Load balancing - the heart of a resilient Health IT system

Leading the way in highly available enterprise imaging

As a pioneer in providing ADC solutions to the imaging sector, Loadbalancer.org have gained unrivalled knowledge in supporting clinical workflows, DICOM worklists and analytical reporting. For more than 20 years, we have worked with a range of ‘blue chip’ customers and partners such as Fujifilm, Philips, GE Healthcare, Change Healthcare, Philips, Hologic, and developed validated solutions for many others.

Our extensive experience engineering healthcare applications (from Enterprise Imaging to Clinical Workflows, EHR to Interoperability solutions) allows us to work closely with existing and prospective customers to develop solutions that facilitate high availability, scalability, and zero downtime for critical healthcare applications.

As such we have an extensive library of resources explaining why and how to load balance a range of medical imaging applications.

How can load balancing advance the healthcare IT agenda?

Healthcare IT infrastructure is extensive and complicated. It needs to connect primary and secondary healthcare providers, hospitals, patients, drug companies, research institutions, pharmacists, IT teams, insurance providers, and financial institutions. This complex web of network, storage, and computing resources requires load balancing to de-risk IT architecture, facilitate interoperability, and support hybrid environments.

Load balancing for simplified IT architecture

Load balancing can help deliver agile digital architecture in a number of ways. Here we explore workload migration and the facilitation of a per app approach.

Supporting a phased approach

For example, there may be an action to migrate a certain workload to the cloud, but there are some scenarios where that data might not be able to migrate. Therefore there needs to be a means of failing back, protecting you from odd events that may happen, causing potential data loss or outages. In this way, load balancers support a phased approach because they are able to help you move and test workloads, making sure they are fully operational prior to migration.

A per application approach

Having a load balancer that is dedicated to a single application, only doing one job, has a number of significant benefits. The main one is that, with a dedicated approach, there is a smaller footprint. The load balancer is committed to that application and any changes are unique to it. This requires less resourcing for maintenance, and the load balancer remains responsible for that workload only.

The result is that it is incredibly unlikely the load balancer can be overloaded by the addition of more services as needs grow. This de-risks the application and ensures the resources are always available to support it.

Multi-site resiliency using GSLB

Using Global Server Load Balancing (GSLB) you can distribute traffic intelligently across server resources and sites i.e. physical data centres, hybrid, cloud, multi-cloud. So no matter where your applications reside, if there’s any failure or part failure within that locality, your user is able to retain access, using the path of least resistance.

Just as a load balancer distributes traffic between connected servers in a single data center, Global SLB distributes traffic between connected servers in multiple locations (whether these servers are in an organization’s own data centers or hosted in the public or private cloud) and are able to provide failover between these sites based on the availability and performance profile of the data centers. Should one server in any location fail, Global SLB re-routes traffic to another available server somewhere else in the world.

By enabling all user traffic to be switched instantly and seamlessly to an alternative data center in the event of an unexpected outage, Global SLB improves the resilience and availability of key applications, and enables organizations to constantly monitor application performance at geographically separate locations. It also ensures the best possible application availability across multiple sites. During routine maintenance, Global SLB enables organizations to temporarily direct user traffic to an alternative site in order to avoid disruptive downtime.

Load balancing for interoperability

Intelligent decision making

A large proportion of work that load balancers do is taking data from a modality (e.g. a CT or MRI image generated by a scanner), making a decision about where that image needs to be stored, and using a particular standard of communication with a health records system so it can be integrated. Because all this information traverses the load balancer, it is able to make intelligent decisions about where that data needs to go and therefore facilitate interoperability.

For instance, there are different methodologies that can be employed to support DICOM and non-DICOM workloads and their different applications – all of which a load balancer can help with. The load balancer helps mitigate the data risk of imaging information and metadata (and patient information and metadata) by managing these different workflows and the applications that sit on the back-end that require that information. The load balancer also manages the client-side and modalities that sit on the front-end that are generating that information or drawing it back out (e.g. a clinician viewing images or patient records).

Load balancing in the cloud

Enhanced storage performance

A complete cloud load balancing solution can optimize your storage environment. It can check the health of storage clusters, making decisions about where images or patient information should be stored. For example, is the data performing well? Can it get in and out of the cloud efficiently? How does it use multiple clusters of data?

Modern storage architecture is good at recovering from failure, rebuilding and ensuring that data integrity is preserved. But it doesn’t account for maintaining consistent access for users, which is paramount in healthcare IT. Without a load balancer, if part of a storage cluster failed, yes the data would be preserved, but it might not allow users consistent access which could be catastrophic.

Reduced cloud costs

Cloud can be a wolf in sheep’s clothing. For example, although migrating to a large public cloud provider such as Amazon Web Services (AWS), Microsoft Azure or Google Cloud Platform (GCP) may be reasonably inexpensive, the costs quickly escalate once you’re there.

A native load balancer within a cloud platform will calculate costs not just based on information flow, but also on how that information is flowing and how it is being processed. With a complete cloud load balancing solution however, running costs are much less because you’re not paying for the processing of that data. You are only paying for the cost of the load balancer to run in the cloud.

Request analysis

A complete cloud load balancing solution can also make decisions based on the content of a request. It can analyze the data and determine that it may not want to send that data to a particular place immediately, as that might be a less cost-effective way of storing or using the information. So in this scenario, the load balancer helps build intelligence on the information flowing in and out of the cloud environment, and therefore the resulting cost implications.

How do you load balance for improved data access and security?

Here we outline how load balancing was used by an NHS Trust to help deliver secure and flexible remote access to clinical applications.

Challenges faced

Nottinghamshire Healthcare NHS Foundation Trust (Notts NHS) hired 2,200 community-based healthcare professionals, which grew their total IT users to around 12,000. This presented a challenge: to improve access to applications for employees while simultaneously maximizing their IT security.

The majority of the new hires were community-based nurses and healthcare professionals who worked from various medical centers, hospitals, and other sites that were owned and operated by third-party organizations. Notts NHS needed to find a way to allow these new employees to access data and systems from third-party sites, without jeopardizing the security of patient information.

Solutions and results

To solve this problem Notts NHS created a virtual desktop infrastructure (VDI) and selected two clustered pairs of our very own Enterprise R20 product as part of this environment. Their IT partner, The Cutter Group, a leading supplier of virtualized computing solutions, optimized the VDI environment to take advantage of the structural flexibility of the Enterprise R20. This ensured secure desktop access for the employees that needed to connect across three different channels:

• the internal Nottinghamshire Healthcare network
• the shared NHS N3 network
• the public internet

Notts NHS was thoroughly impressed with the performance of our load balancer – so much so, that they purchased a further two pairs of our virtual appliances to help further improve the desktop experience for their users. One pair was used to secure the organization’s Microsoft Outlook web servers – enabling employees to access email using smartphones, Blackberries, and other mobile devices. The other pair of virtual appliances were used to balance traffic to clinical applications across its two separate data centers.

NHS Notts’ users now have more flexible and reliable access to clinical applications than ever before thanks to their load balancing solution. This delivered an affordable way for the NHS Trust to provide mobile access while delivering all the security and performance they needed.

How do you load balance for enhanced interoperability?

Here we outline how load balancing helped empower a US government healthcare institution to optimize its Meditech EHR solution and achieve multi-site interoperability.

Challenges faced

A semi-autonomous US government medical agency – made up of three healthcare facilities, but functioning as one unit – was seeking to introduce a layer of interoperability across its multi-site IT infrastructure. The health agency was using Meditech’s EHR system to facilitate seamless coordination amongst clinicians in order to ensure safe and prompt care delivery.

Thanks to the RESTful APIs deployed within the EHR system, physicians and nurses were able to access the information they need – to have a holistic view of patient data. The Interoperability Services (IOPS) – a component of the RESTful API Infrastructure and installed alongside it on the same systems – provided Meditech EHR with next-generation interoperability capabilities. However, the success of a RESTful API involves configuring clustered servers with a dedicated load balancer to distribute traffic amongst the application servers.

Solutions and results

Loadbalancer.org was able to design a bespoke, unbreakable, and cost-effective load balancing solution that was easy to install, simple to manage – and helped the customer achieve scalability, high availability, and zero downtime for its EHR.

With our understanding of medical imaging environments, DICOM (Digital Imaging and Communications in Medicine), HL7 traffic and the importance of HIPAA (Health Insurance Portability and Accountability Act) compliance, we were best-placed to help customers with the communication between older modalities and new healthcare systems – which makes us the preferred load balancer provider for the health IT sector.

In this scenario, we were able to help the customer design a turnkey solution that efficiently load balances its Meditech EHR platform. A pair of our virtual appliances helped the agency achieve zero downtime – one of the most critical requirements in health IT – and the products also ensure increased availability of the EHR system, enabling the client to improve delivery of patient care, and preventing the system from breaking due to heavy traffic or data overload. This ensures clinicians and customers have uninterrupted access to health data, without delay.

How do you load balance cloud applications?

Here we demonstrate how load balancing was used to help Fluid Networks create a stable and scalable cloud-based platform for their hosted medical application.

Challenges faced

Initially, Fluid Networks began creating a remote desktop services (RDS) environment in the Amazon cloud – however, they found that Amazon’s integral load balancer function was unable to meet the requirements of end users. It was imperative that Fluid Networks was able to provide stable end user connections for 12 hours or more, as well as a platform that was scalable to support and increase end user numbers.

Solutions and results

When they discovered Loadbalancer.org’s cloud-based load balancing solution, they found that they could start setting it up in minutes, with superior configuration options and additional features.

The organization selected Loadbalancer.org’s Enterprise AWS cloud-based load balancing solution to interact directly with its Amazon console and implemented two separate instances of the solution in its RDS farm, in an active/passive configuration. Initially, Fluid Networks only used the Enterprise AWS to balance its four gateways, but the installed Microsoft load balancers were struggling to allocate traffic appropriately at the broker and session host levels. The solution was to take all load balancing away from Microsoft and use the Enterprise AWS at all three levels.

Over a period of more than three years, the Enterprise AWS has helped Fluid Networks to provide a stable application environment for its client – and its client’s customers. Doctors and clinicians at hospitals and medical centers across the USA use the cloud-based patient management system every day to help them deliver the best possible levels of healthcare.

The cloud-based solution from Loadbalancer.org has proven to be highly scalable and capable of supporting the unexpectedly fast growth of the hosted medical application. Initially, the load balancer Enterprise AWS balanced traffic for a few hundred end users; now it supports several thousand active users daily.

Most importantly for Fluid Networks, the Enterprise AWS is very easy to maintain, which helps it to manage the application environment for its client.

Regardless of where your health journey takes you, your health data should be accessible at all times in all places. However, medical data is only useful if it can be turned into meaningful information that can be processed by humans and machines. This requires standardized data formats, high-quality datasets and seamless communication across IT systems. However, the fact is that a large amount of medical data is hidden in isolated and incompatible systems, making them difficult to exchange, process and interpret. As a result, most healthcare providers fail to use these data for making important clinical or business decisions.

As more modalities and newer scanning technologies like 3D mammography are being introduced in hospitals, the storage demand has increased significantly. A load balancer can enable additional storage to be added and seamlessly integrated into a hospital’s storage system to match their massive storage requirements and handle the increasing workload. Most hospitals also face data migration challenges while replacing legacy systems with modern databases. Implementing a load balancer can help in extracting, standardizing, transferring and making data usable for augmenting various digital technologies like AI, analytics, machine learning, etc. Healthcare organizations also face multiple issues around security requirements for accessing certain data. In such cases, a load balancer is able to encrypt the transfer of data from one location to another, allowing users to access that data via a secure connection.

How does load balancing enhance digital pathology services?

There’s an urgent need to digitize pathology services globally, but – as you’ll know if you have already started down this route – it isn’t always straightforward. Huge issues need to be addressed in terms of IT performance, system integration, scalability and data storage, before digital pathology solutions can be successfully deployed.

Load balancing can help address these problems and optimize digital pathology solutions in the key ways described below.

Keeping pathology services up and running

Pathology is one of the most critical services provided within the NHS.  Up to 70% of all diagnoses rely on pathology, and over 1 billion pathology tests are carried out each year across 105 hospitals in the UK, according to the Royal College of Pathologists. Given just how important pathology is to patient care, and the sheer number of tests carried out, a top priority for hospital CIOs, CTOs and IT Directors will understandably be reliability.  How will you keep this vital service up and running?

Load balancers address this challenge by sharing user traffic across all the available servers and, where appropriate, across all available data centers.  If one server fails, for any reason, the load balancer will automatically direct the traffic to an alternate, functioning server, enabling pathologists to carry on working without interruption. Equally, load balancers can help provide remote access to digital pathology systems, making it possible for pathologists to work from home or a different hospital and collaborate more easily with colleagues elsewhere in the country to consider complex diagnoses.

Facilitating the hub and spoke approach

To consolidate pathology services nationally, NHS Improvement has proposed the creation of 29 ‘hub and spoke’ networks, with one primary center supporting pathology services in other nearby hospitals. This approach is part of the NHS Long Term Plan and aims to make it possible for hospitals to make cost savings by sharing digital pathology systems and other resources, such as skilled pathologists. Consolidation makes sense, but creates a technical challenge: how can multiple teams, from different organizations securely share the same data and systems?

Load balancers play a key role in multi-site digital pathology deployment models, enabling data to be shared and replicated across several hospitals. They help to preserve the integrity of the data replicated across sites and prevent data loss.  If an outage were to occur in a digital pathology system at one site, it is the load balancer that would step in and redirect user traffic to an alternative location, preventing any interruption in pathology services and delays in diagnosis that could put lives at risk.

Alleviating the challenges of system integration

Unchanged for years, pathology departments rely on lots of very old IT systems that are not standardized across the industry and do not integrate well with modern IT. There are even some systems still in use that are written using antiquated programming languages like COBOL. Consequently, one of the biggest headaches for hospital CTOs, CIOs and IT Directors is integration – how can you make your new digital pathology systems interoperate with the legacy solutions that they will continue to depend on?

This isn’t an insubstantial challenge. IT teams will need to thoroughly investigate all potential integration issues and have a plan for overcoming them, before they start to deploy digital pathology products. In many cases, load balancers can be used to provide an interface between legacy solutions and state-of-the-art digital pathology solutions.

Simplifying the management of exceptional data volumes

The digital pathology process generates almost unimaginable volumes of data.  A single 24-bit color WSI has an image size of 15GB, which would typically be compressed to around 300MB. A larger 3D image of a sample, comprising a stack of 10 images, could create a dataset of 3.75TB, which even when compressed would consume 75GB of storage space. Current guidance stipulates that samples must be saved for at least 12 years, so hospital CTOs, CIOs and IT Directors must think big when calculating the size of their data archives. But it isn’t just the size of the storage that is important – how are you going to handle large image files and ensure that each precious sample is saved?

Hospitals can use load balancers to manage the flow of data into and within data archives to avoid the kinds of failures that can lead to patient data loss. Load balancers can be used with a hospital’s own vendor-neutral archive (VNA), a data archive supplied by a vendor or a public cloud, such as Azure or Amazon Cloud. Over time, hospitals are likely to adopt hybrid approaches to image archiving that include on-premise data archives and cloud-based systems, and load balancers can facilitate this model, by directing high volumes of exceptionally large images to the most suitable servers, based on performance and availability.

Opening the door to artificial intelligence

Artificial intelligence (AI) technology has the potential to accelerate the pathology process dramatically, as it can be used to not only count, but also grade, individual cells in samples, in seconds. Recognizing this, the British Government has pledged £50 million of further investment for the development of cutting-edge AI solutions to improve diagnosis of disease. This investment should accelerate the availability of proven AI solutions for digital pathology services and make them more viable and available sooner. But, you ask, how easy will it be to actually integrate AI?

In order for AI to work, it needs to receive a lot of data, fast. This means extracting large numbers of image files from archives and feeding them to the AI application in a tiny fraction of a second. Load balancers can perform this data transfer, integrating the two (or more) systems, ensuring that the AI can operate with consistently high performance and high availability. With the current shortage of trained pathologists (and a large proportion of the workforce approaching retirement), any technology that speeds up the pathology process will be welcome.

Load balancing to accelerate patient care delivery

There’s printing – and then there’s ‘high availability’ printing. While you don’t need high availability for your home printer; for organizations where print is integral to operations, then high availability is a must. The question then, is whether or not printing is mission critical for your organization. A hospital is a classic example of a mission critical print environment, where the cost of downtime would be disastrous. Without a printer, hospitals would struggle to check-in and discharge patients, print prescriptions, wristbands, orders; or medical notes for busy doctors with multiple patients, rushing from one ward to another, with no time to keep returning to a desk to consult electronic records. Hence print management systems like PaperCut and network load balancers like Loadbalancer.org’s are designed to work together to create a high availability print solution.

Hospitals and supply chains for healthcare have been stretched to the limit in so many ways that they need to have solutions that just ‘work’ and can be implemented without any disturbance to the existing conditions. Many are finding that their current printing methods are slowing the process of moving people in and out of the hospital, and may not be compliant with Government regulations. In fact printed notes now follow patients around the hospital, printed wristbands with barcodes help nurses scan prescribed medication prior to administration, to ensure they’re giving the right patient the right medicine and dosage. Discharge papers now include all the doctors that visited you while you were in the hospital so you can share the information with your general physician when you get home, or use it to check that you were billed correctly. All of this information needs to be printed NOW so the clinician can get to the next patient or open up a room for someone else quickly.

In addition, in the US, the Health Insurance Portability and Accountability Act( HIPAA), has introduced a host of digital and hard copy print controls that need to be complied with, to ensure patient medical records are kept secure.

Load balancing object storage for high availability and performance

A poorly managed object storage system can put an entire healthcare system at stake. To set up a robust object storage architecture for patients, an effective load balancing solution needs to be integrated into the storage framework. Load balancing enables improved responsiveness and increases application availability by distributing network or application traffic across a cluster of servers. By adding health checks and failover, load balancers facilitate unlimited scalability in object storage systems across the healthcare IT ecosystem.

Additionally, load balancers allow the storage of data in multiple locations to facilitate zero downtime in case of failover. For example, if data center A fails, load balancing allows users in that locality to access the same data in data center B. Thus, patient data can easily be replicated within nodes and clusters among distributed data centers for additional backup, off-site and even across geographical locations. With an intelligent ability to evenly distribute traffic among backends, load balancers help efficiently manage object storage systems and prevent complete data center failures.

Load balancers monitor and perform health checks on each node to ensure traffic is routed correctly to the healthy nodes. As a result, if data center failures occur, load balancers are capable of allowing users uninterrupted data access. Most load balancers also come equipped with a range of security features protecting data from external threats such as the WannaCry ransomware attack.

As healthcare institutions come to terms with ever-increasing data storage demands in the modern application-focused world, the next-gen object storage system is evolving as the best technology solution for data governance. But having a sophisticated storage solution without accounting for high availability may not result in optimal performance.

Therefore, having a load balancer deployed correctly is increasingly important for clinicians and patients. With simple, flexible, fully-supported deployment models for faster start-up, Loadbalancer.org delivers ultra-reliable and effortlessly scalable load balancing solutions.