Scaling EHR with CenturyLink cloud

Founded in 2002, Nightingale is one of the largest providers of cloud-based Electronic Health Record (EHR) and practice management solutions to Ontario healthcare organizations, and is expanding its business in several other Canadian provinces and the US. Adopting a workflow-based approach, the company works to automate processes in practice management, medical records management, billing and digital communication between organizations in the healthcare ecosystem through solutions targeted at customers ranging in size from the solo practitioner, to the medical group or enterprise, to the “jurisdiction,” or large governmental body responsible for healthcare administration across a wide region. A key feature of the Nightingale platform is communication and data interoperability, tech capabilities designed to address healthcare imperatives such as continuum of care, leading to better patient outcomes, and ultimately cost savings in the delivery of healthcare services.

Ijaaz Ullah, VP, information technology and privacy officer, Nightingale
Ijaaz Ullah, VP, information technology and privacy officer, Nightingale

Business challenge

Recently, the company has been focused on launch of version 10 of the Nightingale solution, a $15 million product redesign that went into commercial release this week. Aimed at migrating the US client base from Nightingale’s Medrium practice management solution, the new Linux and Java-based product, which will run in parallel with the company’s traditional Microsoft environment for existing clients, has been built to handle the rapid scale-out required to support onboarding of new customers. According to Ijaaz Ullah, VP, information technology and privacy officer at Nightingale, “Java is the new web. It is a highly scalable, new technology that is easier to run, is more dynamic and can respond more quickly to changes in the environment. This will allow us to rapidly deploy, to rapidly scale – and the overall cost of deploying a Linux/Java product is significantly less.” The new open platform product will feature more support for different browsers and devices, such as mobile phones and tablets, as well as connections for third-party devices such as blood pressure monitors that are integral to healthcare practice. As Ullah noted, the company “needed a platform that we could readily add capability to, and that would have an API that other devices could connect with.”

A key challenge for Nightingale’s growth strategy, however, are the differences between cross border regulatory environments: “the whole Canada/US dynamic is painful to say the least. You have HIPPA and PIPEDA legislation and regulation around location of healthcare data, which leads us to have multiple installed bases [of our solution],” Ullah explained. The requirement to house Canadian healthcare data in Canada, and US data south of the border, combined with scale expectations led Nightingale to consider outsourcing IT infrastructure needs to a provider with presence in multiple jurisdictions. CenturyLink fit this bill. Leveraging the company’s extensive data centre footprint (58 sites), Nightingale would be able to create an instance of its solution in one site, and easily replicate that across the globe. “All the automation we build into a solution in a data centre in New York,” Ullah explained, “can easily be duplicated in Chicago for backup. So while the code base is identical across data centres, the data is physically located at each site facility.”

Cloud options

Nightingale chose to engage CenturyLink cloud and colocation services – cloud for its v 10 production environment with instances in New York, Chicago, Toronto and Vancouver, and colo for corporate equipment and potentially for offsite backup services. The decision to opt for cloud was influenced by two considerations: building on cloud in highly managed, secure data centres with biometric access enabled Nightingale to offer customers an alternative to the single point of failure represented by the doctor’s physical file folder or on-premise server; at the same time, outsourcing infrastructure needs would allow the company to scale without concern over aging hardware. As Ullah described it, “We have right now, infrastructure for Nightingale On Demand, and it’s aging. So we’re going to have to make a capital investment to replace all that hardware and then go through a lengthy upgrade process, which at some point involves failing over to our secondary site, replacing hardware and failing back.” By outsourcing to a cloud provider, on the other hand, the company could avoid this process – at least to support new growth associated with v 10. And while Nightingale has built considerable reputation for its protection of healthcare data through encryption, multi-factor authentication and use of security tokens over the last data, CenturyLink was transparent on its security architectures and able to provide security audit findings, certifications and policies that offered assurance of its security capabilities – an important benefit for a company operating in the healthcare space which has especially onerous data privacy needs.

Partnership with CenturyLink began approximately a year ago, when Nightingale began to use the company’s infrastructure for test/dev and sales environments. The company also took advantage of its v 10 build process and end user demonstrations to learn more about CenturyLink cloud, in advance of launching the full production environment. This work was accomplished through use of internal Nightingale staff – the majority of it managed, in fact, by a single resource, and the majority of effort devoted not to building the product, but rather to building automation around deployment. “It took four months to build the first environment – our production, staging and QA – and the first iteration was very difficult,” Ullah explained, “but once we knew how to build it, automation takes over and it takes three hours to build the second, third, fourth, etc.”

Defining benefits

For companies considering transition to cloud, Ullah believes that knowing what you need to get out of a provider relationship is critical. “Cloud services are very different from colo services in terms of what they can deliver, and where the performance improvements and cost savings are” he remarked. For Nightingale, the priority was on-demand scale, and the ability to make decisions about service delivery in different regions without massive capital investments. “The question for us,” Ullah noted, “was do we invest half a million to a million in capital to build out a data centre, or do we spend $100,000 to $200,000 over a year to build four of them and pay for it as we need?” – an equation that essentially begs the question Ullah posed, especially when equipment maintenance and potential skills gaps are taken into account. Ultimately, working with CenturyLink allowed Nightingale to take advantage of automation through rapid scale in multiple locations: “we build some once and reuse it multiple times,” Ullah noted. It also allowed the company to lower operating costs by reducing the total amount of resource needed to run the entire infrastructure. CenturyLink runs VMware, a platform that Ullah described as “industry standard.”

Going forward, the company expects to take additional advantage of CenturyLink innovation – in the area of block object storage and advanced networking, which each play to Nightingale’s specific data requirements. Lab reports or x-ray files, for example, present as huge chunks of image data that are difficult to replicate, so Nightingale would be interested in having a provider deliver fast, highly available backup storage that is optimized for I/O and indexing. Another attraction is a disaster recovery product developed through AppFog, CenturyLink’s PaaS offering. Ultimately, Ullah expects to see complete migration of Nightingale IT to an outsourced model: “we are a cloud provider. If we didn’t believe that outsourcing was the key to success, we wouldn’t be in the business. We kind of have to drink our own Kool-Aid.”

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