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A Step Towards the Cloud
By Mark Moffitt
People tend to use the terms SaaS and cloud interchangeably, when in fact, they are two different things.
Software as a Service (SaaS) delivers software as a service over the Internet, eliminating the need to install and run the application on the customer’s own computers and simplifying maintenance and support.
Cloud computing is about using economies of scale and sharing cheap, commoditized computing resources to lower overall costs. To realize these economies of scale large data centers are built and managed to protect and secure customer data at the lowest possible cost. These data centers are huge (see photo below).
Cloud software takes full advantage of the cloud paradigm by being service-oriented with a focus on statelessness, low coupling, modularity, and semantic interoperability. Cloud storage uses shared-nothing, distributed data stores so that low-cost, commodity storage technology can be utilized. Traditional RDBMS don’t fit into these new storage models. The reason is RDBMS need to join data from multiple tables. This requirement is incompatible with the distributed storage configuration found in cloud storage services.
Google’s Dalles, OR data center on the Columbia River
On the banks of the windswept Columbia River, Google is working on a secret weapon in its quest to dominate the next generation of Internet computing. But it is hard to keep a secret when it is a computing center as big as two football fields, with twin cooling plants protruding four stories into the sky. New York Times, June 8, 2006
Few HCIT vendors have architected their system for the cloud. The good news is that healthcare systems don’t have to wait for HCIT vendors. They can take advantage of cloud computing today by storing and archiving clinical results such as lab results, transcribed reports, images, and waveforms in the cloud.
Clinical results are well suited to take advantage of cloud storage for reasons such as:
- Results do not require a schema or other features of a RDBMS to store and access data. Yes, that includes lab results.
- Key-value (object) stores are better suited for storing results than RDBMS.
- Key-value data stores can use cloud storage technologies that are less expensive than the cost of using a vendor’s RDBMS to store and archive data.
- Clinical results often need to be shared beyond the walls of an organization and, therefore, ideally suited to being stored in the cloud.
Amazon’s S3 cloud storage prices run about $18,000 per year for 10 terabytes of data. These prices include storage, archiving, and security. 500 terabytes is priced around $800,000 per year. There are additional fees related to access, but this number gives the reader a ballpark estimate of the price for the service. Other vendors such as Google and Rackspace offer a similar service at about the same price.
Other potential costs include deploying a system to provide local caching of often-used data in the cloud. This is accomplished by deploying a hybrid cloud to include local storage as depicted in the diagram below.
Savings are real and immediate when an organization pursues the cloud storage strategy for clinical results when replacing hardware such as moving from MEDITECH Magic to 6.0 or MEDITECH Magic to Cerner; or upgrading an image archive system. Cloud storage can eliminate the need for hardware and software that would otherwise be needed to store and archive existing and future clinical results.
It seems to me that cloud storage is a better model for an HIE than reposing clinical results into yet another fixed-schema RDBMS. The reasons are:
- Providers are obligated to maintain a copy of results for legal and reimbursement obligations.
- Providers save money by storing and archiving clinical results in the cloud.
- HIE organizations can use clinical results stored in the cloud and focus their efforts on providing services unique to an HIE such as electronic opt-in/opt-out functionality, security, and record locator services for clinical results as a way to offer personalized EHRs to patients.
The transition to cloud computing in HCIT will take years as the business case for the approach becomes financially and operationally attractive as compared to alternatives and customers understand and accept the new paradigm of cloud computing and cloud storage. The transition to cloud computing will not be a waterfall event, but rather a gradual diffusion of the technology into HCIT. Storing, archiving, sharing, and securing clinical results in the cloud may be the first step in moving HCIT to the cloud.
Mark Moffitt, MBA, BSEE, is a former CIO and is working as a consultant while looking for his next opportunity.
Why IT Can Never Be Irrelevant
By Shubho Chatterjee
Over the last few years, journals, trade magazine articles, editorials, and even a textbook (Does IT Matter by Nicholas Carr) have prognosticated the irrelevance and strategic demise of IT. Many thought-provoking articles and blogs have debated the pros and cons of this prognostication.
I am going to add one more and argue that IT can never be irrelevant in organization, strategically or operationally. Here is my argument.
Firstly, IT is a discipline, much like engineering, finance, marketing, and others. Within engineering and finance exist multiple disciplines. As long as the world exists, both disciplines will exist. IT is similarly an assembly of different disciplines providing a very important outcome. Do we come across arguments that engineering or finance is irrelevant? No. Similar rationality will negate the IT “demise” thought leadership.
Secondly, following from the first argument, can we imagine today any organization operating without technology and IT? Take out IT — ERP, EMR, CRM, data networks, Web sites, ad infinitum — from any organization and the entire organization will collapse. Who plans for this, who should strategically plan for this, and who operates these systems? IT. IT is probably the most critical component of a functioning organization.
Thirdly, let’s examine IT functions and how it provides context to this debate. At the lowest level, Tier 1, is the basic infrastructure support, such as, help desk, network management, telecommunications support, and others. These activities are very commoditized and often outsourced, on-shore or off-shore. Outsourcing has also provided a rationality support for the “IT irrelevance” thought camp. But let us examine what happens and who does it.
Even when such functions are outsourced, somebody in IT has to do it, even though it is done by another organization. Often the outsourced employees are absorbed in the outsourcing organization. Therefore, in this case, we cannot say that IT is irrelevant — the function and activity has shifted organizationally and is also managed by IT of the vendor. The outsourced vendor relationship is also managed by the customer IT organization. Similar arguments hold for application development and support activities. For off-shored activities, the job losses are a fact, but it does not make IT irrelevant.
At the middle level (Tier 2) of IT operations, let’s say, at the business analyst, project management, vendor management, or network operations management levels, the IT aspects are critical. For example, the business analysts are key to developing IT product or service development and delivery requirements and pipelines, the IT vendor managers are key to selecting, evaluating, and managing vendor relationships. Can any other disciplines perform these functions? No. Why? Because these activities require domain knowledge and experience. For example, who other than IT can plan how a wireless network will integrate with a wired network to provide a point-of-service usage of EMR for medication management at a patient’s bedside?
Finally, no other function can be responsible for, perform, and meet the strategic technology requirements. Here, IT leadership is key in determining and ensuring the alignment of organization business strategies with technology strategies.
Consider the following example of Miami Jewish Health Systems operating the EMR, HR, Enterprise Content Management, and other applications operating in a cloud (SaaS) environment. The strategic planning and business case for moving to a cloud environment was completed by IT leadership, in collaboration with executive management, as were the tactical and operational aspects.
IT is uniquely positioned to provide results-oriented technology and process leadership to an organization. The future also holds enormous significance for IT, not only in healthcare, but in all industries. Let’s think about the healthcare landscape and the technology leadership requirements. For example, how will Accountable Care Organizations (ACO) function, who will plan and implement the strategic ACO technology requirements, how will cloud computing change service delivery and how will data security be impacted at all levels? These are some of the many very strategic questions that require deep IT involvement.
I believe IT can never be irrelevant. The discussion, while sensational, is moot.
These opinions are mine and do not reflect current or previous employer views.
Shubho Chatterjee, PhD, PE was formerly chief information officer of Miami Jewish Health Systems of Miami, FL.
What Tom Munnecke Is Thinking About Today
I exchanged e-mails with Tom Munnecke after mentioning his VistA-related Congressional testimony. I was fascinated with his 1998 HealthSpace concept paper and asked him if he had updated it or what he was thinking about twelve years later. Here is his reply.
My thinking now largely deals with the deeper implications of time. Here’s a talk I gave at the International Society for the Study of Time and some more in this interview from 2005 for the Pew Internet Visionaries.
I’ve been also very interested in the physics of anticipation. As this relates to health IT: a deeper understanding of what is sometimes called the placebo effect, but in a broader sense is the self-referential feedback loop between our anticipation of the system and its net effect on us. Also, the need to support the notion of flow or state in our communication systems.
The Web was built on a stateless protocol, but health information is very stateful, linking things over time. So, I think a "diachronic" model (flow of things over time) is a critical addition to our current "synchronic" (everybody synchronize their transactions, protocols, interfaces, and standards to current).
VistA was designed to be an evolutionary approach from the git-go. We created a "good enough" seed system, and planted it to see it grow. As I’ve learned in my studies of complex adaptive system (Stu Kauffman in particular), the most critical factor shaping evolution is the fitness function, the metric by which "survival of the fittest" is determined.
In VistA, this fitness function was user acceptance. If people didn’t like or use a module, then it wasn’t fit and fell off the evolutionary path. The finer the granularity of these experiments and the quicker you can get a lot of feedback, the faster you can accomplish the error-making and error-correcting evolutionary process. When you try to do a $100 million centrally-planned change, you lose this graceful process and end up in front of a Senate panel asking what happened when it inevitably crashes.
I think we need to come to grips with the notion of personalization (see my 1999 "personalizing health" paper) beyond just today’s FaceBook craze. While the HHS/ONC focus is weighted to the enterprise-centric (aka the Disease Industrial Complex), turning patients into "consumers," I think we need to turn the healthcare system upside down, putting the patient at the top and the providers as supporting elements. I talked about this a bit in the Opening Chapter (co-authored with Rob Kolodner) in Person-Centered Health Records: Toward HealthePeople.
What we are seeing now is a heroic battle between rigid, hierarchical top-down control (Blumenthal telling vendors, for example, that it is "imperative" that vendors support less insured populations) and grassroots, peer-to-peer, Net-based activities (FaceBook, Patients Like Me, Cure Together). Looking at the evolutionary fitness functions, I think that the grassroots will eventually win out, but only if the proper constraints can be applied (Tim Berners-Lee constrained the evolution of the web to TCP/IP, for example, a "good fence" that made "good neighbors").
So, I think we need to rethink health IT as a "space" rather than a "system." Perhaps people think that we can keep adding thousands of pages of legislation per year to the 125,000 we already have to end up with a "more perfect" health care system, but sooner or later we are going to have to declare a complexity crisis and admit that our intellectual paraphernalia with dealing with health care is inadequate.
It’s a bit like if Tim Berners-Lee tried to create the Web by going to the UN and asking for the UN High Commission on Innovation to create a Web subcommittee, who would then create global subcommittees and standards for specific applications. The sub-subcommittee of the high commission would meet with all the auction houses to collect all the stakeholders (Christies, Sothebys, etc) to create an integrated approach respectful of all parties and complying with all international regulations, UN regulations, etc. The very thought that Pierre Omidyar would write a simple program to auction off a broken laser pointer and turn it into eBay would be totally beyond belief 🙂
Yes, I’ve been doing a lot of thinking about the future of health and health care IT and dropping notes into my blog. Try the tags for VistA and AHLTA. You can read some of my early thinking at the bottom of this page. And here is some of my early thinking on the personal health record.
Tom Munnecke is a leading expert on healthcare IT, having been involved in the creation of both the VA’s VistA and the DoD’s CHCS and served as VP and chief scientist of SAIC. He is a consultant, entrepreneur, and board member of several health IT startups. He holds frequent workshops, salons, and networking events in a cabana at his home in Encinitas, CA.
Dreaming IT to Reality
By Ron Olsen
For years as a hospital IS manager, I had the tag-line of ‘Dream It To Reality’ in my e-mail signature. I meant that. You dream it and I, the humble IT guy, will do my best to bring it to reality.
Einstein once said, “Innovation is not the product of logical thought, although the result is tied to logical structure.” Thinking about that quote, I realized that to truly innovate, you must not necessarily think illogically, but you must think outside the sandbox you play in every day.
To meet the ever-changing needs of your organization, you have to empower your IS/IT team to approach problems from different angles — every day — and to not be afraid of failing once in a while. The logical structure is all around us, so when looking at processes, give everyone the freedom to question what you’re doing, at all levels.
With the many masters a hospital IT staff serves, what was once good enough for yesterday will never be good enough for tomorrow.
Ron Olsen is a product specialist at Access.