November 16, 2009

Virtualization — In Many Ways Better Than ‘Real’ Systems

By Dan Harvey
Radiology Today
Vol. 10 No. 18 P. 8

You’ve likely heard that only 10% of most people’s brain power is used, with 90% remaining untapped. A similar ratio applies to computer technology, including medical imaging’s networked systems, servers, and storage.

“Only about 10% of resources available on any physical server are actually used; the remaining 90% are wasted,” says Jim Conyers, advanced solutions manager of network systems for FUJIFILM Medical Systems USA, Inc. But computer technology has found a way to tap more of that potential: It’s called virtualization. Companies are harnessing this approach to increase healthcare systems’ functionality, minimize downtime, and protect against disaster.

Virtualized Vision
Basically, storage virtualization separates logical storage from physical storage. Conyers describes the impact: “Physical servers possess numerous resources such as memory, processing power, bandwidth, disc space, CPU [computer processing unit], network cards, among others. Virtualization enables utilization of all available capabilities.”

However, virtualization involves more than just deploying underexploited resources. Virtualized server environments utilize storage and server configurations that increase efficiency via minimized downtime and through remote archiving, business continuance, and disaster recovery capabilities. Virtualization eliminates so-called single failure points, providing business continuance during upgrades and preserving data during disasters.

“Complete hospitals were lost during Hurricane Katrina, and recent severe storms in Iowa knocked out facilities’ data centers,” says Conyers. In the event of future calamities, advanced virtualization technology could enable damaged facilities to shift to a data center located in an unaffected area in only a matter of minutes. “That’s crucial to the referring physicians and radiologists who administer patient care,” Conyers says. Virtualization permits clinicians to be up and running as quickly as possible.

Additional Benefits
Virtualization also reduces costs. “It allows us to place between five and 50 virtual machines within a single box,” says Conyers. “Virtualization lets users realize the most bang for a buck from a $20,000 server.”

This approach also shoehorns capabilities into a small footprint. “Historically, PACS and RIS have encompassed many servers,” says Conyers, adding that an environment that included as many as 198 servers spread across 22 server racks wasn’t unusual. “Virtualization can reduce that conventional environment down to nine servers and reduce server racks to one.”

A reduced footprint addresses “real estate,” which is at a premium within a healthcare facility or health system. As Conyers points out, virtualization allows management to shift its focus from computer systems to patient care and new technology implementation. “Administrators have more important things to consider,” notes Conyers. “They’d rather direct their financial resources toward enhancing their oncology capabilities, for instance, or to expanding their radiology department or increasing the number of patient beds.”

While organizations seek to decrease costs and space usage, they must remain fully functional. Agility is the key, says Conyers, and virtualization fosters that suppleness. “Systems must be robust and agile and provide room to move. If not, an application outgrows core technology. When that happens, you can’t support advanced imaging technology such as multislice CT technology. Virtualization fosters scalability, and scalability fosters organizational growth,” he says.

Advancement Through Collaboration
Two years ago, Fujifilm began collaborating with VMware Inc, a Palo Alto, Calif.-based virtualization technology provider. PACS and RIS are intensively intrusive implementations on a healthcare network, so Fujifilm sought to ensure that customer environments would be suitable to sustain applications such as its Synapse technology for PACS, RIS, and cardiovascular applications. Suitability, Conyers adds, is accomplished through Fujifilm/VMware development, testing, benchmarking, and product validation. “The approach enhances customer benefits, as it ensures that our core architecture’s continuous and unlimited evolution proceeds without any roadblocks,” he says.

Now, more than one dozen sites working with Fujifilm are fully virtualized. Customers run the gamut, from the small, 10,000-annual-study sites up to large organizations that perform 1.8 million annual studies, reports Conyers. No matter the size, the customers are completely virtualized and haven’t endured the problems that can arise with a mix-and-match approach.

OhioHealth Goes Virtual
OhioHealth in Columbus provides a representative example. The five-site, 2,000-bed health system includes 120 radiologists working from a common PACS. The relationship began in 2005 when OhioHealth sought a cost-effective way to implement many new software solutions, as well as facilitate a comprehensive business continuity and disaster recovery strategy.

“For us, virtualization is about removing all physical hardware associated with the many applications we run,” says Scott Starkey, the organization’s director of digital imaging. The most important benefit, he adds, is the resiliency that hardware elimination provides, as well as the mitigation of hardware failure risk. “If necessary, we can move applications between data centers, which is important to a large enterprise such as ours.”

The process began in 2006 and involved OhioHealth’s most critical components, including PACS servers. VMware’s technology helped virtualize the servers and environment. Specifically, OhioHealth implemented the company’s ESX 2 solution to virtualize its Hewlett Packard Blade physical servers.

OhioHealth started by running 60 virtual machines on four physical hosts. Now, nearly two thirds of servers reside in the virtual environment, including all hospital information system servers, 18 PACS servers, and most DICOM servers. With critical servers currently virtualized across the second data center (a live remote center with a replicated storage area network and redundant server farms and network infrastructure), OhioHealth quickly and easily shifts to its virtual server when problems occur.

Starkey says such benefits, especially when coupled with reduced costs, offset any challenges. “It’s substantially less expensive to deploy a virtual environment, from both a hardware and operating system [OS] perspective,” he says. In a virtualized environment, machines typically cost about $1,000 compared with physical server configurations that can run as high as $15,000. In addition, peripheral costs related to power output and cooling and space requirements are greatly reduced or eliminated.

But the most important advantage is the resiliency provided between replicated data centers, says Starkey. OhioHealth experiences zero recovery time, or downtime, which it couldn’t have achieved without virtualization. “The previous stand-alone production system recovered from disaster with spinning disk and tape. But this proved vulnerable to human error and resulted in prolonged downtime,” he says.

Upgrading Desktops
As it moves forward in the virtualization direction, OhioHealth is focusing on the desktop element of PACS, which will enable referring physicians to view reports and images through its Synapse product. The enterprise has nearly 8,000 desktops. “Desktop maintenance is one more challenge inherent in the physical environment,” explains Starkey. “As we’ve virtualized the back end, we’re now shifting our focus to the front end, which means virtualizing desktops for the thousands of physicians that read our images.”

To this end, OhioHealth is testing VMware technology and a virtual suite to promote remote access. This will not only improve service to referring physicians and radiologists, it will also further improve cost-efficiencies and increase referrals. Ultimately, it will contribute to the overall positive impact that virtualization has on patient care delivery. “PACS needs 100% uptime. We can’t allow any opportunity for downtime. That’s the key to all of this,” says Starkey.

Symbiotic Development
Virtualization not only helps the healthcare facilities and systems that embrace this evolutionary direction, it also benefits system providers. “It helps a company like us because we focus much of our work on system development and integration,” says J. Martin Pfaff, PhD, president of Intuitive Imaging Informatics, LLC, another virtualization-focused business. “Every time a new OS or piece of hardware is introduced, we spend 30% to 40% of our time migrating and validating software between different systems, to be able to support better and faster OS technology.”

Like Fujifilm and VMware, Intuitive offers affordability, scalability, and customization.
“Storage needs and storage technology are more complex,” Pfaff says. “Sophisticated applications must handle the distribution of exams across a multitude of servers, each with OS and hardware differences.”

Hardware independence is a driving force. “Developers and users don’t want to constantly modify their systems to accommodate the latest hardware and OS, as these things tend to change every six to 12 months,” explains Pfaff. “Virtualization offers a lot to companies like Intuitive that seek to take advantage of the latest technology.”

Intuitive offers a complete, integrated imaging solution comprised of Rational Imaging PACS, the Web-based ImageQube PACS, storage, and RIS integration. These are interoperable with other standards-based PACS/RIS components. “PACS customers need the ability to expand their storage capacity, and we designed our storage applications to handle a variety of distributed ‘appliance’ type storage servers. Virtualization greatly helps this architecture,” says Pfaff.

Such needs drive Intuitive’s development, and its relationship with Mercy Medical Center in Cedar Rapids, Iowa, illustrates this symbiosis. The medical center has worked with Dell and Hewlett Packard, which provide affordable hardware prices. “We’re a PACS provider that offers an integrated solution, but this case represented an exception. We partnered with the center to develop software and functionality on the center’s preexisting hardware,” Pfaff says. “This gives our customers more choices and allows them to leverage preexisting relationships.”

This is where virtualization became important, he points out. “It allowed us to utilize our software without modification and let the virtualization technology handle the OS/hardware differences,” he says.

“PACS has become a critical component of patient care,” Pfaff adds. “In hospitals providing urgent care, server downtime is not an option. Fortunately, Stratus, our virtualization partner, developed server clustering virtualization, allowing one of the servers to function independently if the other server fails. This is a breakthrough because our system and the databases used were not designed for clustering, yet we can now provide this functionality through virtualization.”

Thin Provisioning
Pfaff cites another client example, involving AtlantiCare Health System, southern New Jersey’s largest healthcare provider. The organization is one of Intuitive’s largest customers, and it realized benefits from one of virtualization’s many elements: thin provisioning. “This enables you to increase storage space on the fly,” says Pfaff.

For instance, if a facility server possesses a 50 TB storage area network and the facility needs more for radiology, the need is easily accomplished. Previously, it was a bit more difficult, as facilities would have to carve out new disc space and buy new hardware. “That’s what AtlantiCare likes about virtualization,” says Pfaff. “Not only did we simplify the process, but they don’t have to bust their budget.”

Intuitive serves both large and small customers and doesn’t always need to create innovative new solutions. “For instance, smaller accounts typically don’t need the level of horsepower provided by multiple, independent servers,” says Pfaff. “They can place the PACS image manager and RIS database on a single server, using virtual OSs to provide acceptable environments for each.”

Broad Perspective
While radiology professionals may not comprehend the specific IT elements of virtualization—after all, it’s not their province—they quickly grasp the no-downtime advantage. “I’ve talked with radiology department directors, radiologists, and technologists, and they all want to know what virtualization means to them and how it differs from a physical environment,” says Conyers. “But what they’re really asking is how it will impact their systems’ availability. What happens when their system is upgraded? How long will they have to do without? Will they experience a backlog?”