September 2009

Reformation of Healthcare Services through Workforce Development in Healthcare IT : Prof. Indrajit Bhattacharya and Prof. RK Suri

The paper provides an elaborate description of ‘Cloud Computing’ and its applications and advantages in the healthcare domain.

e-Health in India
e-Health offers some ready products for accelerating the health sector reforms in India. The shortage of infrastructure, manpower and services in health sector in India is mainly attributable to the large gap in overall development between rural and urban areas. This gap levies substantial disincentive on health manpower for working in rural areas. e-Health offers a good option wherein a significant proportion of patients in remote locations can be successfully managed locally with advice/ guidance from specialists in cities, without having to travel far. This allows linking patients in remote areas to urban standard services without delinking urban service providers from their environment. The arrangement offers easier, cost effective consultation, prescription mechanism and allows a referral chain. e-Enabling also improves depth, range and refresh rate for disease surveillance and response. However, this change over to digital way of thinking in the health sector has rather high initial costs. The licensing terms and conditions, bilateral and interconnection agreements, nonexistence of regulations, security and trade issues are serious bottlenecks which need to be addressed. India is the ideal setting for telemedicine assisted health care. We already have a strong fiber backbone and indigenous satellite communication technology with large trained manpower in this sector. Various state governments, departments of the Government of India, private institutions and NGOs have been running a number of e-Health projects over recent past with successful outcome. In this scenario, a country level e-Health plan is long due to steer e-Health. The enhanced allocations for e-Health over the XIth Plan can be used for the following major activities to accelerate and expand the reach of the architectural correction in the health system which is envisaged under the NRHM.

Reformation of Healthcare services in India
While the government controls most of the health care resources and prices, hospitals are financially independent and make their own HIT choices. A growing healthcare services sector is leading to a significant imbalance in the HIT development between highly developed regions versus those at the country level hospitals or in rural settings. A late HIT development advantage that Indian infrastructure has to be equipped with more current and advanced hardware infrastructures and modern approaches to software development, such as service-oriented architectures (SoA) and the latest application development platforms. Since overall hospital HIT investment is small, much of the current software is of low quality and low cost.

Cloud Computing
By accessing technology that handles various tasks, from electronic health records (EHRs) to on-line appointment scheduling, as a service through the Internet instead of developing, purchasing and maintaining technology on-site, it is possible to update clinical processes and increase key efficiencies to improve patient care. For example, by digitizing health records and other processes, medical transcription costs can be reduced upto 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 7 days to less than 24 hours. In the United States, the new American Recovery and Reinvestment Act will infuse USD 19 billion into healthcare IT and calls for the utilisation of an EHR for each person by 2014. While EHRs help deliver smarter healthcare systems with real-time access to critical patient health information, only an estimated 38 percent of US physicians used partial or full EHRs in 2008. In current IT circles, the Internet is often referred to as The Cloud. Think of multiple computers in a giant mesh all inter-working together. Now think of many such meshes and step back � see The Cloud?


The power of computing measured in terms of tens of trillions of computations per second is now applied to delivering personalized medical information, computational chemistry and biology over the web. The idea behind the concept is to network large groups of servers that have low cost PC configuration to do distributed data processing activities across the network using specialized connections. The industry has been always uncertain whether they need software that is located centrally or have software that resides on the user’s system. With the development of high speed networks and with highly sophisticated and ever evolving cheap server technology the computing capabilities are being shifted to data centres. Cloud computing is quite similar to grid computing but it is a more powerful, hybrid and a safer computing arena. Cloud computing can be defined as a set of virtual servers working in tandem over the internet. The applications are easily accessible through the internet and these applications use large data centres and powerful servers that host web applications and services. Grid computing involves dividing large tasks into smaller tasks and running those in a number of parallel systems. In contrast cloud computing architecture is a collection of resources which are managed dynamically and can be provisioned, de-provisioned, monitored and maintained at any point of time.

Cloud computing, also called Software as a Service or SaaS, has particular value in the healthcare industry. It is inexpensive, ubiquitous, and secure. All data and applications are stored on secure servers accessible from anywhere there is Internet access. Healthcare IT is, as usual is lagging behind the rest of the universe. In the early part of the decade, companies like Amazon began architecting their websites in such a way that you could utilize their services simply through the use of a browser like Netscape or Internet Explorer. Fast forward to now when companies like Google and Microsoft offer “in the cloud” services that do not require hardly any additional software on your local computer, beyond the operating system of the computer or device and a browser. Some services are offered for free by merely signing up, while others are offered as a recurring, monthly, per-seat subscription; schemes include Software-As-A-Service (SaaS) and Application Service Providers (ASP). It is a trend and a pattern that is quickly gathering steam.

Cloud Computing as it applies to Healthcare
The trend appears to be irreversible. Many software applications, services, and data once in the realm of a local computer or local server safely secure in your building are now in the domain of the public Internet. Private health information once confined to these local networks is migrating, wholesale, onto the Internet. Patients voluntarily grant access to their health records every time they sign a waiver to the health insurer that then decides on the payment disposition to the doctor, pharmacy, or hospital. For the most part, the collection and organization of this data is completely legal. It then follows that companies want to automate and accelerate access to these records in order to then offer “in the cloud” products and services to both patients, doctors, and institutions. The fact that Google and Microsoft are heavily invested “in the cloud” extends to their new offerings for medical records services, such as Microsoft’s HealthVault and Google Health. While still in beta testing, these software giants have partnered with large healthcare providers for their programs: Microsoft with Kaiser Permanente and Google with The Cleveland Clinic.

Convergence of events can be envisaged considering the new Obama initiatives like “Transforming healthcare” and “Enabling Healthcare Reform Using Information Technology” � recommendations by the Healthcare Information and Management Systems Society (HIMSS) to the Obama administration and the 111th Congress. There would be a vast influence of cloud computing in healthcare. With healthcare providers looking at automating processes at lower cost and higher gains cloud computing can act as an ideal platform in the healthcare IT space. Cloud computing could be seen as a boon to healthcare IT services as a number of hospitals could share infrastructure with vast number of systems linked together for reducing cost and increasing efficiency. This also means real-time availability of patient information for doctors, nursing staff and other support services not within the country but possibly across various countries as medical professionals can access patient information from any internet enabled device without installing any software. In the cloud computing scenario the EMR (Electronic Medical Record) software or the LIS (Laboratory Information System) software and information are located in the central server and not on the users or computer. Patient information and data can be accessed globally and resources can be shared by a group of hospitals rather than each hospital having a separate IT infrastructure. Cloud computing would help hospitals to achieve more efficient use of their hardware and software investments and increase profitability by improving the utilization of resources to the maximum. By pooling the various healthcare IT resources into large clouds, hospitals can reduce the cost and increase utilization as the resources are delivered only, when they are required. The use of cloud computing architecture helps in eliminating the time and effort needed to roll a healthcare IT application in a hospital.

Applications of Cloud Computing in Healthcare:

Some of the applications seen in Healthcare are as under :

  • Pharmaceutical Analysis: Researchers expected a protein analysis comparing 2.5 million compounds to take a week of processing on internal servers. Using hundreds of servers in the cloud, the job completed in one day.
  • Insurance Claims Loss Control: Systems for detecting fraudulent, improper or duplicate claims in batches of millions of claims required months of processing time to run and millions of dollars in capital outlay to build. Using the cloud, these batch runs now finish in a few days.
  • National Doctors’ Registration Database: This can be mandated for yearly renewal and hence location of doctors can be identified. With shortage of medical resources in the country, it may be useful to seek medical expertise of good doctors wherever they may be through tele-medicine.
  • Storage of Images: Interoperability will reduce overall costs as duplicate orders can be significantly reduced. Especially in Govt hospital scenarios, where referrals would be common, diagnostics can be completely filmless thereby savings significant money for the Government.
  • Bio-surveillance: Online outbreak of communicable diseases would be possible and even for lifestyle diseases it would be easier to launch health programs for specific areas.
  • Research & Analysis

Standardization of infrastructure of Healthcare IT
The adoption of cloud computing would help standardize the infrastructure for healthcare IT solutions in contrast with the current highly disparate situation. In addition, vendors get to specify the infrastructure and leverage the implementation to adopt aspects such as SAN (Storage Area Network) storage. Since a lot of the hardware servers are virtualized, the cost is reduced tremendously and the only other requirement might be the use of middleware. Vendors could also offer hospitals the option of pay by use of resources in CPU (Central Processing Unit) hours, or gigabits consumed and transferred, which is quite compelling. Cloud computing also helps vendors with hospitals hesitant to sign long-term healthcare IT services contracts as with a cloud infrastructure there is no long term commitment. At the same time the clouds can support nearly any type of healthcare IT application the hospital might want to implement as long as it does not require any specialized hardware.

Cloud Computing affecting Physician’s Practice
In the coming months and years several factors are converging into a “perfect storm” of opportunity and challenges. For most solo, small, and medium practices, Cloud Computing represents a juncture of significance. Do you invest up front and build your local computing infrastructure and keep your data local or do you amortize your investment over recurring monthly charges and keep everything “in the cloud,” including your data. Either choice presents additional challenges: What about backups, disaster recovery and 99.999 percent uptime to the Internet? What about HIPAA compliance of these services and applications offered both as local and “in the cloud”? What about hybrid applications that leverage both local infrastructure and the “cloud”? According to the Certification Commission for Healthcare Information Technology (CCHIT), there are over 300 vendors that currently offer some variance of Electronic Medical Records � some “in the cloud,” some locally, and some in both.

They include:

  • Electronic Health Records (EHRs)
  • Electronic Medical Records (EMRs)
  • Personal Health Records (PHRs)
  • Payor-based Health Records (PBHRs)
  • Electronic Prescribing (E-prescribing)
  • Financial/Billing/Administrative System
  • Computerized Practitioner Order Entry (CPOE) Systems

As part of your SWOT analysis, the path of practice needs to be determined first : local, “in the cloud,” or a hybrid of both. Then and only then IT infrastructure needs to be procured to meet the software, hardware, and network requisites for that application, in that order. Correctly implementing and utilizing information technology will offer enormous benefits for improvement to the healthcare professional, local, cloud computing, or a hybrid of the two. This practice will have better access to healthcare services and information that would subsequently result in improved outcomes, fewer errors, and increased cost savings.

Healthcare IT vendors need to evolve and introduce cloud computing infrastructure as it would prove a cost efficient model for automating hospitals, managing real-time workload, reducing IT complexity and at the same time introducing innovative solutions and updates. The versatile architecture makes it possible to launch web 2.0 applications quickly and also upgrade healthcare IT applications easily as and when required. With hospital across Europe cutting down on costs there is an eminent need for innovative solutions, which can be easily implemented and maintained. The cloud computing architecture can help healthcare IT vendors prioritize innovation of their applications and at the same reduce the implementation time of healthcare IT solutions. The automated framework of cloud computing would provide increasingly cheaper and innovative services.

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