When he joined Great Ormond Street Hospital as IT director three-and-a-half years ago, Mark Large was faced with immediate issues as the result of an ageing IT infrastructure.
Staff were tied to their desks because there was not a viable mobility option, wireless coverage was poor, and there was an inability to locate assets in a timely fashion. This led to a lack of efficiency that had to be resolved.
"The first week I was here, the problems the hospital had became graphically clear to me," he said.
Large's first priority was to get the network fixed. He took the opportunity to assess the best strategic direction the hospital’s IT should take. Along with his immediate goals, it was a priority for Large to have no single point of failure in IT.
He views the IT platform at Great Ormond Street as a tool to provide clinicians with the information they need wherever they are, whether that is at the bedside or in a remote clinic. Building this platform required an entire renovation of the hospital's IT infrastructure.
He chose Cisco for a medical-grade network, with no single point of failure, which could provide the resilience the hospital needed. The network is run as a managed service, which is currently provided by Block Solutions.
Why standards work in healthcare IT
Great Ormond Street Hospital IT director Mark Large has been working in IT for 30 years, having started out at Guys Hospital. "I started in IT in the days before we had computers in schools. I had to wait until university before I saw my first computer," he said.
Prior to Great Ormond Street Hospital, Large worked mainly in the private sector. He spent eight years at Oracle, where he ran consulting practices, including Server Technology and Technical Architecture in the UK, and created the UK arm of the System Performance Group.
His motivation is to bring the experience of the private sector to the NHS, and he is a firm believer in strategy, standards and architecture.
The hospital recently upgraded its picture archiving system to one that is based on open standards.
Large said it told the supplier: "We don’t want to bring in another SAN. We have a pair of SANs already which are perfectly capable. Nor do we want to have to move the images again when we replace the picture archiving system.”
As a result, Great Ormond Street chose a vendor-neutral archive-based system, which supports the XDS and XDSI standards, and the potential for cross-enterprise as well as cross-organisation sharing using IHE (integrating the healthcare enterprise) standards.
“The NHS Information Strategy is no longer about one size fits all. It’s about interoperability; you can only interoperate easily if you follow standards and have a strategy to work together," he said.
The network project ran for over two years. "We replaced the entire wired and wireless networks. We moved from basic wireless coverage in some clinical areas to site-wide wireless," he said. The wireless network at Great Ormond Street now provides seamless roaming as well as being the basis for a highly accurate asset tracking network. This allows clinicians to walk throughout the hospital wirelessly connected, unlike the old wireless system which lacked coverage.
The wireless LAN also works in conjunction with radio frequency identification (RFID) asset tracking. More than 950 pieces of medical equipment have been fitted with electronic tags, including wheelchairs, infusion pumps, beds and specialist cots. "We now have an asset-tracking network that can track assets to within two metres," Large said. “Staff can locate equipment quickly when they need it, freeing up more time to be with patients.”
Video collaboration with telepresence is another key part of the hospital’s transformation strategy, which is built on top of the network infrastructure. Clinicians can use a tablet to watch recordings of operations, participate in multidisciplinary meetings, share visuals such as x-rays, or pull up a presentation. Laptops are loaded with Jabber for TelePresence, so that the clinicians can set up telepresence sessions in real time.
Improving the reliability of IT
In terms of reliability, Large said that when a wireless controller hit problems recently, no one even noticed. "That is the beauty of a proper architectural approach – resilience is built in," he said.
The network uses dual network cores with switches configured in stacks. The cores are in different locations, so if there is a problem in one area, the network will continue running – unless there is a really major catastrophe, in which case IT may not be an immediate problem. Dual fibre links connect communications rooms to each of the cores, so if one link fails, the other carries on working. This is a key foundation stone in the objective of having no single point of failure.
The server rooms have also been virtualised on Citrix Xen, with dual redundancy using two buildings – Southwood and York House on either side of Great Ormond Street – connected by fibre links across the road. "We have multiple virtual pools spanning the server rooms on either side of the road, so if there is a problem in one server room, services can be accessed from the other," said Large.
There is a dual NetApp SAN running in both server rooms, so even on a hot day, if one of the air-conditioning units fails in a server room, he has choices. For instance, he is able to switch off one half of the SAN to maintain reasonable operating temperatures, thereby maintaining the widest possible range of services, albeit at a slightly higher level of risk.
Large prefers virtualised environments, due to their inherent stability and the flexibility virtualisation offers. But if an application cannot be virtualised, he tries to run it in a clustered environment, to minimise the risk of downtime. Those applications that cannot be virtualised or clustered, are run on dual servers.
"This is the technical architecture strategy we have in place to preserve the business continuity and stability of our systems," he said.
The network, for instance, which was offline during part of the week Large joined Great Ormond Street Hospital, now offers six to seven nines availability – which represents 3.15 seconds of unscheduled downtime per year.
But such a low level of downtime is no longer available only to the largest institutions and governments with massive IT budgets. The architecture Great Ormond Street Hospital has deployed means Large can minimise scheduled downtime at a price that is affordable.
“Technology has moved on so much that, if you do it the right way (by following a technology strategy, building up the architectural layers and making sure everything works well together), resilience and high availability can be achieved at a very reasonable cost,” Large said.
This level of stability and resilience is what is needed to run clinical systems. It is the stability that gives him the confidence to embark on a major push to provide mobile access. “When you have mobility, you must not only [provide] stability in terms of the network connection, but also stability of the systems,” he said.
At Great Ormond Street Hospital, Large is pioneering the drive to IT consumerisation. "The key driver for us is moving away from paper to electronic information, thus it must be common sense to provide secure access to systems at the bedside. Otherwise, people will continue to print paper and write on it,” he said.
Using paper restricts people's ability to access real-time data, because the paper notes can only be in one place at a time, and any updates need to be keyed in at a terminal.
"Our whole technology push is about putting in a stable platform based on commoditised IT, which is there in the background," said Large. "It is extensible and can scale in whatever direction we need. Mobility is really key. Having electronic medical records without access to them at the bedside does not make any sense."
Previously, IT did not support Apple devices on the network. Large believes having conversations about which devices to support is a waste of time. "What we need to do is provide a service that can be consumed by our clinicians," he said. "It's about providing secure choice."
The patient administration system, for instance, requires a larger screen, which makes it suitable only for tablets and laptop devices. However, Large has deployed iPod Touch devices among the hospital's allied health professionals that run an app which looks like something from the Apple Appstore. The app is actually a web page that can only be accessed within the hospital's secure wireless network.
"As a busy nurse, you don't have the need or capacity to carry an iPad, but the iPod Touch fits in a pocket and is superb for entering small amounts of observation data," said Large.
Being able to choose the right device for the circumstances is key. At its most basic level, Large is aiming to provide a Citrix desktop to any client device that can use Citrix Receiver software to run a protected virtual environment.
Citrix takes care of the security aspect because your mobile device just becomes a window onto the systems. Beyond Citrix, e-mail and calendars can be accessed from other devices. For instance, the hospital has deployed iPads, using MobileIron to deploy policies and standards to enforce security and block classes of apps that might be a security or governance risk.
He said it has to be particularly careful of some of the social media apps, since it is a children’s hospital, so it tries to stick to a gold image of known apps, so they are deployed centrally. “There is no problem people requesting apps to be installed, and we will look at whether those apps are useful to the wider hospital.”
We have had a wireless controller hit problems and no one notice. That is the beauty of a proper architectural approach - resilience is built-in
Mark Large, IT director, Great Ormond Street Hospital
Hospital-issued iPads use a security certificate to connect to the wireless network. “We want people to have choice, but that must be in a secure way,” said Large.
Before he arrived at Great Ormond Street Hospital, the IT department was not keen on taking Apple devices in-house, but could not ignore the fact that clinicians were doing innovative things with Apple products. Along with the iPad, the cardiac MRI system uses Apple servers.
It had clearly grown into more than a secure local store, he said – it had become a key part of a critical service, but at the same time, ran on a single server, and thus it had a single point of failure.
“We worked with Cardiac MRI to take the system out of the department into pair of server rooms, with two servers, so that if one failed the department could continue to provide service from the other, and we put them on the network,” he said.
This improved workflow, in terms of getting images from the cardiac MRI system to theatre. He said the system now has the capacity to grow and, in time, it will become part of the main PACS supplier-neutral archive.
“We made the Cardiac MRI system robust and secure, and transferred all the images onto our network,” said Large. This means workstations in operating theatres can call up images from the image store on the network in seconds, using Mac workstations and iPads with the Osirix image processing engine.
Challenges in planning ahead
Given that the network is highly resilient, and his IT infrastructure is built on the principals of no single point of failure, Large said the challenge for him is in planning ahead.
Having moved the hospital on a long way, the expectations are still high about what more can be delivered. He believes those expectations are justified.
"While a lot has changed, we are still far from a perfect situation. There is still more that must be done," he said. "Three-and-a-half years ago, when I was being interviewed by the finance director [for the post at Great Ormond Street Hospital], I did a presentation on the future of the hospital. Six months ago I revisited that presentation. Even I was surprised at how much had been achieved, and the ongoing relevance of the parts that had not yet been completed. But any strategy can only talk sensibly about a three-year plan – years four and five are more of a vision than a firm plan, so you have to keep updating the strategy.”
Large is now on the second iteration of his IT strategy, which runs over a three to five-year timescale. "We think about the most efficient way to change not only the lives of the people who work in the hospital, but also the experience of the patients, many of whom are very technology literate," he said. "They think nothing of using social media in ways that we can find very challenging to engage with. For them, it is second nature."
Large has selected a few key strategic suppliers: Cisco for the network; Citrix for virtualisation; Microsoft for the database, configuration management, etc; and NetApp for the storage area network. He feels it is important to have a real partnership with the strategic suppliers, which have the blue sky thinkers that can help the hospital understand what is out there, in terms of technology options, and where the future could take us.
“The key is to make sure the architecture is robust – and robust architectures tend to be simple in the way they are conceived. If you have something that is too complex it becomes a nightmare to maintain,” he concluded.