The Virtual Kiosk System (VIOSK) and Its Impact on IM/IT Device Cost
Savings and Staff Productivity
Point of Contact: CPT Alex C. Montgomery, (317) 414-1464,
alex.c.montgomery.mil@mail.mil
Group Involved with the Project. The Information Management Division, Brooke Army
Medical Center (BAMC)
Submitted by CPT Alex C. Montgomery
13 May 2013
Executive Summary: The Virtual Kiosk System (VIOSK) was identified as a best practice for
its connection to increased staff productivity and patient satisfaction, the creation of a secure
accessible network environment and its projected IM/IT device cost savings. The VIOSK creates
a better patient experience using IT for operational efficiency, and increases staff productivity
due to decreased wait times, cloud printing, secure email and adapted open session’s
applications. With the use of thin client devices compared to purchasing individual computers,
Brooke Army Medical Center (BAMC) estimates a savings of $4,875,000, over the next nine
years. Upon introduction of the VIOSK within the Family and Community Medicine
Department, their Army Provider Level Satisfaction Survey (APLSS) “Overall Satisfaction”
scores increased from 90.1% to 94.3%, in six months. In addition, their “Spent Time with You”
and “Wait Time” satisfaction scores increased an average of 4%. Utilizing M2, staff
productivity, captured by analyzing Provider Aggregate Relative Value Unit (RVU) Total per
encounter increased 18%, during the same six-month timeframe.
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Objective of the Best Practice: To provide IM/IT device cost savings in line with Executive
Order 13598 and create a better patient experience using IT for operational efficiency, by
customizing and connecting workstations to a virtual mainframe. This process reduces the need
for three-year lifecycle upgrades on end user devices and eliminates restrictions due to desktop
capabilities. Furthermore, the secure technology relies on a single server update for patches and
software upgrades, and provides better access for employees, effectively increasing overall
productivity, employee satisfaction and in turn patient satisfaction. “If physicians experience
slow systems or unavailable networks, patient care can be jeopardized,” Pat Milostan, Chief
Operating Officer, CareTech Solutions (H&HN, “Most Wired” July 2012).
Background: For the past several years, BAMC’s Systems Engineering and Design team has
been at the forefront of virtualization. BAMC was the first Medical Command (MEDCOM)
facility to create kiosk systems, which allowed providers to complete patient documentation on
auto login computers. The kiosks were locked-down public workstations with a small set of
applications. Prior to their induction, providers were “tied” to their desktops or workstations,
because logging-in to another location translated into increased wait times and an inability to
replicate applications. However, the kiosk system did not require end-user authentication to gain
access to the domain, which presented a security risk for protected patient information, there
were zero opportunities to customize settings, multiple users decreased processing speeds and
providers could not save data to the desktop. To solve these issues the engineering team utilized
Citrix XenApp and successfully virtualized every application on the kiosk system. The result was
the VIOSK, which BAMC’s Systems Engineers applied to both thin client and fat client desktops
to optimize patient flow, communications and existing IT infrastructure.
With virtualization, the computer is no longer a limiting factor in access or capability, as long
as there are backend mechanics to authenticate and run programs through the server. The VIOSK
also solved other access related IT issues. It provides a secure environment, which allows
providers to use email for professional correspondence or patient care on any device. System
Engineers developed cloud-printing applications to increase flexibility and adapted open sessions
to allow providers to stop documenting in a clinical application (i.e. Essentris) on one computer
and start documenting in the exact same session on a different computer by simply moving their
common access card (CAC). Moreover, engineers can customize the VIOSK to the end-user
regardless of the system they login to, and grants folder redirection to allow providers and
administrative staff to maintain access to their personal documents.
Literature Review: In an article by FierceHealthcare, which is tied to PwC Health Research
Institute, the top three issues U.S. Hospitals will face in 2013 are; the implementation of the
Affordable Care Act cost reductions, a shift from volume to value based reimbursement, and the
need to increase security parameters in order to capitalize on IM/IT cost and patient care
solutions (Cheung-Larivee, 2013).
According to Comodo Internet Security, “The Virtual Kiosk provides an extremely secure
environment for Internet related activities because it isolates your browser from the rest of your
computer.” The kiosk averts malicious code installations and prevents key-logging software from
recording information (Comodo Help, 2013).
A thin client is the hardware that links the user to the virtual mainframe. It is a pass through
device or remote system, which relies heavily on the connecting server for function (Nieh, J.,
Novik, N. & Yang, S., 2005). The use of a thin client in other settings, to include federal sector
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application, is adaptable and easily replicated. Several articles tout the reduced cost of ownership
associated with thin client computing and the relative ease of maintaining one server network as
opposed to hundreds of personalized workstations. On the other hand, the establishment of a
virtual kiosk is much more technical and the reliance on an extensive server network and
knowledgeable support staff is paramount to the systems success.
Implementation Methods: After completing the initial trial with Family and Community
Medicine, BAMC Information Management Division (IMD) Systems Engineers repurposed the
necessary equipment to facilitate use of the VIOSK throughout BAMC. This included
transitioning physical servers (Dual Quad-Core Central Processing Unit (CPU) with Hoper
Threading and 98GB Ram) into virtual servers. Each physical server transitioned into seven or
eight virtual servers with the ability to operate 20 concurrent users. In addition, Systems
Engineers established five virtual servers for VIOSK infrastructure and redundancy.
During the implementation cycle, the IMD deployment team established virtual capabilities
one clinic at a time, using Wyse RIOC ThinOS thin clients, as their pass through device. After
installing the initial hardware, first-line support personnel were present and available to clinic
personnel for one week to conduct training and mitigate system issues.
Results: The cost savings associated with the use of thin client devices compared to purchasing
individual computers, over a nine-year period, is listed in the chart below. The analysis does not
take into account the physical server cost or the cost of network engineering staff.
Table 1. Thin Client Cost Savings Comparison.
Type of
Cost per
Number of
Device
Device
Clients*
Desktop/Laptop $1,200
Computer (PC)
Thin Client
$350
Total Cost
1500
$1,800,000
1500
$525,00
Lifecycle
Replacement
over 9 years
3
Total Cost
$5,400,000
1
$525,00
Total Savings: $4,875,000
* Number of Clients based on total number of BAMC VIOSK users, as of January 2013
In addition to cost savings, staff productivity and patient satisfaction have increased because
of the VIOSK. The VIOSK not only provides adapted open sessions, the Windows 7 login time
is reduced from three minutes to 30 seconds and because applications function off the server and
not the desktop, the Armed Forces Health Longitudinal Technology Application (AHLTA),
Composite Health Care System (CHCS), and Essentris are all faster. Analysis used data from the
Military Health System Management Analysis and Reporting Tool (M2), and the APLSS
website. Upon complete implementation of the VIOSK within the Family and Community
Medicine Department, which included four locations (McWethy Troop Medical Clinic, Fort Sam
Houston Clinic, Warrior Primary Care Clinic, and Taylor Burke Clinic), their APLSS “Overall
Satisfaction” (APLSS question #24) scores increased from 90.1% to 94.3%, in six months. In
comparison, strong drivers for overall satisfaction such as “Spent Time with You” (APLSS
question #1) and “Wait Time” (APLSS question #12) satisfaction scores increased an average of
4%. Utilizing M2, staff productivity captured by analyzing Provider Aggregate RVU Total per
encounter, increased 18%, from an average of 1.524 RVUs per encounter to 1.807 RVUs per
encounter, during the same six-month timeframe.
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Conclusion: The future of computing is a cloud based virtual computing environment. The
research related to use of IT systems in a healthcare setting, show improved access and
communication capability, to prevent complications and shorten wait times, has value. The
VIOSK and the infrastructure behind it are an outstanding example of how IT helps clinicians,
and positively affects their ability to conduct patient care. The VIOSK system achieves both
efficiency and effectiveness, and aligns with current fiscal directives. For their efforts, BAMC
was one of only three military medical systems/facilities to receive recognition as a “Most
Wired” health network, in the July 2012 issue of Hospitals & Health Networks®.
References
Cheung-Larivee, K., (2013). 3 Top Issues Hospitals Will Face in 2013. Retrieved from
http://www.fiercehealthcare.com/story/3-top-issues-hospitals-will-face-2013/2013-0109#ixzz2HhvThB72
Comodo Help, (2013). Retrieved from http://help.comodo.com/topic-72-1-451-4894-runningbrowsers-inside-the-virtual-kiosk.html
Hospitals and Health Networks, (2012). 2012 Most Wired, American Hospital Association.
Retrieved from http://www.bamc.amedd.army.mil/articles/docs/BAMC-named-mostwired.pdf
Nieh, J., Novik, N. & Yang, S., (2005). "A Comparison of Thin-Client Computing
Architectures". Technical Report CUCS-022-00. New York: Network Computing
Laboratory, Columbia University. Retrieved from
http://www.nomachine.com/documentation/pdf/cucs-022-00.pdf
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