Cloud computing: Is it right for your practice?

The idea of putting your data in a cloud -- storing it on the Internet instead of on your practice's computer -- is gaining steam.

By Pamela Lewis Dolan — Posted Oct. 18, 2010

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You may have heard the term "cloud computing" in recent months. You also may have heard that it could save your practice thousands of dollars when compared with other electronic medical record solutions.

Cloud computing refers to a number of technology solutions that share three characteristics: They run on the Internet; use shared resources such as storage, processing, memory and network bandwidth with other users; and are "on-demand," meaning capabilities such as network storage can be adjusted virtually without an IT staff tearing apart your computers and adding hundreds of feet of wires and cords.

There are three types of services offered on the cloud:

  • Software as a Service (SaaS), which has the capability to use Internet-based applications such as an EMR.
  • Platform as a Service (PaaS), which has the capability for developers to deploy their applications on a cloud infrastructure -- for example, smartphone applications.
  • Infrastructure as a Service (IaaS), a fully outsourced computer infrastructure that includes networks, databases, processing and other software.

For purposes of small physician practices, they probably will be looking at SaaS services that are offered on a community cloud, meaning it is shared by several organizations. There are issues to consider before making the jump to the cloud.


Experts say there are many advantages to going with a cloud-based solution, and the No. 1 advantage cited -- and the one most likely to get attention from potential consumers -- is cost.

"You don't have to worry about having servers, you don't have to worry about going out and hiring or contracting with an IT guy to maintain this for you. All that is now controlled by someone else, and you don't have to deal with it," said Mark Gilmore, president and co-founder of Wired Integrations, an integration company based in San Jose, Calif. "So that is definitely a pretty good trade-off to small offices doing that type of thing."

Generally, all physician practices would need to use a cloud-based EMR system are workstations with computers that have an Internet connection. Because the infrastructure is maintained outside the practice, upgrades or downgrades to the network -- for increased or reduced bandwidth and data storage, for example -- can be made on an as-needed basis at any time.

Pinning a cost on cloud computing can be difficult, because it depends on your needs, and it can change if you need more storage. However, it's generally acknowledged in tech circles that cloud-based programs tend to be less expensive and more flexible for your needs.

Speed and storage

But just like with any storage system, the advantages don't come without pitfalls that could cost you more in the end. And one of those pitfalls is speed.

Gilmore said that although the systems are flexible in terms of growth needs, some first-time cloud users might be disappointed with the speed at which systems run on the cloud.

"If you're moving a particular service that you currently have housed internally, that might be running on a server or two, and you push it out to the cloud, out through the Internet, you're not going to be getting the same type of response that you have running it internally," he said.

Bandwidth is the speed at which data can be transferred electronically and is measured in megabits. Gilmore said most internal networks run at 100 megabits, and the average Internet connection is 1 megabit.

Although the cloud allows the flexibility for the bandwidths to be increased, people's expectations usually aren't set before adopting a cloud-based system. They may find themselves making upgrades right away that could cost a few hundred dollars more a month, Gilmore said.

But the needed speed, as well as the amount of storage you require, can be adjusted at any time, which is an advantage.

"It has certain elasticity," said Dadong Wan, senior research scientist with Accenture Technology Labs, the research and development arm of the global management consulting firm Accenture. "So that means if your practice grows over the years, you can pay a little bit more, and if it shrinks, you pay a little bit less. It's flexible in that regard."


Let's face it -- you went to medical school to keep patients healthy or fix their health problems. You didn't go to learn how to keep your IT infrastructure healthy or fix a crashed hard drive. Therefore, physicians might find cloud computing attractive because it's a virtually maintenance-free infrastructure. Vendors take care of all maintenance off-site, and very little has to be done in-house.

But experts say a potential downside is that because the systems are being run off-site, as a client, you are at the mercy of the vendor when and if things go wrong. These are issues that need to be resolved in a service level agreement, or SLA, which is basically a contract spelling out the vendor's obligations.

"If this is a mission-critical application for the doctors, meaning they can't live without it, how is this cloud vendor set up for disaster recovery?" Gilmore asked. "How is their primary location set up in case of a fire or has a power outage? Does the site go down, or does it go to some other location that is up and running?" These are questions that must be answered in the SLA, he said.

SLAs should include a time frame for how outages are handled. Most cloud vendors have a primary location and one or more backup locations. These backup facilities can take over and keep clients online when the primary location is knocked off-line.

Leslie Spasser, an attorney with LeClaireRyan in Virginia Beach, Va., said she advises clients to inquire about the location of the secondary facility. She said location can matter for many reasons, including natural disasters such as hurricanes and floods, that could put both primary and backup locations off-line if they are located too close together. Something else to consider is whether facilities are outside your state or country, where the same privacy laws might not be in effect.


Assuming the systems are running smoothly, a big advantage to cloud-based computing is access. When data are in the cloud, they can be accessed from nearly anywhere using any Web-enabled device. As more physicians adopt smartphone or tablet computers, Wan said, this flexibility will become extremely valuable.

However, Spasser said doctors need to know that easy access still must be secure access.

First and foremost, vendors should be able to articulate how they ensure compliance with security and privacy laws, she said.

"As you go out and look at cloud computing solutions, you still have the responsibility to ensure your vendor complies with HIPAA," she said.

Data protection and ownership

Along with securing the data, the vendor must ensure that practices have access to the raw data when they need it or when a patient requests it, which is required under the Health Insurance Portability and Accountability Act. This means not only guaranteeing that outages don't knock practices off-line, but also that practices have the ability to give patients their files in a usable format upon request.

Gilmore said clients' ability to back up their data is limited with cloud solutions. When data are accessed at the practice, they are generally in a read-only format that allows physicians to add to the databases, but not download what is in the files. Therefore, any contract with a vendor should include a clause that not only requires that the vendors back the data up, but also fully provide your archived data within a specified amount of time when requested.

Another contractual issue that needs to be resolved is ownership of data. In the event you break ties with the company, or the company goes out of business or is acquired by another firm, you want to be able to keep your data. The contract not only should guarantee the transfer of data, it also should specify the format in which it is transferred, Spasser said.

Having data stored somewhere else can be a major psychological barrier. Wan said the shift from paper files, which you can physically see and touch, to electronic files makes many people uneasy, even when data are stored on servers in their office, let alone on a cloud.

Despite the uneasiness many feel about storing data off-site, the cloud can be safer to store private information than an in-office server, analysts said. Servers in physician practices run the risk of being stolen. Even though the data presumably would be backed up at a practice, many cloud system providers have multiple backup facilities, so the data are less likely to become permanently lost if something goes wrong.

A survey by Mimecast, a cloud-based EMR vendor, found that many in the medical industry consider cloud computing a viable option. It found that 32% of the health care industry is using cloud-based applications, and 73% of those are planning to add more applications to the cloud in the future.

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Who uses cloud computing?

A national survey found that 36% of respondents use cloud-based solutions for data storage, and that 73% of health care organizations that do so want to put more data on the cloud.

Portion of industry using cloud-based solutions
Technology 53%
Financial services 41%
Legal/professional services 37%
Retail 35%
Health care 32%
Manufacturing 32%
Education 29%
Energy 24%
Government 19%

Source: "Cloud Computing Adoption Survey," Mimecast, February

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