Cloud Computing in Healthcare
Vishal Gupta, VP Advanced Services and Leader Healthcare Practice (East), Cisco
The healthcare industry has traditionally been considered to be a slow adopter of technology; and there are valid and obvious reasons for their cautious approach. Many of the healthcare players have not adopted technology completely in their environments as yet and their primary focus has been on automation of back office systems, payment and reimbursement, digitisation of medical records, and business intelligence for regulatory compliance and accreditation. In many emerging/developing countries like India, IT budgets are very low. Investments in IT compete with other priorities like radiological equipment or operational expansion.
Evolution of Cloud Technology
Technology has penetrated in human lives so much that it has started to become an intrinsic part now. Mobile phones have brought in a revolution in the way we live. A sample study of usage of Smartphones by US physicians in US is depicted in the figure below. We increasingly look to social media to inform our personal and business decisions. Our expectations on communications, data, content, and applications have increased dramatically and we look for instantaneous and ubiquitous access to information.'anytime', 'anywhere' access to information has become a defacto requirement in today's world.
The combination of rising expectations and a rapid rate of change, pose a challenge to traditional approaches for information technology (IT). A new approach is needed to free individuals and organizations from the constraints of traditional IT. Cloud is a new computing paradigm. In Cloud, IT resources and services are abstracted from the underlying infrastructure and provided on-demand and at scale in a multi-tenant environment. Cloud has several characteristics:
- IT, from infrastructure to applications, is delivered and consumed as a service over the network
- Services operate consistently, regardless of the underlying systems
- Capacity and performance scale to meet demand and are invoiced by use
- Services are shared across multiple organizations, allowing the same under-lying systems and applications to meet the demands of a variety of interests, simultaneously and securely
- Applications, services, and data can be accessed through a wide range of con-nected devices (e.g., smart phones, laptops, and other mobile internet devices)
Cloud encompasses several variations of service models (i e., IaaS, PaaS, and SaaS) and deployment models (i.e., private, public, hybrid, and community clouds), as defined below.
Infrastructure as a Service (IaaS) provides users with processing, storage, networks, and other computing infrastructure resources. The user does not manage or control the infrastructure, but has control over operating systems, applica-tions, and programming frameworks.
Platform as a Service (PaaS) enables users to deploy applications developed using specified programming languages or frameworks and tools onto the Cloud infrastructure. The user does not manage or control the underlying infrastructure, but has control over deployed applications.
Software as a Service (SaaS) enables users to access applications running on a Cloud infrastructure from various end-user devices (generally through a web browser). The user does not manage or control the underlying Cloud infrastructure or individual application capabilities other than limited user-specific application settings.
An example set of services that are provided to a Cloud consumer is shown in the accompanying figure (Source: NIST Cloud Computing Reference Architecture Ver1.0).
Cloud Deployment Models
- Deployment of a cloud can be done in the following ways:
- Private clouds are operated solely for one organisation. They may be managed by the organisation itself or by a third party, and they may reside on-premises or off it.
- Public clouds are open to the general public or a large industry group and are owned and managed by a Cloud service provider.
- Hybrid clouds combine two or more clouds (private or public) that remain unique entities but are bound together by technology that enables data and application portability.
- Community clouds feature infrastructure that is shared by several organizations and supports a specific community. They may be managed by the organizations or a third party and may reside on-premises or off it.
In a CDW Cloud Adoption Poll, 47 per cent of IT managers say their organizations are most likely to use a private cloud approach.
Cloud Technology - Addressing Challenges in Healthcare
Healthcare lags most other verticals in the adoption of technology. Most healthcare organizations depend on workflows that consist of paper medical records, duplicate tests, film-based radiological images, handwritten notes, fragmented IT systems, and silos of information. Information sharing across providers is inefficient and data portability is rare. Care providers rely on outdated technology for their communication needs. Collaboration and coordination of care processes is a major challenge.
The Digital Divide: In major cities across India, we have some of the best hospitals in the world in terms of adoption of technology and provision of high quality of healthcare services. However, the scenario is completely different in rural hospitals, which lack even basic infrastructure, let alone high end technological infrastructure. This means that the doctors, nurses, administrators, and other personnel working in the rural hospitals are not exposed to technology at all, as opposed to their counterparts in the major cities.
There is a need for sustained efforts from both the Government and private sector to create uniformity in healthcare technology adoption. The good news is that cloud technology can make healthcare applications like EMRs, HIS, PACS, and others affordable and easily accessible.
High cost of implementing and managing multiple diverse infrastructural components: The general feeling is that traditional technology requires elaborate infrastructure and manpower to run. For example the computer network requires a separate infrastructure, as opposed to the telephony network. In addition, devices like pagers, nurse call systems, public address systems, etc. requires a different set of infrastructure. There is a need for a common integrated network infrastructure, which can create the 'Foundation for Connected Health'. To capitalise on technology investments now and in the future, hospitals need an integrated IT network that helps diverse entities to collaborate and communicate effectively. The cloud can act as the foundation for connected health to support a range of complex, disparate, and mission-critical applications. The cloud helps the hospitals and healthcare providers to use the applications, hardware, and services on a'pay per use' model, which allows them to avoid heavy capital expenditure on buying and deploying expensive technology.
Data Centre Virtualisation for Healthcare The rapid adoption of electronic health records: EMR, HIS, PACS, and other advanced clinical applications are creating a critical need for more data storage, resulting in the expansion of the range of healthcare services, and increased IT spending. Cloud technology provides the answer by ensuring that users have access to the data and applications they need on demand and from any location.
These new advancements in cloud technology are fundamentally changing the way healthcare providers operate their technological infrastructure. They are realising the benefits of adopting cloud technology, instead of owning and maintaining huge data centers that need massive investments in technology and human resources.
Concerns about patient data confidentiality and security issues are also weighing down heavily on the adoption of cloud technology. As patient data will reside at a location distant from their own facility, there is a concern about the possibility that sensitive data could be lost, misused, or fall into the wrong hands. Technology vendors have to build robust security and disaster recovery features into the cloud technology, to ensure that all administrative and clinical data is securely and safely maintained.
Gaining confidence of all the stakeholders is also an enormous challenge. Gaining the buy-in from both internal and external stakeholders is very crucial. Healthcare providers still do not see the value of the cloud as an enabler of faster, safer, efficient, and more effective healthcare. Providers are often unwilling to make investments in cloud-based initiatives. Hence it is important to take the entire ecosystem into confidence, before embarking on any large-scale cloud initiative.
Training of the users also can be a significant challenge because of the'digital divide'. Training of the users should be tailored according to the needs of the users and should take into account their educational background, aptitude, and pace of learning. Training may also need to be conducted in the local language.
Cultural Issues and Change Management: Implementing the cloud solution involves significant changes in the processes being followed by the healthcare providers. Healthcare facilities have been dependent on legacy systems and processes, many of which are outdated and are not efficient. The infrastructure needs modernisation. However healthcare providers tend to avoid modernising their IT infrastructure, because of lack of funds and a tendency to avoid capital expenditure on new technology. Moreover healthcare stakeholders have traditionally been very resistant to change. Hence healthcare organizations require a significant amount of support from their technology partners, to manage the change and ensure a smooth transition to the new system and processes.
Benefits of cloud technology for healthcare - Transforming Service Delivery
The Yankee Group is observing the emergence of new business models based on anytime, anywhere IT services, propelled by end-user creativity and expectations. The Yankee Group asserts that "anywhere IT" will be the largest technology-enabled transformation in our lifetimes, potentially reaching two billion people by 2012. It believes that this trend represents the convergence and synergy of cloud computing, application mobility, and social media.1 At the center of this trend are the companies that design, aggregate, and deliver IT services.
The keys to transforming service delivery through the cloud require the following:
- Reducing capital expenditure and leveraging existing assets
- Controlling ongoing development, delivery and operations costs
- Increasing the speed and flexibility of developing and providing new (differentiated) services
- Efficiently managing the customer relationships over the cloud (e.g. billing)
- Such challenges illustrate the complex interdependencies required to provide cloud services and currently no single service partner can deploy and manage all the services that end customers are demanding.
Healthcare on Cloud
More and more vendors are offering healthcare solutions and services such as telemedicine, electronic medical records, medical imaging, and patient management that can be consumed or integrated by healthcare providers, payers and customers over a cloud. We see good traction in cloud Adoption as demonstrated in a recent poll conducted by CDW.
We expect majority of the larger healthcare players to set up their own'private' cloud in the near future. The primary focus would be to offer IaaS to their internal stakeholders. This will help healthcare organizations to reduce costs and increase its agility in provisioning, orchestrating and managing the applications and the infrastructure. Mid-tier and smaller players are expected to move their administrative applications like Registration, Billing, Scheduling, and Reimbursement, to the cloud. As the cloud adoption in healthcare evolves, we expect a major chunk of healthcare services to move into cloud; and this would let healthcare players focus on providing cost effective and efficient healthcare services.
Service providers play a major role in adoption of cloud in any industry, and healthcare is no exception. Cloud can enable service providers to rapidly and cost-effectively integrate their applications, end points, and operations capabilities into a set of cloud services that can be deployed to customers, be it providers, governments, payers, or patients, using a wide range of network connections (fixed and mobile). In many cases these services can be composed of existing applications, infrastructure, and workflows that may be located anywhere in a cloud configuration (without requiring co-location) to a set of consumers that can either be permanently or temporarily connected into the cloud. The service connections can be provisioned for high levels of security and can be monitored to precise endpoints (such as a device or user) to enable accurate billing, usage and metering information for the individual services.
Increasing Business Agility
Healthcare service providers need to maximise their investments in IT assets, operations, training, and management of their solutions to support the cost economics that drive healthcare. An agile service delivery model is required to support the need to dynamically scale services up or down to optimise availability of resources with minimal delay and waste. Cloud computing can help them increase business agility.
Gartner predicts that 30 per cent of consulting and systems integration revenue will be delivered through cloud computing by 2011.ii, Frost & Sullivan predicts that hosted services will account for the majority of unified communications services revenues, hovering just above the halfway point by 2014.1
Key Benefits of Cloud Technology
Cloud transforms the economics of IT from capital-intensive to pay-as-you-go. Service level agreements guarantee the capabilities needed, when needed. Costs are tiered and metered to accurately reflect requirements and usage. All applications, including legacy, run more efficiently and sustainably with greater utilisation of the underlying infrastructure.
Cloud can improve information management and reduce operating risks: Coupled with context-aware systems, Cloud protects sensitive information through automated policy enforcement. Additionally, the resilience of Cloud deployments increases uptime and simplifies disaster recovery.
Cloud accelerates business by allowing healthcare organizations to transform ideas into new services, with greater speed. This allows healthcare providers to scale up their operations, and launch new services quickly and easily. Cloud can provide nearly limitless scalability, enabling businesses to grow, without the investment in time and resource intensive technology infrastructure.
Cloud brings powerful IT resources to the healthcare providers: Healthcare organizations of all sizes, across all geographies, can access information technology resources that previously were out of reach. World-class applications and computing infrastructure are available to all without considerable up-front investment.
Cloud makes new business models possible and unlocks revenue potential, for healthcare entities. Hospitals and other healthcare providers can enter new markets, respond more quickly to changing customer needs, collaborate more effectively to drive innovation and business value, and execute on strategies that might not have been cost-effective in the past.
Most healthcare organizations today need to modernise their IT infrastructure, to be able to provide safer, faster and more efficient healthcare delivery. This requires massive upgradation of their existing IT infrastructure and involves huge upfront capital expenditure and sizeable operating expenses. Cloud technology mitigates the need to invest in IT infrastructure, by providing access to hardware, computing resources, applications, and services on a'per use' model, which dramatically brings down the cost and simplifies the adoption of technology. Several EMR vendors are offering their solutions as a cloud-based offering, providing an alternative approach to help hospitals better manage the otherwise massive capital IT investments that would needed to support EMR implementations.
However, there is an ongoing debate within healthcare as to the viability of cloud-based solutions given the need for patient privacy and sensitive personal information. In considering cloud computing for health care organizations, systems must be adaptable to various departmental needs and organizational sizes. Architectures must encourage a more open sharing of information and data sources. Many HIS and clinical systems deal with processes that are mission critical, and can make the difference between life and death. Cloud computing for healthcare will need to have the highest level of availability and offer the highest level of security in order to gain acceptance in the marketplace. Hence there might be a need to create a 'Healthcare-specific Cloud' that specifically addresses the security and availability requirements for healthcare.
Many regions in the US and other developed countries are establishing health information exchanges (HIEs), which are cloud-based information clearing houses where information can be more easily shared between hospitals, health systems, physicians, and clinics. There are many technology vendors and service providers, who are already building cloud-based HIEs, many of which are already functioning and providing tremendous value to patients, administrative authorities, and providers. Many pharmaceutical companies are starting to tap the cloud to improve research and drug development to discover newer, cheaper, and more effective treatment protocols and medicines. Hospitals and physicians are starting to see cloud-based medical records and medical image archiving services. The objective is to offload a burdensome task from hospital IT departments and allow them to focus on supporting other imperatives such as EMR adoption and improved clinical support systems.
Early successes of cloud-based physician collaboration solutions such as remote video conference physician visits are being trialed. Extending such offerings to a mobile environment for rural telehealth or disaster response is becoming more real with broader wireless broadband and smartphone adoption.
Partial solutions will not win over industry resistance. Healthcare-specific Cloud solutions from technology vendors that understand the intricacies of healthcare, can build winning solutions. We are convinced that traditional healthcare IT vendors will benefit from aligning and collaborating with each other, such that healthcare domain-specific clouds can be created, creating a transformational shift in the healthcare industry.
1.As defined in NIST Definition of Cloud Computing @ http://csrc.nist.gov/publications/drafts/800-145/Draft-SP-800-145_cloud-definition.pdf
2 Gartner, 2009 Top 10 Predictions
3 Frost & Sullivan, Market Demands for Hosted UC Services, December 2008
Frost & Sullivan, Market Demands for Hosted UC Services, December 2008