Healthcare CIOs Opt for the Cloud

This article appears in the October 2012 issue of HealthLeaders magazine.

Cloud computing is taking hold in healthcare as a form of data sharing and for archival storage, an infrastructure cost-cutter and a time-to-market accelerator, and even as a method of recovering from disaster. But as author William Gibson famously said, if the future is already here, it isn't evenly distributed yet, and cloud computing is a textbook example. Concerns about security, privacy, regulatory compliance, and service-level agreements are just a few of those cited in and around healthcare as go-slow signals for adoption of the cloud.

Just don't show those signals to a growing contingent of CIOs and other healthcare technologists who are making real use of cloud computing today to help solve pressing needs.

"We have several examples of what we're doing in the cloud,” says Joe Bengfort, executive director and CIO of University of California San Francisco Medical Center, which posted net patient service revenue of more than $1.8 billion in 2011. "Some are quite closely related to the medical record system and patient care. Some of them are more back in the weeds of the infrastructure and the back-end technology.”

At the same time as UCSF is making these preliminary steps into the cloud, it's also just bet big on a traditional client/server-based electronic medical record from Epic, which went live in June 2012. "We use an approach we call development on the edges of the medical record,” Bengfort says. "Our strategy is to develop capabilities outside of the medical record, and then feed that information back into that system, or to link from the medical record environment into some outside system.”

One of those outside cloud systems, Salesforce.com, has deep ties to UCSF. In 2010, its founder, Marc Benioff, pledged $100 million of his fortune to the UCSF Children's Hospital now under construction. Salesforce.com's development engine is powering a breast cancer research project spanning UCSF and the rest of the University of California system, Bengfort says.

"We're using the Salesforce platform to develop applications really around surveys—surveys associated with screening or survivorship, things of that nature—that our patients utilize,” Bengfort says.

"They can either utilize it by going into what looks a lot like a website, but it's really the Salesforce cloud,” he says. "Or they can access it through an iPad application that we've developed that they use on an iPad while they're at the doctor's office.”

UCSF has different programs written in the Salesforce.com environment that do basic things like organize the data from the survey. These programs also do computations on the risk scores for developing breast cancer based on the input that they've gotten from the patient. These results can be linked to or moved into the medical record, so that if this patient presents at the hospital or at a clinic, that information is accessible by his or her care team, he says.

"We still have all the issues of patient information, PHI that has to be protected, that can't be shared unless it's agreed to by the patient, so you still have all those restrictions,” Bengfort says. "We've done a lot of work with Salesforce in certifying their environments for our PHI, so we think we're in good shape around all those issues.”

UCSF's boldest cloud move has been to develop a way to back up its new Epic medical records to the cloud. "All the infrastructure is in place,” Bengfort says. "We're replicating our data right now. We're through two rounds of disaster testing, and we're at a point now where we want to test the ability to not just fail over to switch to a redundant system but to fail back to restore the system to its original state.”

The capability is so new that the providing cloud vendor, Dell Healthcare, has only implemented it with UCSF, Bengfort says. This implementation was key to UCSF as it prepared to achieve compliance with Meaningful Use 2011; the 600-bed main hospital was on track to attest last month.

Those medical records predating the Epic system also found a home in the cloud. Legacy Data Access takes records from old medical systems and converts them to a format that can be stored and retrieved in the cloud. "They will custom-develop a webpage so you can see it in the format you want to see it back, and then you just pay a subscription service for the access to that data,” Bengfort says.

Some healthcare organizations laid solid groundwork for the move to the cloud by investing substantially in application virtualization some years back. "We've always been a proponent of looking at how we use computing resources on the fly without having to add a lot more hardware infrastructure and software licensing to go along with that,” says Dee Cantrell, CIO of
Emory Healthcare.

With more than 1,830 licensed beds, more than 20 health centers, and 9,000 employees, Atlanta-based Emory has partnered with GNAX for the past five years to provide niche clinical systems.

"I've actually taken work off of my technical team, who was previously having to work on setting up servers and getting the hardware connected appropriately with the network and making sure all the security safeguards were in place, as well as loading the applications, and of course with that comes a lot of licensing expenses,” Cantrell says. "Now, instead of doing that, we actually have our technical resources really focused more on going out and working with our customers, looking at strategy for new solutions, and working on implementing new things.

"So they don't really do the setting up of the hardware, the application, or supporting that anymore. We actually get that service through the cloud offering that GNAX provides.”

One such niche system being served up in the cloud is Emory's cardiology images, Cantrell says. "We actually acquired two new hospitals that have their own systems that we're in the process of consolidating and moving to the Emory Healthcare systems,” she says. "We need to be able to store these images in a secured location and not have to do a lot of up-front investment for hardware. The cloud offering allows us to do a subscription-based approach, so we're using operating dollars instead of the capital dollars that are so hard to come by these days.”

Some software controlling Baxter infusion pumps is now being provided via software as a service. Cantrell says migrating these types of applications over to the cloud has realized Emory a 30% savings by avoiding unneeded hardware, hardware maintenance, and related infrastructure components.

Sheer speed of deployment is driving many hospitals to implement their ambulatory medical records via software as a service. Three years ago, Continuum Health Partners—a New York City–based system with seven major facilities, 2,180 certified beds, and an annual operating budget of $2.8 billion—selected eClinicalWorks as its ambulatory EMR.

"We really didn't want to expand our internal staff organization to the degree necessary to really support the implementation and the rollout at the same time,” says Mark Moroses, senior vice president for information technology and CIO at Continuum. "We could move quicker by not having to support the application infrastructure as well as the complexity of going from practice to practice and dealing with the application integration issues, the data migration issues, the workflow issues, and the adoption issues.”

By the end of 2012, Continuum will have more than 500 physicians utilizing eClinicalWorks, Moroses says. "So that's been pretty successful for us.”

Moroses makes the point that the software-as-a-service industry has attracted vendors who now have their own clinical resources on staff, supporting the rollout of cloud services in healthcare in a far more knowledgeable way than just a few years ago.

"These are companies that are specifically focused on healthcare, so they understand the HIPAA regulations,” Moroses says. "They understand all of the privacy concerns. So when we express those, they have a better answer, and they also are able to provide and are more willing to provide different things that we would insist upon, like a biannual audit of their data center that they have to provide us with their own internal audit documentation.” Moroses says the software can review the audit trails on a consistent basis.

"In another industry, that maybe seems onerous or they may not be able to provide those as regularly, but because these guys are savvy in healthcare, our lawyers and the data people, anything that we ask, they weren't surprised at the request, and they had an approach to answer it,” Moroses says.

One place where the cloud and healthcare seem to have a natural fit is the build-out of health information exchanges. Cantrell says cloud computing makes image sharing in such an exchange much easier.

Likewise, Moroses says Continuum went live in January with a cloud-based HIE from Caradigm, the joint venture between GE and Microsoft.

"We didn't want to have to deal with the massive amounts of data and the complexities of integrating with every practice we brought on board,” says Moroses. "We wanted to focus on the use of the HIE and the use of the data, so it was really a strategic decision to say, ‘Okay, the things that are really most important to us are not the infrastructure nuts and bolts kind of stuff. That, we can just go to the cloud for. We can just rely on somebody else and pay a flat fee.' ”

Archiving in the cloud is also on Continuum's radar. "We're having conversations with people around the idea of putting images and long-term archive in the cloud, and that has some appeal to us, too, because as part of a medical record, it's a pretty dense element of data,” Moroses says. "Images are pretty large size, and for people to be able to access them anywhere and not have it really pulled across your network is appealing.”

Static storage media, such as DVDs or optical disks, have a lifespan. Pediatricians may have to keep images for 21 years, and even tape won't last that long, Moroses says. "Probably the safest thing is some kind of form of spinning disk that I can either mirror or have multiple copies. [of].”

Still, all three health systems are typical in that they continue to run their own data centers for storing their primary inpatient EMRs. A big reason: These systems were purchased so recently in the rush to attest for meaningful use, the institutions are still amortizing the cost of building and equipping these data centers with software licenses. "It is going to be a matter of finances as we look to do more migration,” Cantrell says. "One of the first things that we look at now, any time a new solution is approved for implementation, is [to] offer it through the cloud service offering through GNAX.”

Bengfort sees rapid growth for cloud computing in healthcare. "From a medical center standpoint, I tend to be a little bit more conservative about it,” he says. "It may not sound that way, because we're using a lot of cloud today, but we're using things that either we've been personally involved in developing the criteria for, much like the Dell example, or they are quite mature, proven rock solid.

"When you are providing care to patients, the closer it is to the patient, the more rock solid it has to be,” says Bengfort. "I love innovation. I hope you can tell I'm certainly pushing the edges where I can, but when it comes to patient care, it's got to be a well-proven and very secure environment. From a medical center standpoint, I might be a little more cautious than we're going to be on the university or the research side, where we can be a little bit more assertive about what we push into the cloud. So that's kind of just the high level of it, but I certainly think leveraging capabilities like this are going to be more and more prevalent as we move forward.”

Another concern is to address service expectations with the vendor.

"The contractual arrangements that you have in your agreement are really key,” Cantrell says. "I don't think you can shortchange that process, because you do want to define pretty clearly what your service-level expectations are, not only from a performance perspective, but also from a turnaround time perspective, if you happen to have an issue.”

The cloud also represents a starting point for many future innovative healthcare technologies. "In
the home healthcare space, where you're sending patients home with monitors and telemetry data is being sent back out, I would see using a cloud-based service to gather that data, process that data, maybe analyze it, have certain thresholds, certain trends that they're analyzing for,” Bengfort says. "I would see that as a great innovative service for the cloud that doesn't exist today, specifically for the healthcare space.

"We could probably come up with lots of examples as we start to push accountable care organizations and we're trying to manage proactively the health of a community before they ever even present at the hospital or at the clinic,” Bengfort says. "There's got to be creative cloud-based solutions to help provide services to those accountable care groups.”

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This article appears in the October 2012 issue of HealthLeaders magazine.