Hospital Israelita Albert Einstein's Telemedicine Service Scales to Serve More Than 2 Million Patients on AWS

The telemedicine center of the Hospital Israelita Albert Einstein (Einstein Hospital) was created in 2008, when Dr. Eliézer Silva, current director of diagnostic and outpatient medicine at the institution, presented as his MBA course completion work in health management the idea of creating a center focused on providing distance medicine services. Moving from theory to practice, the project was presented to Brazil's Ministry of Health and then included in the Institutional Support Program of the Brazilian Unified Health System in 2012, which encourages the accomplishment of specialized education, research, technology assessment, management, and assistance projects aiming at strengthening and qualifying the Brazilian Unified Health System throughout the country.

The telemedicine project included the provision of second-level services for critically ill patients in hospitals in remote locations. With remote care, health professionals at these locations were able to discuss these cases with doctors at Einstein Hospital virtually 24/7.

Einstein Hospital's IT and digital transformation manager, André Santos, recalls that in June 2014 telemedicine was already a business unit within the institution and the first contract with a client in the private sector was agreed upon. “We started to serve the oil platforms,” he explains, noting that, in the same period, the telemedicine service was placed in the newly created innovation department.

Within the new department, the unit's strategic focus turned to the development of new business and service models, allowing the team to delve into the technology and define what worked best from a clinical point of view. During this period, the telemedicine unit counted on a diversified portfolio with 42 services, consisting of digital health programs such as dietary re-education and even services for other health providers, such as medical appointments and care in ICUs.

Santos recalls that, from 2012–2015, all services provided by the telemedicine unit were supported by an internal IT structure. As demand for the service grew, the innovation team decided it was time to disrupt the model and move its framework to the cloud. The only thing left to do was to choose a provider.

To choose its cloud provider, Einstein Hospital's innovation team benchmarked the options in the market, ultimately deciding on Amazon Web Services (AWS). “AWS was very innovative, and we understood that it offered the most mature services we needed,” says Santos.

Santos also remembers that the migration to AWS came at a time of transformation for the business unit. When telemedicine reached 42,000 patients served per year, the institution's board concluded that it was no longer a “startup.” With that, telemedicine went from the innovation department to the diagnostic medicine department. “At that moment, we started building a new team to develop this technology. Little by little, we were recruiting people with the desired profile and setting up a dedicated technology team for telemedicine,” Santos says, noting that the team, which started with four employees, now has more than 80.

It was this team that expanded the use of AWS within the telemedicine business unit. According to Santos, the challenge was that telemedicine services were experiencing downtime on the existing architecture but needed to continue operating for patients. So, the team started build the services on Amazon Relational Database Service (Amazon RDS) and on AWS Elastic Beanstalk.

In early 2020, just before the onset of the COVID-19 pandemic, the teams from Einstein Hospital and AWS Professional Services began a process of reviewing the architecture and creating a new model that was highly scalable and secure. "In addition to the modernization and to all the information security part, we adopted an architecture capable of scaling to support any volume of assistance," he says, noting that the change was made at the right time, since the volume of assistance jumped from 900 calls per day in 2018 to an average of 1,200 calls per day in 2020, at the peak of the pandemic.

With the migration, Einstein Hospital's telemedicine services started using Amazon DocumentDB (with MongoDB compatibility) with Amazon RDS, to automate processes, and Amazon Elastic Container Service (Amazon ECS), to ensure the availability of all applications. The architecture also uses services as Amazon Simple Storage Service (Amazon S3), Amazon CloudFront, AWS Certificate Manager (ACM) and Amazon Route 53. With the changes, all telemedicine services distributed via microservices saw significant improvement in availability.

To test the new architecture, the IT team applied performance tests against benchmarks and obtained a series of metrics. The original architecture, at one endpoint with 150 concurrent users, saw a 12 percent error rate and averaged 12 seconds of latency. The new cloud architecture, at the same endpoint with the same number of users, had no errors and averaged only 2.5 seconds of latency.

The new telemedicine architecture also supported the implementation of Blue/Green Deployment, which introduces new software versions in parallel environments for testing before full roll-out. Once the new version is tested and operational, traffic from the original environment is then redirected to the new one, providing a smooth transition. “The AWS Professional Services team was essential in this process, which today allows us to detect functionality bugs before users can feel any impact,” says Santos. 

In 2016, the team developed Einstein Conecta, a service that aids the collection of feedback from physicians and patients. Initially tested only at the hospital's Faria Lima unit, the project started with 40 appointments and slowly gained more users until all the institution's employees, their dependents, and, finally, the health care providers joined.

The flexibility and scalability of the new architecture also supported the creation of a specialty assistance program for the North and Northeast regions of Brazil, which provided remote assistance during the pandemic. This project, according to Santos, yielded a series of partnerships and contributed to the creation of other projects.

In April 2020, for example, Brazil’s Ministry of Health sought out the Einstein Hospital team’s help, which temporarily assigned the Cockpit medical platform to the Brazilian Unified Health System from April to December 2020. During this period, Cockpit’s use spanned 24 Brazilian states. Cockpit, which also runs on AWS, is a critical tool for doctors. “It's where doctors talk to their patients, check the data, and write prescriptions. It is an electronic medical record with digital control and certification and one of Einstein Hospital's core platforms,” Santos says. By the end of 2020, Einstein Hospital received almost 75,000 visits per month via the Cockpit platform, and the Ministry of Health aided nearly 5,000 patients per month when using the tool.  

Einstein Hospital’s new projects required scalability that would not have been possible without the cloud infrastructure. The telemedicine service reached 30,000 patients by the end of 2018. The following year, that number grew to 300,000 and, by the end of 2020, the service had more than 2 million patients. “The growth was exponential. Today, remote service and digital transformation are widespread, but, 4 years ago, it was not like that. There were barriers regarding patients and doctors who were reluctant to use the technology. We have moved past all that,” says Santos.

Using the cloud provided the Einstein Hospital team the independence to develop new solutions quickly and the agility to keep up with the structure's growth in volume and processing capacity. “The main thing is that we were able to start small without spending huge resources and then were able to grow quickly,” says Santos. 

In addition to the number of patients served, the Einstein Hospital team also considers patient satisfaction to be a key metric for measuring success. Among the 2 million patients served in 2020, the satisfaction rate was 82 percent, with praise focused on the excellence of care and doctors. “Building on AWS allowed us to rapidly develop the platform and then quickly reach a high level of maturity,” says Santos. 

While Einstein Conecta is the flagship tool of the telemedicine unit, the IT team also inherited other systems from around the hospital. Therefore, the team is developing a second project, which will migrate services that are still in the hospital's private cloud to AWS, taking advantage of all the knowledge acquired so far. “We are talking about a considerable amount of services, such as the population health system, primary care, and virtual reception software, among others,” says Santos.

In addition, the IT team will continue experimenting with new services and developing new solutions. “We will continue on this journey. We have built all of this over the last few years and will continue to mature these services,” says Santos.