Citrix XenDesktop Delivers Cost Efficiencies for Hospital

• Needed to streamline desktop delivery while supporting multiple campuses.
• Construction of new main hospital limits staff onsite, therefore remote access for staff are remote sites are critical.
• “…without the centralized management capabilities of XenApp and XenDesktop, I would need twice as many people.”

Alameda County Medical Center

Alameda County Medical Center in Oakland, California, serves as the healthcare safety net for the county, providing care to all residents regardless of their ability to pay. The medical center has six campuses that include two hospitals, ambulatory clinics, rehabilitation services and a psychiatric facility. There are approximately 2,700 employees.

The challenge: streamlining and tailoring desktop delivery to reduce IT workload

As user requirements evolved, the IT team began looking at ways to tailor the standard desktop being delivered to all clinicians and staff. “For simplicity, we created one published desktop with all the applications that the clinical and support staff could possibly require. Unfortunately, even if they didn’t use all these applications, people tended to click on the icons to see if the applications would work – and call helpdesk when they didn’t. This situation added to our workload – and with multiple campuses, we were already stretched very thin. We needed to find an easier way to build and deliver customized desktops with only the applications each person needed to do their job.”

Expanding the Application Delivery Infrastructure from Citrix

When Citrix introduced Citrix® XenDesktop™ for desktop virtualization, Alameda County Medical Center decided to add this solution to its application delivery infrastructure. Bennett selected the Platinum Edition of XenDesktop to enable delivery of tailored, virtualized desktops to about 200 users.

In addition, the medical center turned to another Citrix solution – server virtualization – to support a planned disaster recovery site. “We have a small datacenter located about 13 miles away from the main campus that we want to use for disaster recovery,” said Bennett. “To save money and optimize flexibility, we decided to implement Citrix XenServer and Citrix Provisioning Server for Datacenters. Virtualization will reduce the amount of server hardware needed in the failover site, and will accelerate server provisioning during an interruption.”

Policy-based desktop virtualization enhances control, efficiency and flexibility

Bennett looked at XenDesktop as a way to leverage the existing Citrix XenApp environment, but manage it more easily and efficiently with a small IT staff. “XenDesktop offered us the ability to use policies to tailor desktops to the particular needs of different users. We can provide a basic desktop and then specify the required applications for each user or group of users. For example, based on policies, registration clerks will get all the applications and resources they need – but no more. With XenDesktop, we don’t have to spend time building each desktop or worrying about adding a new resource – everything is automated, and the correct desktop is dynamically assembled each time the user logs in.”

With XenDesktop, policies can also be applied to control the user’s environment, such as limiting the ability to upload files if the user is connecting from a home PC, to support confidentiality of medical information.

He added, “And Citrix technology has improved the performance of our picture archiving and communications system, or PACS, enabling us to include it and any other problem application together with XenApp hosted applications in the virtualized desktops. XenDesktop gives us more flexibility in what we can deliver to our users, and avoids the need to run applications locally.”

“Overall, Citrix enables us to accomplish more with the staff we have. In fact, without the centralized management capabilities of XenApp and XenDesktop, I would need twice as many people.”

A consistent user experience on any device

With Citrix virtualization technology, the medical center’s employees can access their desktop from any device in any location, such as a cart on wheels, or a PC in a doctor’s home office. “Some of our doctors want to connect remotely in order to work outside the medical center,” said the IT director. “XenDesktop supports that by delivering a desktop with same look and feel they are used to in the hospital.”

Another benefit of XenDesktop will come into play when Alameda County Medical Center begins rebuilding a portion of its main hospital to meet earthquake standards. During construction, only a limited number of staff will be able to work on the main campus, and many will have to be relocated to remote sites. “XenDesktop will help facilitate this project because we can centrally deliver desktops anywhere, with the same user experience. We expect this to ease the disruption for employees and my IT team.”

A cost-effective solution for server virtualization

In addition to providing flexible, consistent access to applications during normal operations, Alameda County Medical Center is working to ensure uninterrupted delivery in the case of a disaster. With Citrix® XenServer™ and Citrix Provisioning Server™ for Datacenters, the organization not only will benefit from rapid provisioning of virtual servers in its new failover center, but is saving money in the process.

“Public hospitals today face severe financial challenges, so any time I can get more bang for the buck I need to do it. We compared XenServer to the competition and found that we could achieve the same results but at a definite price advantage. I estimate we saved 30 or 40 percent with XenServer, and we got the Platinum Edition to boot.”

Bennett concluded, “We have had phenomenal success with Citrix products and now we are expanding on that success with desktop and server virtualization. Citrix is changing the way we look at application delivery and opening new doors for the medical center.”

Electronic Medical Records (EMR) implementations have their own, unique challenges. Healthcare organizations are concerned with selecting a vendor, complying with a myriad of regulations, and basically transforming the way healthcare is delivered to their patients.
Given the transformative nature of an EMR implementation, virtualization is often just a side thought for health CIOs. Therefore, I’d like to shed some light into the topic and share my personal top 5 reasons to pursue this topic further- starting with the centralization of medical records data.
For a quick definition of the term itself, please refer to yesterday’s blog.
I assume that the backend database for your electronic health records reside in a single, centralized datacenter. Through global server load balancing, you may have already implemented site-to-site redundancy, but that’s beside the point for today’s discussion.
So, traditionally, you would have rich client applications or web browsers on the user’s endpoint to consume and manipulate the medical records data. This automatically implies that a lot of health data moves to and from the datacenter and often to remote locations where it is challenging to maintain a tight grip on security.
Application or Desktop Virtualization can solve that problem. Both of these techniques move the client software piece (or web browser) to the datacenter, where it executes securely inside your facility. The health data never even leaves the datacenter. The user interaction happens via a secure, high performance protocol (such as Citrix’ HDX in the XenApp and XenDesktop product lines) and gives the user a snappy interaction with the software, while only exchanging screen updates and keyboard/mouse events between the end user and the datacenter. Additional data streams pertaining to peripherals, printers, USB devices, scanners, and client hard drives are possible, but can easily be disabled to promote further security.
No data ever makes it to the end point, and therefore reducing the risk of HIPAA/HITECH covered security breaches. In addition, user sessions can be audited to establish an independent trail of information in case the regulators or courts require a closer look.
If you’re curious, I encourage you to check out Dan Feller’s Ask the Architect site. Dan has a wealth of information on desktop and application virtualization and associated whitepapers and reference architectures.
Florian Becker
Twitter: @florianbecker
Virtualization Pulse: Tech Target Blog
Ask the Architect – Everything Healthcare

The following is a blog I posted on my “other” site – Virtualization Pulse, hosted by Tech Target. Most readers on these pages are already very knowledgeable, so please forgive the simplistic view. In the near future, I will publish additional blogs on virtualization and specifically focus on the the healthcare IT space. Consider this one a relatively simple level-set for the audience. Enjoy.
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Given that there are a lot of incentives associated with the adoption of Electronic Medical Records, medical CIOs and their teams are inundated by vendor messages these days. Phrases like “Meaningful Use”, “HITECH”, “HIPAA” are on the forefront of everyone’s mind, but you may also hear about virtualization. Given that there is still some confusion on the topic, I’d like to clear a couple of things up:

“Virtualization” is a term that has been traditionally used in the context of server virtualization. The technology involved is often referred to as “Hypervisors” which basically allow a modern server with plenty of CPU and Memory resources to share those resources between multiple “workloads” or “virtual servers”. So, instead of having one physical server with 16 CPU cores and 128 GB of RAM, this server can often house 40-60+ individual workloads that act on your network just as if they were much smaller individual servers. The benefits are obvious. Today’s servers are relatively cheap to acquire and most server workloads don’t require nearly as many computing resources to do their job. IT departments can lower cost by running fewer physical servers, consume less rackspace, lower power consumption and cooling costs. Advanced virtualization solutions also allow for virtual servers to automatically move to a separate physical host in case of a hardware failure. The failover process is often seamless and therefore provides resiliency, but typically requires a separate, redundant storage area network for this to work on the fly. Workloads with less criticality can be moved in a semi-manual fashion where they are simply restarted on another physical host by the administrator.
Vendors in this space include VMware (vSphere), Citrix (XenServer), Microsoft (Hyper-V) and a number of other players.

Application Virtualization. This is another form of virtualization, which has virtually nothing to do with server virtualization (pun intended). In this model, an application (think about your office productivity suite, or your electronic medical records client) is installed on a central server and executes there. The user connects from their endpoint (PC, laptop, thin client devices, etc.) via a remoting protocol and essentially controls the application remotely. This can be done on the simple level with Microsoft Terminal Services and the RDP protocol, and on the higher end via specialized solutions such as Citrix XenApp (formerly known as Presentation Server or MetaFrame). The benefits are obvious. Applications can be centrally managed and IT support personnel would no longer have to touch an end users system to install or patch an application. All updates are performed on a few centrally located servers. This approach also has the advantage of the application being physically close to the backend data of the app (on a low-latency, high bandwidth network), which leads to faster execution of the app and much increased security as the data never leaves the datacenter. The only information that is exchanged between the end-user’s device and the central server are screen updates and mouse and keyboard events. The protocols also include the capability of conveying information such as audio, printing, USB device support etc. The performance is actually astonishing in many cases and the most demanding customers in the area of engineering run their complex design applications via Citrix XenApp.

Desktop Virtualization. This is the latest and greatest. Instead of executing just a set of applications in the datacenter, the industry is moving towards executing desktop operating systems in the datacenter and allowing users to connect to the desktops . One could write a whole book about desktop virtualization, so I am trying to keep it brief. Some vendors tout a “VDI” or “Virtual Desktop Infrastructure” model, where each user basically has their own, assigned, virtual desktop in the datacenter. This model moves the headache of desktop maintenance to a central location, but still encounters some of the same challenges associated with traditional desktop management (such as the need to patch multiple desktop instances and troubleshoot/fix corrupted or infected desktops).
More advanced models go towards a shared desktop image model, where each user connects to a brand new, pristine desktop operating system, which folds the applications and user settings into the desktop as the user connects. This has the advantage of ensuring the highest performance (after all, a brand new desktop always performs best) and can also cut down on the number of desktops to maintain. Having just one or a handful of desktop master images to patch and maintain for thousands of users provides great efficiency gains and cost savings.

So, let’s recap. Server, Application, and Desktop Virtualization are three distinct disciplines in healthcare IT and are important to understand. Don’t fall for the siren’s song and believe that a particular vendor who is good at one discipline is automatically an expert at the other virtualization disciplines.
Check back on these pages in the near future for my rundown on virtualization techniques for your EMR implementation.

Florian Becker
Twitter: @florianbecker
Virtualization Pulse: Tech Target Blog
Ask the Architect – Everything Healthcare

…No, I am not talking about the world-famous subway system in London, but rather like to pick up the topic by Dr. Philip Chase on the Physician’s view of an EMR. Dr. Chase describes how a recent visit to his physician revealed that the esteemed healthcare provider spent a lot of time typing Dr. Chase’s answers into an EMR application. The physician’s attention was divided between the patient and the computer system and the entire encounter had the appearance that the EMR itself interfered with the doctor – patient relationship; hence the “gap” between data acquisition and data entry.

Since there’s a lot of talk on EMR’s these days (one recent blog post describes the HITECH Anxiety), I figured it be a good time to reiterate some of the common sense EMR thoughts and best practices.
• Doctors don’t want to be IT admins. Correct. I don’t think they have to. Purely Internet-based EMR vendors use this tagline to entice providers to move all of their patient data to a hosting provider, but many physicians are more comfortable with on-premise solutions. Roughly 50% of office visits are delivered by 1-2 doctor practices. Like many other small business in all kinds of verticals, physicians can rely on other (often small) businesses in the IT / Computing world to setup a local system and support a locally running EMR. It’s “my computer guy” who takes care of installing, maintaining, patching, and backing up the systems in any small business, regardless of the industry. Action: Think about hosted vs. on-premise systems and pick the ones that you are most comfortable with.
• Usability is key. You don’t want your patients to stop seeing you, because the visits have become impersonal. Don’t focus more than 5-10% of your patient time looking at a computer screen. This will require discipline and some practice. Pick EMR software that lets you work from selection lists and templates rather than free text. Practice some typing (if that’s new to you) and have a vendor demonstrate the speed of documentation and order entry to you.
• Devices play a big role. Bigger than you think. Vendors bombard you with different options. Everything from regular office PCs, laptops, tablet PCs (including the Apple iPad), to computers on wheels (COWs) are options. Depending on your practice setup, one or more of these may fit. Here are some thoughts: Don’t set up your devices statically (that would require you to turn your back on the patient on occasion). If you go for wheeled devices, make sure they are not clumsy or blocking your space and movement in the practice. Ensure that wireless networks reach all your exam rooms and provide good signal strength. Consider a tablet device as you can carry it around. Be mindful of the device often occupying at least one of your hands that you won’t have avalailable to examine or treat the patient. Some devices with smaller form factors are said to fit in a lab coat. Try it before you buy! Consider the devices battery life and screen size. Action: Try the different devices in conjunction with the short list of EMRs you’re considering. Some vendors have specific user interfaces for mobile devices or iPads that improve usability when using a multi-touch interface.
• Multi-user environments pose special challenges. If you have more than 1 clinical user or running a group practice, consider the fact that physicians will physically move away from a device and into the hallway or next exam room. Unless you choose portable devices, consider fast log off and log on modalities and session roaming. The latter can be achieved through application and desktop virtualization, where your application executes centrally and the “terminals” in the exam rooms and hallways just provide interactive access to the application.
• Offsite usage. Nothing is more annoying than not having access to a system when you need it. Ensure that your system has secure offsite access built in. In most web-based EMRs , you should be covered. More elaborate systems may require app or desktop virtualization where the apps and data stay securely tucked away in the data center (or data closet, depending on your size) and allow your users to connect securely over the Internet to the user interfaces of the apps. Action: Discuss those options with your “computer guy” and your EMR vendor.

I plan on sharing more specific virtualization best practices with you in the upcoming weeks and months. Please let me know if there are specific topics you would like to hear about.

Florian
Twitter: @florianbecker
Ask the Architect – Everything Healthcare
Tech Target Blog – Virtualization Pulse

Computerworld posted an article titled E-Health and Web 2.0: The Doctor will tweet you now. The title made me cringe, to be honest. If any medical provider would communicate with a patient via facebook or twitter on patient related topics, we’d have an avalange of lawsuits on our hands. Thankfully, it is not that bad as the article cited above describes electronic communications between doctors and patients accurately. However, the slightly misleading title still leads me to believe that some clarification on web and social media is in place.

• Ever heard of email? It’s this killer app that spread from scientists to the rest of the world in the mid-to-late nineties. It’s not inherently secure, but there are systems that allow for secure communication and it is slowly being discovered by the healthcare world to allow patients and providers communicate with one another. Instant messaging also falls into this category and so is text messaging (txt is really a special form of telephony and we have been using that killer app for at least 50 years to communicate with our doctor). Sophisticated EMR vendors have implemented such capabilities into their systems. There are many, but Epic’s MyChart module comes to mind – for an idea on how it works, check out the various Group Health Seattle Ads: I actually only found a recent one here. Group Health Seattle implemented MyChart and secure patient to doctor communication in 2002/2003 – long before YouTube became mainstream, so I can’t find the original ads, which also shows you that this is nothing new. The key here is that patients and providers don’t use the “traditional” email systems that are often available for free by various providers on the Internet, but implement a system directly into the Electronic Medical Records app, which has the added benefit that the communication becomes part of the patient’s record.

• Twitter and facebook are still relatively new, and are certainly not intended for any kind of point to point communication, but rather for dissemination to larger groups or “Communities of followers”. Businesses (Joe’s Pizza as much as a doctor’s office, larger group practice, or large hospital) leverage twitter, facebook, MySpace, etc. to update their customers about things they deem important. Announcing new products or services, sending links of interest, or providing patient education on general topics are all things that lend themselves greatly to twitter and facebook. By the way, the same information can be effectively distributed via email lists, but twitter and facebook allow for customer controlled opt-in and opt-out. Both sides win – customers don’t get annoying unsolicited emails and business don’t have to manage email lists. Again, evem the direct message feature in twitter does not lend itself to securely communicate with patients, hence my introductory cringing at the beginning of this blog.

• Speaking of blogs….Blogs are also labeled “social media”. The idea is really nothing new. In the old days (by that, I mean the very old days in the mid 90s), we had to teach ourselves HTML, stand up a web site, and voila – we could get our thoughts and comments out on the web. In my mind, blogs are the great equalizer as they are very easy to use and provide the technical means to publish articles and opinions to the web (some are rants – actually, this blog could be described as a mild rant) . Blogs often allow for others to comment on the original article and that way get a nice discussion going. In healthcare, blogs play an important role as patients can discuss their own conditions with others (often anonymously by using screen names instead of their real names). This also allows for the sharing of information and the establishment of a support network. It’s the 2009 version of Fight Club without the hugging. Twitter and blogs often go together as bloggers leverage twitter to announce a new post to their community of followers. Healthcare providers can provide pro-active patient education via blog sites and use twitter to let their patients know that something noteworthy has been published.

So – none of these concepts are new or revolutionary in my mind. These are old technologies that either make the administration easier (blogs) or allow more user control when it comes to information blasts (twitter, facebook), or facilitate point to point communication (email, IM,txt). It goes without saying that both patients and providers must carefully consider their privacy (and the associated regulations) when using either of these media forms.

Thoughts? Comments? Please post them here.
Follow me on twitter: @florianbecker