There has been much focus on the cloud computing model and its potential usefulness in health care in the past few years. Both Google Inc., with Google Health, and Microsoft, with HealthVault, have invested heavily in their cloud-based personal health record (PHR) services. Given the involvement of these two technology giants, there is good reason to suspect that cloud computing will be a significant platform for health care in the near future.
Moreover, telemedicine, which enables the remote delivery of health care services, could similarly benefit from cloud computing. Telemedicine can serve an important role in health care by reducing costs, improving patient satisfaction and extending services to remote areas.
Both PHR services and telemedicine are good candidates for the cloud computing model -- but does the cloud have a place within a more traditional health care environment? Will hospitals, physicians' offices and ambulatory surgery centers migrate to the cloud?
Addressing EHR implementation obstacles
Health care traditionally has lagged behind other industries in adopting IT. This may actually propel health care to embrace the cloud. "The fact that a lot of health care has not already moved into second- and third-generation IT solutions could definitely pave the way for cloud computing solutions," said Randy Barnes, chief operating officer of Unifi Technologies Inc., a Bend, Ore.-based developer of cloud-based clinical, practice management and patient portals.
In a recent Harvard School of Public Health study, inadequate capital was the most commonly cited barrier to implementing electronic health record (EHR) technology, which is central to federal efforts to upgrade health IT and lower health care costs. The second-highest-rated barrier was high maintenance costs.
The cloud removes these barriers. The cloud computing service provider bears the majority of the IT infrastructure's cost. Because the provider hosts the servers and system, the end user's maintenance costs are minimal. Cloud computing lets organizations shift costs away from investments in hardware, software and labor, and move to an operational cost model tied to actual resource use.
Essentially, cloud computing's cost structure is like a monthly utility bill. With this pricing structure, health care organizations can budget more effectively, following a monthly payment schedule. They don't have to delay installing EHR because they need to set aside millions of dollars for the system implementation.
The emerging private cloud
The hybrid cloud computing model, which combines public, private or community clouds, is gaining popularity within health care. With this model, an organization can blend a private cloud environment and Software as a Service (SaaS) applications, and benefit from the cloud's portability and ease of use while controlling its own environment. An organization can outsource many of its IT functions to a hosted provider, often improving its disaster recovery plan and connectivity.
Stanford Hospital in Palo Alto, Calif., is an example of a large institution that moved its services to a hosted provider -- in this case, Perot Systems, which is now part of Dell Inc. (Other organizations employing similar IT outsourcing strategies are San Francisco-based Catholic Healthcare West and Tufts Medical Center in Boston.)
By incorporating the cloud computing model into its overall strategic platform, Stanford Hospital was able to receive from the Healthcare Information Management and Systems Society the HIMSS Analytics Stage 7 Award, which fewer than 1% of U.S. health care organizations have received. Stage 7 represents the highest level of EHR implementation, which results in patient encounters that are completely paperless and integrated. According to HIMSS Analytics, "this stage allows the health care organization to support the true sharing and use of health and wellness information by consumers and providers alike. Also at this stage, organizations use data warehousing and mining techniques to capture and analyze care data for performance improvement and advancing clinical decision support protocols."
Infrastructure as a Service (IaaS) is another model that, though new to the health care market, is getting some attention. With this model, the organization's environment is essentially a hosted private cloud.
Ken Birmanprofessor of computer science, Cornell University
Surgery Center Partners, an ambulatory surgery center (ASC) management company based in Los Altos, Calif., chose to move to an IaaS model. The company manages 17 ASCs, 16 in California and one in Texas. Senior management elected to move to a Citrix Systems Inc. virtual environment hosted by Southfield, Mich.-based Secure-24 Inc. for its corporate office and ASCs. Secure-24 specializes in managed hosting, remote management, disaster recovery and services for enterprise-level business-critical applications. Management felt that moving to this platform would improve data security, disaster recovery and system availability for staff and physician partners.
An improved disaster recovery protocol is another way organizations can benefit from moving to cloud computing. Because it is their core business, hosted providers are well equipped with substantial backup services for power, cooling and security. Obviously, an organization would need to perform due diligence to make sure the vendor it selects provides comprehensive security and disaster recovery protocols.
Highly rated data centers have strict biometric security measures in place, and comply with Statement on Auditing Standards No. 70 (SAS 70) and other security best practices. SAS 70 defines the standards an auditor must employ to assess the contracted internal controls of a service organization. Many health care organizations, especially smaller facilities, would have a difficult time matching the recovery protocols provided by a hosting site, and simply would not have the IT expertise or the funding to implement and maintain a world-class disaster recovery plan.
Building trust in the cloud computing model
Of course, with any model there are both advantages and disadvantages to consider. Critics of the cloud cite security, control and availability. "The simple fact is that a business with data in the cloud has absolutely no control over where that data actually lives," said Ken Birman, professor of computer science at Cornell University. He cited trust as the biggest obstacle to cloud computing. "So, creating trustworthy cloud computing is, for me, the highest priority -- and the lack of trust is the biggest risk today," he said.
According to Birman, security and privacy are central needs, although data availability, consistency, fault tolerance and rapid response times are other critical properties of a platform. Cloud computing providers often lack consistency in order to guarantee a quick response, he said.
Organizations looking for a hosted provider also should take into consideration the provider's stability, the firmness of its pricing structures, and its availability or uptime guarantees. Organizations also must ensure a provider has sufficient bandwidth: It would be very frustrating for practitioners to wait several seconds for pages to load. These factors often deter health care organizations from considering a cloud model as an optional IT platform.
Cloud computing services and meaningful use
The impact of cloud computing within health care can be debated, but there is no doubt that cloud models offer organizations a cost-effective alternative to a traditional client/server installation. The pressure to install EHR systems to meet the Health Information Technology for Economic and Clinical Health (HITECH) Act's meaningful use criteria and to improve efficiencies in treating aging patients and their increasingly complex medical needs will push many health care organizations to look to the cloud as a potential solution.
Given the variety of cloud computing models, an institution has several alternatives when it chooses a cloud-based system. Each model has different operating characteristics and properties that may be attractive within different health care settings.
• A small, one-room ASC lacking capital and IT support may find that the SaaS model makes the most sense. More than likely, the cloud would provide better security, disaster recovery and availability than servers set up directly in the center that rely on clinicians to install backup tapes.
• A physicians' practice group may also find that a SaaS model will serve them and their patients most efficiently. The Internet allows for greater connectivity among providers, laboratory companies or other testing facilities.
• A larger hospital or organization that can afford higher capital, however, might look to the IaaS model and developing a private cloud platform that provides more control and security.
It is clear there is potential for the health care cloud to have a silver lining -- with the understanding that one cloud size doesn't fit all.