital and about 10 local clinics.


Overlake uses MEDITECH for its inpatient clinical and administrative systems and plans to upgrade to MEDITECH Client/Server v6.0 in August 2010. The outpatient clinics run eClinicalWorks for practice management and EMR, and in addition to the 10 hospital-owned clinics, an additional 1,000 community physicians are supported for a total of roughly 3,000 end users. Director of Technology and Information Security Officer Joseph Wolfgram will deploy desktop virtualization to 900 desktops out of his 1,800 workstations in 2010 and expects to see substantial future growth and the need to add additional endpoint hardware to support EMR users including clinical documentation.
Before selecting VMware, Wolfgram conducted a technology evaluation and vendor selection process, as well as a formal proof-ofconcept process, and looked at multiple vendors. Overlake's criteria for selection included the ability to deliver a virtual desktop with a user experience identical to that of a local workstation, with no delays or pixelation, and the ability to offer full-screen, slow-motion video without pixelation or chop. After a successful proof of concept using PC over IP display technology on a virtualized client, he began a VMware standard evaluation, assessment, and deployment project. Today, about 100 users at Overlake use a VM every day, the new clinical system is being built on the VMs, and Wolfgram is deploying virtualized production servers and storage. All EMR training and eventually clinical documentation at bedside will use the virtual machines.

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Overlake plans to use VMware View to deploy MEDITECH systems for EMR and CPOE, as well as the eClinicalWorks practice management and EMR in its affiliated clinics. While the clinics currently use tablet PCs as their thin client, the virtualized system may deploy on the iPad in the future, which Wolfgram expects to be more reliable than the PCs currently in use. According to Wolfgram, "Any clinical application that we can move to a virtualized desktop, the plan is to move it there. I'm not aware of any specific technical limitations today that we've run across for any of our 160 applications we support." Like his peers at the University of Toledo, Wolfgram has run into licensing and support limitations. Wolfgram finds that license offerings from vendors lack options that are efficient for the virtualized environment, and he prefers to duplicate problems on a nonvirtualized machine to ensure they are not related to the environment before accessing vendor support. He uses NetApp storage and a "snapshotting" feature to move the applications from a virtual  machine to a physical machine quickly.


The benefits that clinicians at Overlake have seen from desktop virtualization include:

● User experience on virtual machine that is identical to user experience on local machine. In order for desktop virtualization to be successful, the user experience with the virtual machine needed to be identical to the user experience on a local machine. For example, start menus and scrolling on the virtual machine needed to behave identically to those on the traditional, local desktop.

● Video capabilities for training and patient education. Fullmotion video is delivered to the virtual machines without chop or pixelation, allowing clinical staff to complete annual training requirements that are delivered as video segments and to make videos available to patients. Although Overlake is not using telemedicine, videoconferencing tools such as Skype are being used to connect remote clinics and deliver information via video.

● Reduced cost. Overlake will realize cost savings by using virtualized servers and storage, in addition to using desktop virtualization to lower costs associated with thin-client workstations.

● Faster log-ins and mobility for clinicians. The upgraded clinical systems will provide advanced functionality and improve security, but at the same time they will require individual log-ins to replace shared workstations, which was expected to add to log-in delays for both Windows and the clinical systems. Mobile clinicians in Overlake's hospitals may need to log in hundreds of times during a shift, making these delays quite significant. The virtualized desktops will follow the clinicians, allowing for quick connections and disconnections, while the desktops and functionality follow the provider.

● Easier desktop management and faster software delivery. From the IT perspective, it will be easier to manage desktops, and staff will be able to deliver and maintain software more efficiently.

● Improved security. With a virtualized desktop, the data never leaves the datacenter, and patient data and sensitive information is not resident on the end devices. This will replace a slew of point solutions that are currently in place and maintained on local machines, such as local firewalls and encryption, creating a win for maintenance, support, and security.

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At Overlake, IT goals include virtualization of clinical workstations  as well as administrative workstations. The number of virtualized clinical workstations is expected to reach 900 initially, but it could grow to 1,100 with the implementation of the new EMR and could reach  2,000 across 12 facilities with the added administrative workstations.

Phase 1 of the effort will virtualize about 80 clinical and business applications that are delivered on individual user virtual desktops.  Overlake's clinical IT environment includes about 90 applications that will be virtualized. Applications that will be virtualized later include financial systems and departmental systems for emergency and surgery. Some legacy clinical applications will continue to run outside the virtualized environment as Overlake considers the value proposition for virtualization. According to Wolfgram, a few clinical applications have "really strict access control criteria and run on proprietary hardware, so many of our clinical systems that are like that, we have no plans to virtualize it, even if we could technically make it work, it doesn't make sense, too much effort."
Physician buy-in has been a focus at Overlake. According to Wolfgram, "For the EMR, the MEDITECH upgrade, we've got a physician champion, and we are working very closely with him to make sure he's exposed to our piloting. He was in on the proof of concept. He's giving us guidance in terms of what our physicians are expecting to see out on the floor — are the connects and disconnects fast enough, is it running across enough platforms including mobile devices like the iPad, that sort of thing. So we're in the throes right now of gaining buy-in from the physician community." Physicians' concerns about the workflow changes from the EMR clearly outweigh those about the virtualized environment. "They actually see the virtualized desktop as something that's going to be saving a lot of pain for them because without it, there would be a lot of really slow log-ins that would need to take place," said Wolfgram.

One of the lessons learned about virtualization at Overlake included understanding the costs. In the virtualized environment, it was important to have high-speed servers, a high-bandwidth network, and significant available storage, which added to the costs of hardware — mainly servers, disks, and networking equipment — to support the virtualized environment and achieve the required performance levels.  A local implementation partner at Overlake also played an important role. Wolfgram emphasized that "it's critical to have an implementation partner that has done virtualized desktop deployments in production and in a healthcare setting. There are things that are unique to this environment, and you want an organization that has had experience, not just the education of virtualized desktop implementation, because there are a lot of technical details that don't exist in the traditional desktop environment that really matter in a virtualized environment … having an implementation partner that has kind of blazed their trail before you that's helping you avoid potential problems, I think that's critical."

Clinical benefits from virtualization at Overlake have included:

● Faster log-in times for providers. The ability to log in quickly and easily improves the productivity of providers who must log in from different locations many times during the workday. ● Continuous sessions. Provider sessions are continuous when the
providers change locations because they can reconnect to an
existing virtual machine in a new location and pick up where they
left off, improving productivity.
● Remote access. Compared with existing systems, the virtualized
desktop provides a significant improvement to the performance of
the clinical applications when accessed remotely. Providers may
access their desktops from any location with the Internet and a
Web browser, and the access is faster and less complicated.
● Improved security. Security on the thin-client devices used in the
hospitals as well as for remote access has improved as a result of
centralizing data and information.
● Ease of use. Accessing systems is less complicated, response times
are faster, and thin-client devices are allowing providers to access
clinical data in a more mobile fashion.
Case Study #3: Phoebe Putney Memorial Hospital
The IT department at Phoebe Putney Memorial Hospital is responsible
for systems at 3 hospitals and about 15 clinic sites throughout southwest
Georgia. The three hospitals include Phoebe Main, a 450-bed acute care
hospital; the newly acquired Phoebe Sumter, with 74 beds; and
Phoebe Worth, a 25-bed critical access hospital. In addition, the IT team
is adding responsibility for hosting a MEDITECH system at the
Southwest Georgia Regional Medical Center in Cuthbert, Georgia.
The hospitals have different administrative and clinical systems, and
given the varying sizes of the hospitals, they have different goals
and requirements for their systems that prevent the standardization of
clinical and administrative systems.
Phoebe Main has the McKesson Horizon Inpatient Suite and Horizon
Ambulatory Care installed at its clinics. At Phoebe Main, CPOE
implementation is two-thirds complete, putting the hospital well on the
path to achieving meaningful use and qualifying for ARRA incentives.
The Phoebe Sumter and Phoebe Worth hospitals will be migrated from
Healthland to MEDITECH Client/Server v5.6, and the newly acquired
Southwest Georgia Regional Medical Center will also be migrating to
the upgraded version of MEDITECH, which will allow it to access
clinical applications including CPOE. All of the IT systems for the
hospitals will eventually be centralized at Phoebe Main, with
applications distributed to individual sites using server virtualization
and VMware View for desktop virtualization. Virtualizing the servers
has allowed the IT team to put 28 servers on 6 physical boxes, saving
considerable space and money.
The three rural MEDITECH hospitals will have a total of 800–900
users; about 100 people are using VMware View right now.
Each patient room at Phoebe Sumter will have a thin client using VMware View, and this hospital could eventually have 200–300
VMware View seats. At Phoebe Main, 5–6 of the McKesson
application servers were virtualized when the hospital upgraded to
version 10.1. In addition, home-based transcriptionists and coders and
the oncology department are using virtual desktops. A rollout planned
for this fall will include Horizon Expert Documentation as well as
wired Wyse thin clients in hospitals for nursing documentation.
Horizon Expert Orders physician documentation is planned for
rollout next year.
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About two years ago, the IT team at Phoebe Putney first looked into
virtualization for its home transcriptionists when it needed to replace
an aging Citrix implementation. The team looked at multiple options
and considered the costs of training and hardware, alongside ease of
use, installation, and support. It determined that centralizing support
with the VMware solution offered the best option to support the
current needs of the remote users and the future needs for clinical
applications and growth in the hospitals. Additionally, a resourceintensive oncology application it was running in many remote clinics
did not support Citrix but could be optimized on VMware View. The
requirement to support the oncology application across a limitedbandwidth link was a key factor in the decision to use View.
The Phoebe Main hospital will eventually have 400–450 thin clients in
patient rooms to support Horizon Expert Documentation. The IT team
expects it to be easier to have the solid state thin client in the rooms
and run the operating system on the back end using View. Benefits to
nurses from using virtualized clients are expected to include:
● Reduced downtime. The thin clients will replace PCs and be
locked down and less likely to break or malfunction. Patches can
be done on the back end to the operating system, and users don't
need to worry about rebooting when patches are installed.
● Faster log-ins. Nurses will see improved speed of access and be
more efficient due to the addition of single sign-on and multiaccess
log-in.
● Improved mobility.  Users will have the ability to pick up open
sessions when they change locations, making them more efficient.
● Expanded functionality. Nursing documentation functionality has
been implemented at the bedside using the virtualized thin clients.
The hospital also has a medication administration system installed,
and nurses are able to scan medication barcodes and document
administration of medication using the thin clients. In the future, the
thin clients will also be used to implement CPOE for physicians.


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Clinical testing has been done within departments and clinical
informatics using the thin clients and nursing documentation
applications. Although the system has not been rolled out on floors yet,
according to Michael Elder, Director of Technical Services, "…clinical
informatics has given us thumbs up on all the applications, the speed,
the efficiency of the unit … the application is working well, printing is
working, everything seems to be a go for that. So far the applications are
working well; the efficiency of it, speed, ease of use — all that's really
good. Integrating that single sign-on solution with it too is a big part of
that and all that seems to be working without any problems."
The IT team expects the providers to appreciate the speed, response
time, and mobility advantages of the virtualized solution. In addition,
the IT team expects to virtualize the physician portal that doctors use to
access PACS images and EMR data remotely, which will eliminate the
need to send technicians to provider offices to perform updates to the
software, which is currently installed locally at provider offices. To date,
the system has made early users, the home-based coders and oncology
clinics, more efficient. Home-based coders and transcriptionists report
that even when working from a setting without high-speed Internet
access, they have been able to work efficiently and experience less
downtime using View.
For the IT team at Phoebe Putney, key learnings have included the
need to educate users thoroughly about the process for using the
virtual desktop sessions in order to keep things running smoothly and
to test systems thoroughly before going live. The IT team also reports
significant ROI from the use of virtualization. In addition, the hospital
is reaching out to other hospitals in the region that are not part of the
health system to see if they want to partner to share resources and
access the hosted MEDITECH implementation.
F  U  T U R  E   O U T L O O K
IDC Health Insights expects to see extensive adoption of all types of
virtualization, including client virtualization and application
virtualization over the next three to five years. Growth in use of
virtualization will occur as healthcare organizations increasingly see
the benefits of virtualization and its ability to help them meet the
demands for efficiency and productivity that are resulting from new
healthcare reform and IT initiatives. Providers will begin to observe
their peers putting in place virtualization implementations; conducting
successful proof-of-concept projects; and putting virtualization into
production with new EMR/EHR, ordering, and other clinical systems.
IDC Health Insights also anticipates that the use of virtualization as an
infrastructure used to manage desktop environments will continue to expand with the growth in the capabilities and maturity of virtual
desktop platforms, alongside the compelling clinical benefits and ROI.
Early adopters of virtualization technology in healthcare will continue
to provide a proving ground for horizontal vendors that are moving
into the high-growth healthcare market. An increasing number of
centralized virtual desktop (CVD) platforms will become available to
healthcare organizations, driving competition in pricing as well as
products and features, including industry-specific functionality. The
willingness of legacy application vendors to support healthcare
information and clinical systems in a virtualized environment may
limit growth initially. However, it is expected that clinical vendors will
improve support for virtualization as the demand from providers grows
and as the ability of virtualization to provide performance, application
and data security, and complementary features that are not accessible
or difficult to improve in their legacy applications becomes clear.
Additionally, inpatient and ambulatory healthcare IT vendors will
begin to facilitate virtualized implementation, creating more seamless,
simple, and comprehensive platforms.
E S S E N T I A L   G U I D A N C E
Desktop or application virtualization may not be right for all
organizations or for some user populations in healthcare. Virtual
desktop infrastructure does add a layer of complexity to the existing
infrastructure that might deter some organizations from going ahead in a
short time frame. Clinical application vendors have hindered the
advance of virtualization across the industry — as many have been slow
to embrace virtualization or to support and/or certify the performance of
their products in a virtualized environment. However, this is more of an
issue with server virtualization than with desktop virtualization, and IT
executives in provider organizations have responded accordingly.
Care should be taken when implementing desktop virtualization to
ensure that it is an efficient approach for utilizing all of the application
services that a specific user, or class of users, is accustomed to
accessing. Applications that are graphic intensive, for example, may
not perform as well in a virtualized desktop environment.

While server virtualization may require a larger environment and
number of servers to reap benefits, desktop virtualization is not subject
to the same constraints. Application virtualization and repackaging may
complicate accessing vendor support for healthcare applications, but the
benefits may outweigh this risk for many healthcare organizations and
applications; as with any new technology implementation, an
assessment of the benefits and risks for the organization and its IT
infrastructure should be considered. The majority of provider
organizations support desktop environments sufficient to justify the
investment and see considerable economic and operational benefits.


C  O N C L  U S I O N
With stimulus funding in the mix, the outlook for investment in
clinical applications is strong. Although hospitals have been slow to
adopt EMR and CPOE technology and current adoption of
comprehensive EMR and CPOE is estimated to be below 20%, various
industry estimates predict that 50–60% of all U.S. providers will take
advantage of stimulus funding to install EMR and CPOE by 2016.
This will bring EMRs into use by the majority of providers and
dramatically increase the responsibility of hospital IT departments for
supporting clinical desktops and applications.
Tools like desktop virtualization and application virtualization will be
required in order to support these additional desktops while
maximizing the productivity of both IT and clinical resources. The
benefits that accrue from desktop virtualization projects include cost
savings that will help stretch IT resources and capabilities,
productivity enhancements for providers that will help ease the change
required to move to electronic clinical processes while keeping
providers mobile, and security measures that will help control data
access in the expanding clinical computing environment.

Fast Facts on Stroke

Stroke is a brain attack, cutting off vital blood flow and oxygen to the brain. In the United States, stroke is a leading cause of death, killing over 133,000 people each year, and a leading cause of serious, long-term adult disability.1,2

Approximately 795,000 strokes will occur this year, one occurring every 40 seconds, and taking a life approximately every four minutes.2 Stroke can happen to anyone at any time, regardless of race, sex or age. From 1997 to 2007, the annual stroke death rate fell approximately 34 percent, and the actual number of deaths fell by 18 percent.2 Approximately 55,000 more women than men have a stroke each year. African Americans have almost twice the risk of first-ever stroke compared with whites. Types of Stroke: Ischemic stroke occurs when arteries are blocked by blood clots or by the gradual build-up of plaque and other fatty deposits. About 87 percent of all strokes are ischemic. Hemorrhagic stroke occurs when a blood vessel in the brain breaks leaking blood into the brain. Hemorrhagic strokes account for thirteen percent of all strokes, yet are responsible for more than thirty percent of all stroke deaths. Two million brain cells die every minute during stroke, increasing risk of permanent brain damage, disability or death. Recognizing symptoms and acting FAST to get medical attention can save a life and limit disabilities. The prevalence of transient ischemic attacks (TIA – ―mini strokes‖) increases with age. Up to 40 percent of all people who suffer a TIA will go on to experience a stroke. The estimated direct and indirect cost of stroke in the United States in 2010 is $73.7 billion.

Time is Brain. Call 9-1-1.

Few Americans know the signs of stroke. Learning them – and acting FAST when they occur – could save your life or the life of a loved one. Remember that stroke strikes FAST and you should too. Call 9-1-1.

Use the FAST test to recognize and respond to the signs of stroke.

F = FACE Ask the person to smile. Does one side of the face droop?

A = ARMS Ask the person to raise both arms. Does one arm drift downward?

S = SPEECH Ask the person to repeat a simple sentence. Does the speech sound slurred or strange?

T = TIME If you observe any of these signs (independently or together), call 9-1-1 immediately.

Reducing Stroke Risk

Everyone has some stroke risk. Some risk factors are beyond your control, including being over age 55, being a male (stroke is more common in men than women at younger ages, but more women experience strokes at older ages and more women than men die from stroke), being African-American, having diabetes, and having a family history of stroke. If you have one of these risk factors, it is even more important that you learn about the lifestyle and medical changes you can make to prevent a stroke. However, everyone should do what they can to reduce their risk for stroke – learn more by reading and following the Prevention Guidelines below.

Medical stroke risk factors include:

Previous stroke, previous episode of TIA (or mini stroke), high cholesterol, high blood pressure, heart disease, atrial fibrillation and carotid artery disease. These medical risk factors can be controlled and managed even if you have already had issues with any of them in the past. Talk with your doctor about what will work best for you.

Lifestyle stroke risk factors include:

Smoking, being overweight and drinking too much alcohol. You can control these lifestyle risk factors by quitting smoking, exercising regularly, watching what and how much you eat and limiting alcohol consumption.

Public Stroke Prevention Guidelines

1. Know your blood pressure.

If it is elevated, work with your doctor to keep it under control. High blood pressure is a leading cause of stroke. Have your blood pressure checked at least once each year—more often if you have a history of high blood pressure.

2. Find out if you have atrial fibrillation (AF).

If you have AF, work with your doctor to manage it. Atrial fibrillation can cause blood to collect in the chambers of your heart. This blood can form clots and cause a stroke. Your doctor can detect AF by carefully checking your pulse.

3. If you smoke, stop.

Smoking doubles the risk for stroke. If you stop smoking today, your risk for stroke will begin to decrease.

4. If you drink alcohol, do so in moderation.

Drinking a glass of wine or beer or one drink each day may lower your risk for stroke (provided that there is no other medical reason you should avoid alcohol). Remember that alcohol is a drug - it can interact with other drugs you are taking, and alcohol is harmful if taken in large doses. If you don’t drink, don’t start.

5. Know your cholesterol number.

If it is high, work with your doctor to control it. Lowering your cholesterol may reduce your stroke risk. High cholesterol can also indirectly increase stroke risk by putting you at greater risk of heart disease - an important stroke risk factor. Often times, high cholesterol can be controlled with diet and exercise; some individuals may require medication.

6. Control your diabetes.

If you are diabetic, follow your doctor’s recommendations carefully because diabetes puts you at an increased risk for stroke. Your doctor can prescribe a nutrition program, lifestyle changes and medicine that can help control your diabetes.

7. Include exercise in the activities you enjoy in your daily routine.

A brisk walk, swim or other exercise activity for as little as 30 minutes a day can improve your health in many ways, and may reduce your risk for stroke.

8. Enjoy a lower sodium (salt), lower fat diet.

By cutting down on sodium and fat in your diet, you may be able to lower your blood pressure and, most importantly, lower your risk for stroke.

9. Ask your doctor if you have circulation problems.

If so, work with your doctor to control them. Fatty deposits can block arteries that carry blood from your heart to your brain. Sickle cell disease, severe anemia, or other diseases can cause stroke if left untreated.

10. Act FAST.

If you have any stroke symptoms, seek immediate medical attention.

1 Miniño, Arialdi, Jiaquan Xu, and Kenneth Kochanek. Deaths: Preliminary Data for 2008. National Vital Statistics Reports (2010) 59.2.

2 American Heart Association. Heart Disease and Stroke Statistics – 2011 Update. Dallas, Texas: American Heart Association; 2010.

Sitting is Killing You

Oxigenoterapia hiperbárica e AVC

Autor: Francisco Humberto de Abreu Maffei*

* Professor titular de Cirurgia Vascular, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista.

No presente número do Jornal Vascular Brasileiro, são apresentados dois artigos sobre oxigenoterapia hiperbárica (OHB): uma revisão sobre sua utilização em gangrena gasosa clostridiana e na fasciite necrotizante e a apresentação de três casos de afecções arteriais em que o método foi utilizado como terapia auxiliar.
Embora utilizada desde os anos 60 do século passado, para diferentes afecções1, com base no aumento da oxigenação dos tecidos pelo aumento do oxigênio dissolvido no plasma quando o mesmo é respirado em condições de pressão elevada, o uso expandido da OHB é, ainda hoje, motivo de controvérsias. Apesar de existir um grande número de artigos publicados sobre o assunto, (são mais de 300 páginas de referências na Medline), a maioria dos trabalhos realizados resume-se a descrições de casos e ensaios clínicos não controlados ou com controles inadequados2, o que fornece pouca evidência para sua indicação em diferentes situações clínicas.

Embora não existam trabalhos randomizados, em situações graves, como as de gangrena gasosa e fasciite necrotizante, o seguimento de casos comparados com controles históricos, como os citados na revisão de Lima et al., podem justificar plenamente o uso da OHB, quando disponível, desde que esse uso seja feito após o primeiro tratamento indispensável com fasciotomias e amplos debridamentos de tecidos, associados a antibioticoterapia. Entretanto, em outras situações também graves e agudas, como no acidente vascular encefálico e em lesões cerebrais, em que a OHB poderia parecer de primeira indicação, estudos controlados e metanálises acabaram mostrando que não só esse tratamento é ineficiente como pode ser prejudicial3,4.

Nas lesões isquêmicas crônicas, como as descritas por Costa Val et al., o uso é muito mais controverso e, embora o artigo ora apresentado seja interessante por chamar a atenção para uma possível terapêutica auxiliar, a validade de sua utilização e a relação custo-benefício necessitam ser examinados com muito cuidado. Por exemplo, certamente, todos angiologistas e cirurgiões vasculares lembram de casos similares aos descritos no artigo e que, ao serem tratados, mesmo apenas clinicamente, sem o auxílio da OHB, tiveram evolução semelhante. Por essa razão, para validar essa terapia, mesmo que utilizada apenas como método complementar, como indicam os autores, trabalhos controlados devem ser realizados, para sabermos se existe realmente um efeito terapêutico, principalmente quando o paciente é submetido, além de todos os curativos e medicamentos convencionais, a um procedimento tão espetaculoso, como a colocação em uma câmara hiperbárica.

Numa revisão sistemática recente da literatura sobre o uso da OHB para o tratamento de feridas, Wang et al.2 concluem que, embora esse tratamento possa ser útil para algumas lesões, não existe evidência suficiente para indicar quais os pacientes que dela se beneficiarão e qual o momento adequado para início do tratamento.
Chamam também a atenção para o fato de que sérios eventos adversos podem ocorrer e que ensaios clínicos randomizados e controlados de alta qualidade devem ser realizados para avaliar os riscos e benefícios, a curto e longo prazo, permitindo, assim, uma decisão clínica mais adequada.
Dessa maneira, ainda que seja um método terapêutico atraente, até o momento não existe, em nossa opinião, evidência suficiente para, por exemplo, justificar a aquisição de uma câmara hiperbárica para uso em pacientes vasculares. Justifica-se sim, para os colegas que disponham desse equipamento, a realização de ensaios clínicos bem planejados e conduzidos, cujos resultados possam confirmar, ou não, a validade de sua utilização.



Referências

1- Kindwall EP. Hyperbaric oxygen. Br Med J 1993;307:515-16.

2. Wang C, Schwaitzberg S, Berline E, Zarin DA, Lau J. Hyperbaric oxygen for treating wounds: a systematic review of the literature. Arch Surg 2003;138:272-9.

3. Alternative Therapy Evaluation Committee for the Insurance Corporation of British Columbia. A review of the scientific evidence on the treatment of traumatic brain injuries and strokes with hyperbaric oxygen. Brain Inj 2003;17:225-36.

4. Rusyniak DE, Kirk MA, May JD, et al. Hyperbaric oxygen therapy in acute ischemic stroke: results of the hyperbaric oxygen in acute ischemic stroke trial pilot study. Stroke 2003;34:571-4.