Avera Health sends MOSAIQ to the cloud

Avera Health
Oncology Informatics
Apr 14, 2017 7 minute read

Cloud-hosting of OIS and cancer registry eases South Dakota provider’s software management burden

Avera Health is a regional health system that delivers world-class medical care at more than 300 locations in eastern South Dakota and surrounding states. Elekta and Avera Health have partnered to deploy METRIQ® cancer registry, MOSAIQ® Oncology Information System (OIS) and other Elekta solutions across the Avera Cancer Institute, a network of six regional cancer centers.

While MOSAIQ is an exceptional OIS for both radiation oncology and medical oncology, Avera Health’s growth began to tax their ability to maintain this complex oncology IT infrastructure. Over three months in 2015, they moved their three MOSAIQ and four METRIQ databases to Elekta Cloud Solutions, easing their software management burden while simplifying staff access to MOSAIQ and its databases. Since then, they now have five METRIQ and six MOSAIQ databases hosted in Elekta Cloud Solutions.

Serving a population of nearly one million in 86 counties, Avera Health is a massive, and growing, healthcare provider in the Upper Midwest. While deploying MOSAIQ, they also had standardized their oncology EMR under one OIS, while maintaining both this system and the hospital EMR (HIS), which was becoming unmanageable.

“From a database perspective, there was a much larger patient population that was involved with the larger hospital system and the HIS,” says Robert Butler, BS, MLS, Avera Health Sr. Systems Analyst. “When Avera had only four to six departments spread across two sites it was manageable, but our continued expansion made it harder to attend to the infrastructure and databases.”

Avera Health’s radiation oncology and medical oncology service lines were distributed among a Minnesota cancer center and five South Dakota centers, and in multiple MOSAIQ and METRIQ databases, which represent the five radiation centers and six medical oncology sites.

Because not all regions had dedicated IT support, Elekta Cloud Solutions and the move to a single database allowed Avera to use existing IT resources to service the whole health system versus a few regions.

Other MOSAIQ IT challenges related to the healthcare enterprise’s rapid growth included connectivity problems that arose from extreme network demand, which created upload and download saturation that led to system slowness.

“We also experienced outages when someone would make a change in MOSAIQ that would trigger outages for multiple MOSAIQ users,” Butler adds. “Hosting MOSAIQ ourselves meant that we often had inconsistent change control procedures.”

Kristine Becker, Avera Health’s Director of IT Clinical Systems, adds that the organization’s incremental yet rapid growth meant that not all of the MOSAIQ hardware and software used were of the same version.

“It was much more difficult for us to maintain because of those inconsistences,” she recalls “Standardizing all of it would have created a significant extra cost.”

Timely suggestion

John Fitzgibbon, our Regional Sales Manager for Avera, knew that Avera’s IT personnel were being stretched thin managing their overall IT infrastructure, MOSAIQ maintenance and issues related to connectivity and system slowness. In early 2014, John proposed oncology hosting through Elekta Cloud Solutions to Avera’s IT management team.

“I explained that cloud hosting would help them with application stability and slowness issues, and give them a standardized MOSAIQ format and application setup,” John recalls. “I also showed them how cloud hosting would be the perfect marriage between what they were looking for in day-to-day OIS management, data control and change control.”

From Butler’s perspective, cloud hosting would transfer the burden of MOSAIQ supervision from Avera Health’s IT staff to us. “It would allow the Elekta Cloud Solutions personnel to manage both the database and infrastructure and be there for us 24/7/365 to give us the support we needed.”

Avera Health opted to bring MOSAIQ to the Elekta cloud

On July 20, 2015, Avera Health went live with the first database. When the second database went live in August 2015, they ran into an unexpected issue.

“We had expected only 100 users accessing the system at any given time, so Elekta dedicated Citrix server resources to accommodate 120 users,” Butler says. “But the first morning, 250 users were trying to connect. Elekta was extremely responsive. They were spinning up Citrix servers all morning, and by noon that same day users were able to work. Then overnight we were able to clean it up so that by the next morning we saw a much cleaner rollout.”

By the following week, he adds, “everyone could access exactly how they needed to without any issues.”


“We were really pleased with the way Elekta addressed that issue,” says Kris Gaster, Assistant Vice President of Outpatient Cancer Clinics, Avera Cancer Institute. “They acted like a true partner and that spoke volumes among our senior leadership.”

By November 2015, we and Avera Health had repeated the patient record upload and go-live process for the other Avera Health database; the organization’s MOSAIQ medical oncology and radiation oncology applications and METRIQ cancer registry were all in the cloud.

The first indication that remote hosting was working well was when Butler checked data from our error reporting system. One month post launch, the error rate had been reduced by more than half.

Gaster observes that accessing MOSAIQ in the cloud was a victory, since it was essentially “invisible” to users,” she says. “I believe it says a lot about the success of the project.”


Although Avera Health has offloaded the daily burden of managing their OIS infrastructure to Elekta, continual surveillance is critical to head off any issues.

“We contact our Elekta Cloud Solutions team nearly every day for troubleshooting or issue resolution,” Butler says. “My supervisor has a weekly call with Elekta Cloud Solutions for a case overview, issue resolution and tracking the performance indicator.”

The performance indicator – an Avera Health tool – tracks our software’s uptime and is on a repeating 180-day cycle.

“We do this to ensure that system performance is always foremost in our mind and Elekta’s mind,” Becker says. “It also gives us a representation that we can give to the operations team to show that we haven’t had an issue in a given number of days. Elekta promised us system uptime of 99.95 percent. Despite a couple of hiccups that were resolved quickly I would say it’s very close to 100 percent.”

To add even greater focus to system performance, Avera Health is working with us to implement our user experience tool. This system constantly monitors speeds within MOSAIQ itself, in addition to checking speeds across the fiber optic connections to the primary data server.

“If there are any complaints, we can always instantly check the connection between ourselves and the remotely hosted servers,” Butler says.

While Avera Health’s change control protocols have always been good, transferring this function to us was another advantage that reduced workload.

“In Elekta’s change control process, everything is documented, requested and scheduled on their end, and then passed along to us so we can do the same on our end and have that good, clean documentation,” Butler says. “No one here can log in and make changes at any time without specific authorization.”

Disaster recovery

With our dual data centers, Elekta Cloud Solutions provides healthcare centers with a robust disaster recovery solution in our Premium offering. In Avera Health’s case, there is a primary data center, but the organization’s data also are stored in a secondary data center. With our Premium hosting option, Avera’s data are protected by systems that enable Clinical Operations to resume with less than one hour of data loss given a complete data center or network link failure event.

“If a disaster affects our connection to the primary data center, we could switch over to the secondary database without missing a beat,” Becker says. “It gives you peace of mind knowing there is redundancy.”

Remote hosting enables database merge

By Summer 2016, Avera Health merged the three databases residing in the cloud as distinct stores of patient information. A single database would help ensure consistent care across the large, distributed healthcare system and unify all MOSAIQ users by providing access to all patient records across the system with one login.

“Remote hosting made merging the databases much more feasible,” Butler observes. “In fact, without remote hosting the database merger would have been next to impossible given the amount of access we needed and resources it would take to do that, both from Elekta’s end and ours.”


On July 16, 2016, with the merge of the final database, Avera Health began operating from a single MOSAIQ database.

Looking back

The consensus at Avera Health is that converting to the cloud was the right thing to do at a pivotal time in its growth stage.

“Cloud hosting has allowed our infrastructure and server teams to bring their focus back to the larger health system and gave us a larger, dedicated Elekta resource to support MOSAIQ,” Butler says.

“We identified remote hosting as a good solution that met our objectives,” Becker adds. “Our partnership with Elekta is really solid, and because of that partnership if there are issues that arise we can work together to resolve them.”

Enjoy the article?

Feel free to share.