Most CIOs have had to deal with rogue business units \u2014 parts of the organization that, for one reason or another, can stave off any attempt \n\nto modernize, standardize or stabilize its idiosyncratic IT systems, but still need solid data connections to the parent company. Hospital CIOs have to deal with hundreds of those units every day \u2014 connecting doctors' offices that are fiercely independent, too small to \n\nhire IT specialists, and are unlikely to put IT upgrades high on the priority list. Healthcare IT Dilemma: iPad Lust Meets Software RealityBeth Israel Deaconess (BID) Medical Center started solving that problem two \n\nyears ago \u2014 long before the American Recovery and Reinvestment Act (ARRA) \n\npromised the industry $19 billion to pay for a large scale migration to electronic health records. Trying to match pay-for-performance plans that require much more detailed and realtime documentation than the hospital's existing systems, BID \n\nrolled out an electronic health records and practice management system to the 175 or so practices it owns directly. That covered 300 of its core physician network, but not the 900 that work out of more than 300 practices affiliated with BID, but which are owned \n\nand operated independently. The largest employs 14 doctors and about 60 staff. "Most of them are basically mom-and-pop-type shops that work 10 hours a day, see 40 patients a day and don't have time to load the latest \n\nMicrosoft patch or deal with a corruption with MySQL, let alone build a new system," Gillis says. "They can't afford a lot of IT and, really, they're not that interested in it," Gillis says. "But you can't have EHR [electronic health record systems] \n\nwithout a practice-management system and a billing system and most of these offices are small enough that they get along without one."EHR is a requirement for membership in the Beth Israel Deaconness Physicians Organization \u2014 the internal group that provides \n\nadministrative, clinical and technical support for doctors' offices. It's also a requirement if BID or the practices are going to apply for any of the approximately $40,000 per physician that's available to fund the \n\nsystems, let alone whatever pay-for-performance, documentation, automation and other requirements come out of any federal healthcare reform \n\nbill.EHR is more than just a way to make it easier to ship medical records from one office to another, according to Leo Carpio, vice president for the Health Care IT & \n\nServices practice of equity research firm Caris & Co.Medical practices have to hire several times the number of employees they normally would, just to handle the paperwork required for them to be \n\npaid by either Medicaid or private insurance companies, Carpio says. Not being able to connect specific electronic records to billing statements and invoicing systems holds the whole industry back by slowing the flow \n\nof payments for services through administrative friction, not one related to either the quality or type of care, or regulation of the industry, he says. \nEHR is not a panacea. "I'm really concerned when I hear people talking about EHR as a way to rescue healthcare," according to Carl Labbadia, \n\ndirector of Information Systems at Grove Hill Medical Center in \n\ncentral Connecticut. "IT can do a lot of good for patients and a lot for administration," he says. "People may be putting too much reliance on it, though.Can IT Solve the Electronic Health Records Challenge?Building the system ahead of time and hoping the affiliates would sign up was a multimillion-dollar risk in an industry with a history of rejecting IT that \n\ndoesn't suit its needs. Because they're independent, BID had to build a system that would work with even less effort and cost than the one it build for the internally owned \n\npractices, and demonstrate that it worked before any of the affiliates would sign up."We could have gone with a classic environment \u2014 server clusters and building arrays for storage; the problem was that we'd have to build it \n\nfor the largest load we'd ever need and we had no guarantee anyone would use it," Gillis says.The software is a set of EHR and practice-management applications from eClinicalWorks, which licensed the software to BID, but also provides it as a hosted \n\nservice. Physician offices access the cloud using a normal PC with a thin-client connector that provides encryption, authentication and connectivity to the \n\ncloud. "They get a new appliance that front-ends this whole thing for us and can light up a practice with no hardware except what's talking to the virtual \n\ndesktops," Gillis says. "There's still a client on the device, so it's not fully a Web app. But you can get directly to the EHR without messing around with a \n\nterminal-services app."The cloud infrastructure is a set of VMware ESX servers running on half a dozen Hewlett-Packard Co. servers \u2014 a number that can change \n\nwith relatively little effort. Making adjustments to virtual servers rather than physical saved BID $300,000 late in the project, when eClinicalWorks added more muscle to its \n\nSSL encryption and put an unacceptable strain on the existing servers. Gillis spent about $20,000 on hardware upgrades and additional VMware \n\nlicenses, rather than the $325,000 he would have had to spend for new servers in a purely physical server cluster. It also makes capacity planning a lot easier because it's possible to swap out servers or storage or increase capacity to match seasonal spikes \n\nwithout, essentially, even telling the applications it's happening, he says. Because of the need for security, privacy, access to data in exam rooms and support for increasingly technical medical-support systems, healthcare \n\nhas been in the forefront of virtualization for years, according to Jack Santos, executive strategist for consultancy The Burton Group, a former CIO for two hospitals and senior IT executive for \n\ninsurers and other healthcare companies."Hospitals automated the backoffice years ago, but then they kind of slowed up," Santos says. "They're way behind the curve in automation at the \n\nhealthcare level. Running EHR on virtual servers is good if there's an access issue, but it's not a leading-edge kind of thing. You can do most of that with \n\nCitrix, and you can hardly walk into a practice that doesn't have a Wyse or other kind of terminal and has everything remoted to it."Follow everything from CIO.com on Twitter @CIOonline.