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Creating a health care cloud infrastructure without borders

Federal mandates require health care organizations to exchange patient information. Private clouds built on data exchange standards, and with high bandwidth, can make this happen.

As the HITECH Act points out, the main benefits of electronic health record (EHR) adoption for individual health care organizations are improved efficiency and care quality, as well as reduced health care costs. The real kicker, though, is when records are linked through health information exchange (HIE).

When this happens, patient information is no longer confined to data silos within individual institutions. If the dream of the Office of the National Coordinator of Health IT (ONC) comes true, it can be securely pushed to physicians, laboratories, health insurance companies and government agencies around the country.

Building a flexible, reliable and low-cost cloud infrastructure lets clinical data flow among departments. Critically, it also lends itself to extending beyond an institution's walls and exchanging data with outside entities.

Connecting private clouds easy when EHR software is the same

Disparate cloud infrastructures can be most easily connected when two or more health care providers use the same EHR software.

For example, San Francisco users of RelayHealth, a Software-as-a-Service-based patient portal and data sharing system from McKesson Corp., recently formed an HIE organization. The members, which had hitherto been rival hospitals, decided that the potential to improve patient care outweighed whatever competitive disadvantage that sharing patient information may bring.

Meanwhile, Aspirus, a health system that serves patients in northern Wisconsin and Michigan's Upper Peninsula, uses EHR software from Epic Systems Corp. within its private health care cloud. Tom Whalen, infrastructure team leader at Aspirus, said he sees value in Epic's efforts to expand interoperability.

"It's intended to let the [patient] have the same clinical experience no matter where they go," he said. "If I break a leg in Madison and go to a hospital there, the physician can go to the Aspirus cloud Epic environment and … review [my] record as I'm being treated in Madison."

When systems differ, turn to HIE standards

Of course, not every health care provider uses the same EHR system. The best way to prepare a cloud infrastructure for future interconnections, then, is to build it with existing HIE standards in mind.

The foremost set of standards is the collection of core services and specifications known as the Nationwide Health Information Network (NHIN). The ONC, an agency within the Department of Health & Human Services, leads the effort to build and expand the NHIN.

The best way to prepare a cloud infrastructure for future interconnections is to build it with existing HIE standards in mind.

ApeniMED Inc. is a Minneapolis-based HIE vendor that has built a NHIN gateway into its HIE platform. One customer, Marshfield (Wis.) Clinic, uses NHIN to connect directly to the Social Security Administration (SSA).

Another customer, the Lewis and Clark Information Exchange, or LACIE, a four-state HIE based in St. Joseph, Mo., worked with engineers at Cerner Corp., its EHR vendor, to make ApeniMED's NHIN gateway available to end users from within the EHR software.

This means that physicians can connect to the NHIN -- and, by extension, other health information exchanges -- without leaving the EHR interface. To cover legal contingencies that might arise when medical data is sent across state lines, all NHIN participants must sign the Data Use and Reciprocal Support Agreement (DURSA).

"You don't have to sign onto a separate system. That's a huge differentiator," said Jeff Bloemker, executive director of LACIE.

Efforts related to NHIN include initiatives such as NHIN Exchange, a live, limited production implementation of NHIN standards whose participants include the SSA and the Centers for Disease Control and Prevention, as well as the Direct Project, a means of health information exchange that uses the Secure Multi-Purpose Internet Mail Extensions (S/MIME) and Simple Mail Transfer Protocol (SMTP) standards.

Several Direct Project pilot programs are underway. Participants are exchanging many types of clinical data, from lab test results to physician referrals to immunization records.

Standards set by the nonprofit Health Level Seven (HL7) International Inc. can also define how health care entities share data with each other and among software such as clinical applications, medical practice management systems and billing applications.

For example, Pathagility LLC, a Little Rock, Ark.-based provider of Software as a Service (SaaS) reporting and workflow management systems for pathology labs, leverages the EHR-Lab Interoperability and Connectivity Specification (ELINCS) standard in its software. Doing so lets physicians order a medical test such as a biopsy, send the sample to a lab and receive a report, all within a Web browser, Pathagility President Mark McCuin said.

SOA powers cloud infrastructure convergence, at a price

Service-oriented architecture is critical for enabling this kind of interoperability, according to Seonho Kim, chief architect at ApeniMED, which used SOA technologies in implementing its NHIN gateway.

"The first step is for the small provider to connect to the HIE," Kim said. "From there, the question is, how can they add different pieces and parts?"

SOA appeals to health care organizations because it involves addressing each functional process on a network as an individual service. This has two key advantages. One is that it lets organizations move to a cloud infrastructure slowly, one service at a time. The other is that it lets them choose which services to keep within the private health care cloud, which to leave to a SaaS provider, and which to leave to an Infrastructure as a Service provider.

It should be noted, though, that an organization moving to a cloud infrastructure will need to boost its network bandwidth, since more data is being accessed on the Web.

As the number of cloud-based interconnections increases, though, so will the richness of the content being shared -- not just problem lists or drug allergies, say, but also radiology images and other test results that are key to telemedicine technology. What's more, richer content means even greater bandwidth needs.

Although 20 Mbps DSL links are currently adequate in many instances, Kim said it is wise to account for future growth when planning cloud infrastructure. A redundant link may also be necessary.

At Atrius Health, an organization of affiliated health care providers in Massachusetts, CIO Dan Moriarty doubled bandwidth from dual 20 Mbps pipes to dual 40 Mbps pipes. For the sake of fault tolerance, he contracted with two different carriers in order to use different network paths. This ensures that an outage in one service will not affect the viability of the other carrier's service, he said.

Stan Gibson is a Boston-based contributing writer. Let us know what you think about the story; email

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