Screen shot: MedCommons hosts a patient's complete Continuity of Care health record including imaging and documents in the Amazon cloud and displays a real-time dashboard for each patient.

Recent developments in global economics have left the fiscal atmosphere for healthcare a roiling tempest. Looking to the horizon, chief medical information officers may see only thunderheads bearing down on their institutions; however, a new application delivery paradigm—cloud computing—may offer relief from the financial storms swirling over the landscape.

Cloud computing is a schema in which tasks are assigned to a combination of connections, software and services accessed over a network. Although the term can arguably be deemed a re-packaging of grid computing or utility computing, it is a broader concept that relates to the underlying architecture in which the services are designed.

Computing done at cloud scale allows users to access virtual supercomputer-level. Cloud computing’s aim is to deliver tens of trillions of computations per second to problems such as delivering medical information in a way that users can tap through the Web. It does that by networking large groups of servers that use low-cost consumer PC technology, with specialized connections to spread data-processing chores across them.

Google’s search engine and productivity applications are among the most well-known services that locate processing power on aggregated collections of computer servers, rather than on the desktop. Yahoo, IBM, Amazon, AT&T, Sun Microsystems, Terremark Worldwide, Sentry Data Systems, XCalibre Communications, Microsoft and others all have cloud-based services and are marketing their respective architecture to application developers.

The allure of the cloud is that it enables an application provider to “publish” computing resources—such as servers, storage and network connectivity—providing a pay-by-consumption scalable service that’s usually free of long-term contracts and is typically operating system independent.

Most importantly, for cost-conscious health IT executives, the approach also eliminates the need to install any on-site hardware or software—or the personnel required to maintain them.

Implemented correctly, cloud computing allows the development and deployment of applications that can easily grow capacity, deliver needed performance, and have a high-degree of fault tolerance, all without any concern as to the nature and location of the underlying infrastructure.

A little more than two years ago, Bruce Friedman, MD, active emeritus professor of pathology at the University of Michigan Medical School in Ann Arbor, forecasted the advent of cloud computing in health IT.

“It seems to me inevitable that hospital EMRs, LIS, RIS, and other information systems will eventually run on rented servers rather than on hardware owned and managed by the hospitals themselves,” he wrote in Lab Soft News. “In time, the potential cost savings will be irresistible. It also occurs to me, however, that hospital executives would never be able to tolerate using, say, an Amazon server farm or ‘computing cloud’ because of the perception that healthcare computing is different than corporate computing or e-commerce.”

Friedman predicted, correctly, “that specialized companies, or even subdivisions of existing companies like Amazon or Google, will have ‘healthcare’ in their names and will serve only the healthcare industry. In this way, they will be able offer an array of services specifically tailored to the needs of their healthcare clients.”

Azure skies over Redmond

Microsoft is poised to deliver its Windows Azure Web services platform this year, the company has confirmed, and is getting ready for commercial availability in the health IT cloud space.

The Azure operating system is a modified version of Windows Server 2008 and incorporates building bock services, including Dynamics CRM, .NET services, SharePoint, SQL and Windows Live services.

“One of our key business imperatives for cloud computing in healthcare is patient safety,” says Randy Fusco, CTO for Microsoft’s U.S. Health Provider Industry within its Health and Life Sciences division. “For example, we see an opportunity for delivering business intelligence—early detection if you will—for the prevention of sepsis through the cloud.”

Chris Sullivan, national director for Provider Industry Solutions within the Health and Life Sciences division of Microsoft, sees a “crawl, walk, run” role for cloud computing health IT adoption.

“We’ve all seen healthcare customers who have systems running in parallel with one another—one that’s manual, one that’s automated,” he says. “The idea is to have a process and plan in place to migrate over to the fully automated system. I think cloud computing will initially fill the role of fail-safe or fail-over and redundancy scenario. As the market matures, I think we’ll see more emphasis on computing in the cloud.”

Clouds in Big Blue

IBM also has seeded the healthcare cloud market and recently placed one of its application development partners with American Occupational Network (AON). By accessing technology that handles various tasks—from electronic health records (EHRs) to online appointment scheduling—as a cloud service through the internet instead of developing, purchasing and maintaining technology onsite, San Diego-based AON has been able to update its clinical processes and increase key efficiencies to improve patient care. 

For example, by digitizing patient records and other processes, the company has reduced medical transcription costs by 80 percent and now can provide faster and more accurate billing to individuals and insurance companies, reducing the average time to create a bill from seven days to less than 24 hours.

“IBM provides the technical training, infrastructure and hosting services that enable our business partners to deliver cloud-based software to those healthcare providers and businesses that would rather focus on their own core competencies than build a team of IT technical experts,” says Dan Pelino, general manager, IBM Healthcare & Life Sciences Industry.

MedTrak systems of North Muskegon, Mich., uses IBM hosting services and IBM DB2 database software to deliver its software as a cloud-based service to healthcare providers. AON recently converted its clinical billing software and adopted additional capabilities, including EHRs, registering and scheduling with MedTrak software for its five occupational health clinics in Southern California. AON needed a solution to help compete against the larger national occupational medicine chains, yet it lacked the technical infrastructure, IT skills and budget for increased staffing expenses.

“By acquiring these new capabilities as a service, AON has become much more efficient and able to provide a better patient experience without up-front IT infrastructure costs or a need for additional staff for on-going IT maintenance,” says Larisa West, director of administration, AON. “With MedTrak, we’ve been able to streamline our clinical processes, and to have added these capabilities and staff them on-premises, we otherwise would have needed to add two or three technical staff members per clinic.”

Winding out web services

Amazon was one of the first companies to launch a cloud product for the general public, and it continues to have one of the most sophisticated and elaborate set of options. Amazon’s Web Service (AWS) plays host to a collection of healthcare IT offerings, such as Salt Lake City-based Spearstone’s healthcare data storage application, DiskAgent.

Prior to founding Spearstone, CEO Hayden Hartland spent two years managing a dental electronic insurance claims clearinghouse, NIS, DENTRIX’s eServices subsidiary, giving him a background in HIPAA requirements for security and privacy.

“We conducted months of rigorous in-house and beta testing to ensure our encryption and transmission protocols [for DiskAgent] exceed HIPAA requirements,” he says.

MedCommons, a Watertown, Mass.-based health records services provider, utilized AWS to build its personal health record (PHR) offering, HealthURL.

“Our app was designed to be hosted in the cloud and patient-centric from the ground up,” says Adrian Gropper, MD, co-founder and chief science officer. “To be HIPAA-compliant, we had to design our application to allow careful identity management, detailed activity logs, a secure console system that facilitates audit of users and accounts, a clear access consent mechanism, and a locked-down, app-deployment procedure that provides a minimum attack surface—encryption and SSL certificates.”

Pathwork Diagnostics, a molecular diagnostics company, develops high-value diagnostic tests to aid oncologists in the diagnosis of hard-to-identify cancer tumors. Pathwork chooses optimal models for its tests by using proprietary machine learning algorithms to analyze large libraries of tumor specimen profiles.

Although the tests are highly parallelizable, the computation can still take weeks or months using a mid-size high performance computing resource, such as a 64-node cluster.

“Our challenge was a perfect fit for cloud computing,” says Ljubomir Buturovic, chief scientist at Sunnyvale, Calif.-based Pathwork Diagnostics. “We needed access to more computing capacity than we could possibly maintain internally—but only at certain peak times. When we develop and deliver a product for clinical validation, we’ll have weeks where we need access to almost unlimited capacity.”

The Sun peeks through

Sun Microsystems is the newest market player, with an Open Cloud Platform for server and storage services that will debut this summer. Users will be able to run applications under Windows, Solaris or Linus on Sun VirtualBox virtual systems and be able to read and write to files from the browser window.

All in? Not just yet

John Koller, president of Larkspur, Colo.-based KAI Consulting, says that placing limits on the use of cloud technology is a subtle issue that healthcare facilities have to examine closely, measuring the risk against when and where cloud computing can be effective.

“In some cases, the risk is too great to rely only on the cloud,” he says. “Healthcare IT really can be a matter of life and death. And where the decision is made to put some services and applications in the cloud, the practice must address and document—prior to deployment—how that risk is managed for each service or application.”