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Navigating the Cloud

Table of

Contents

Big Data& the Cloud

BYODto theCloud

Cloud-basedEHRs

FinancingCloud

Transition

GovernmentCloud:

Progress &Problems

HIEsEye Cloud

as Revenue Stream

Privacy & Security

in the Cloud


Advertiser Index

white

Navigating the CloudAn e-Supplement to Healthcare IT News and Government Health IT

November 2012

1Navigating the Cloud

Table of

Contents

Big Data& the Cloud

BYODto theCloud

Cloud-basedEHRs

FinancingCloud

Transition

GovernmentCloud:

Progress &Problems

HIEsEye Cloud

as Revenue Stream

Privacy & Security

in the Cloud


Advertiser Index

Table of Contents

Building a Cloud Strategy for Maximum Value ........................................ Pages 2-4Sponsored by Microsoft

Big Data & the Cloud ............................... Pages 5-9 Next-gen analytics is where big data and cloud computing collideSome health IT pros like Christian Carmody of UPMC are beginning to run analytics against veritable mountains of data and finding that big data is not just about volume. The richness of that data has ballooned as well. Therein the opportunity lies, for IT shops that position themselves well today.

Storing Images in the Cloud:Strategies for Security, Accessibility and Disaster Recovery ......................... Pages 10-12Sponsored by AT&T

BYOD to the Cloud ............................... Pages 13-16Heading to the cloud? Bring your own deviceWhether via mHealth, telehealth, or hosted applications, the swing to cloud-based communications is now underway, which means devices have to be expertly configured. And that requires balancing the desire for data everywhere with practical clinical requirements.

Security-Based Cloud Infrastructure: Going above and beyond compliance mandates.......................... Pages 17-20Sponsored by Firehost

Cloud-based EHRs ................................ Pages 21-26The cloud is changing health recordsThink of the model like a golf course. Jonathan Bush sure does particularly when it comes to the oft-touted economies of scale. Aneesh Chopra weighs in, too, with his most important question for healthcare entites considering the cloud.

Harvesting big data to optimize value-based clinical care ..................... Pages 27-30Sponsored by Apixio

Financing Cloud Transition ................. Pages 31-34Cost considerations when transitioning to the cloudOur roundtable of cloud experts on what you need to know about the clouds benefits, costs, and disadvantages for healthcare organizations, including the notoriously suspect levels of customer service.

Taking Healthcare to the Cloud ......... Pages 35-38Sponsored by EMC2

Government Cloud: Progress and Problems ........................ Pages 39-42HHS already leading the cloud charge The Department of Health and Human Services is among federal agencies that have transformed some software applications into outward facing cloud services. HHS, in so doing, has realized benefits and faced challenges.

Taking Workforce Management to the Cloud .......................................... Pages 43-45Sponsored by Kronos

HIEs Eye Cloud as Revenue Stream ... Pages 46-51That precious clich: Financial sustainabilityOne health information exchanges fate hangs on the clouds affordability, while another HIE is plotting to turn the data it hosts into analysis services for a profit. And a third has already mastered HIE financing, with the help of the cloud.

RampingISVs and Healthcare Organizations to the Cloud ................ Pages 52-54Sponsored by QTS

Privacy & Security in the Cloud ......... Pages 55-59A place to tread carefullyEven healthcare first-movers to the cloud, such as Orlando Health CIO Rick Schooler, are progressing cautiously, picking and choosing applications they are comfortable turning over to a cloud host. And realizing that some will remain on-premise for the foreseeable future because of privacy and security concerns.

Ad Index .........................................................Page 60


Table of

Contents

Big Data& the Cloud

BYODto theCloud

Cloud-basedEHRs

FinancingCloud

Transition

GovernmentCloud:

Progress &Problems

HIEsEye Cloud

as Revenue Stream

Privacy & Security

in the Cloud


Advertiser Index

Sponsored content

Cloud computing in healthcare is forecasted to grow at a compound an-nual growth rate of 20.5 percent from 2012 to 2017, according to a July 2012 MarketsandMarkets report. While many healthcare organizations (HCOs) are jumping on the cloud bandwagon, they need to approach implementation and adoption with a clear strategy, according to Dennis Schmuland, MD, chief health strategy officer for Microsofts U.S. Health & Life Sciences.

Go BiG: innovatinG with new ServiceS

One of the major benefits of the cloud is its ability to lower the cost of IT services, but cost savings should not be the only reason to adopt the tech-nology. The business value thats often overlooked in the cloud is that it gives people and businesses the power and speed to do new things in new ways across devices and locations, Schmuland said. HCOs should lever-age the cloud to provide new services such as virtual team communica-tions and collaboration.

A number of forward-thinking HCOs have taken advantage of the cloud to create innovative services and processes across devices that are available anywhere and anytime*.

Mihills Webb, a primary care practice in the southern U.S., deployed cloud-based communication and collaboration capabilities to work alongside its electronic health record system. The ability to enable continuous com-munication and productivity anywhere, anytime and on any device led to improvements in communications and team performance, which in turn boosted customer service. For example, the front desk was able to notify staff of patient arrivals even when the staff was indisposed.

retaininG cloud FlexiBility

When contemplating a move to the cloud, HCOs should ensure that they

retain control and flexibility over the kind of environment their solutions

operate under at all times. Some organizations may find that a hybrid com-

bination a cloud offering with an existing on-site IT infrastructure best serves their business needs. Cloud vendors that only offer an all or noth-ing model, therefore, should be avoided, Schmuland advises. HCOs need to be able to return to on-premise software and servers should the cloud vendor default on its service-level agreement. A mixed cloud environment that takes advantage of the best of the public cloud, private cloud and on-premise apps will be the mainstay for the health industry for the foresee-

able future, he said.

BuildinG a cloud StrateGy For MaxiMuM value

*An appropriate device, Internet connection, supported browser and/or carrier network connectiv-ity are required. Data charges may apply.


Table of

Contents

Big Data& the Cloud

BYODto theCloud

Cloud-basedEHRs

FinancingCloud

Transition

GovernmentCloud:

Progress &Problems

HIEsEye Cloud

as Revenue Stream

Privacy & Security

in the Cloud


Advertiser Index

Sponsored content

PartnerinG with coMMitted data StewardS

The protection of health information is mandated by HIPAA and the HI-TECH Act, but HCOs should not assume that all cloud vendors fulfill the role of trusted data stewards. Those providers committed to trusted data stewardship have engineered privacy, security and compliance into their offerings as a forethought rather than an afterthought, he said. Micro-softs implementation of physical, technical and administrative safeguards required by HIPAA and HITECH laws covers Microsoft online services and platforms like Microsoft Office 365, Microsoft Dynamics CRM Online, and Windows Azure core services. Microsoft established a dedicated Online Services Security and Compliance (OSSC) team within its Global Founda-tion Services Division, which developed the Microsoft Compliance Frame-work for Online Services and conducts risk management reviews among other activities to help with compliance.

develoPinG a holiStic, lonG-terM cloud StrateGy

While many HCOs move their services over to the cloud in a piecemeal strategy, the end result can be unforeseen additional costs and greater risks and complexities because of multiple contracts with multiple cloud providers. Instead, Schmuland advises HCOs to envision a holistic cloud strategy and partner with a single cloud vendor that can provide cloud-based productivity, collaboration, application hosting, data storage and relationship-management applications and seamless, across-the-board protection.

In support of a holistic cloud strategy and as part of its commitment to data stewardship, Microsoft collaborated with academic medical centers, government agencies, providers and health plans to offer a single Business Associate Agreement (BAA), which encompasses the academic community

and HIPAA-covered entities in the public and private sectors across the U.S. Microsoft also offers HCOs a combination of private and public cloud mod-els, which allow entities to match the most appropriate model for their privacy and security needs.

SuPPortinG coMMunication, collaBoration and Productivity

When HCOs partner with a comprehensive cloud solutions provider that serves as their data stewards, they can unleash the full power of cloud computing. The economic and team productivity advantages of the cloud have created a unique moment in history where its actually possible for mobile, virtual teams to share more and collaborate better on any device,

at a low cost, Schmuland said.

View Our White Paper:

cloud checklist For health

Choose your cloud productivity and collaboration solution carefully A checklist for health organizations

Adopting the cloud in health is not so much a question of if anymore as it is a question of

when. With all the hype and confusion over the many cloud productivity solutions in the market,

how do you align your decision around what matters most to your healthcare organization?

Microsoft Office 365 brings together integrated online versions of Exchange for email and calendaring, SharePoint for content management and collaboration, and Lync for unified communications along with our familiar Office Professional Plus suite. It is designed to help meet healthcare organizations needs for patient centered collaboration, robust security and adherence to privacy regulations, including full support for a HIPAA Business Associate Agreement. Microsoft Office 365 provides the user experience, productivity, and IT Management capabilities that healthcare enterprises have come to know and trust for mission critical applications while affording decision-makers the flexibility in meeting challenging business scenarios through implementation and licensing options.

FIVE THINGS YOU SHOULD LOOK FOR IN A CLOUD PRODUCTIVITY SOLUTION

Checklist Questions to Ask Office 365

1. Security, Compliance and HIPAA/HITECH Readiness

- Will the cloud productivity solution provider sign a HIPAA Business Associate Agreement (BAA) to ensure a covered entitys electronic Protected Health Information (ePHI) is managed as required by Federal law?

- Does the cloud productivity solution providers BAA meet the healthcare industrys requirements?

- Are encryption services offered?

- Microsoft wants to be your Trusted Data Stewardto help you achieve and maintain HIPAA compliance, security, and privacy of your datawhile realizing the maximum benefits of cloud computing.

- Microsoft implements HIPAA physical, technical, and administrative safeguards and complies with Breach Notification as required by HITECH.

- Microsofts Business Associate Agreement was created through a collaborative effort with academic medical centers, government agencies, providers, and health plans to ensure broad acceptance in the healthcare industry.

- Microsoft offers the ability to add automated, policy- based email encryption to Office 365 through Microsoft ForeFront Protection for Exchange and Microsoft Exchange Hosted Encryption.


Table of

Contents

Big Data& the Cloud

BYODto theCloud

Cloud-basedEHRs

FinancingCloud

Transition

GovernmentCloud:

Progress &Problems

HIEsEye Cloud

as Revenue Stream

Privacy & Security

in the Cloud


Advertiser Index

Sponsored content

1. Security compliance and HIPAA/HITECH

readiness

WillthevendorsignaHIPAABAAtoensure a covered entitys electronic

Protected Health Information (ePHI) is

managed as required by Federal law?

DoesthevendorsBAAmeetthehealth-care industrys requirements?

Areencryptionservicesoffered?

Doesthevendorenablemetomanagemobile devices like laptops, tablets and

phones that access patient information?

2. Privacy control over your own data

CanIeasilycontrolpermissionstoen-sure only those who need to view ePHI

can do so?

Howeasyisittoterminatetheserviceand delete my data from the cloud?

Willmydatabeusedforadvertisingorother commercial purposes without my

consent?

3. Cloud on your terms

Doesthevendorofferacloudornoth-ing ultimatum rather than giving me

choices of a cloud solution, an on-prem-

ise solution, or a hybrid combination, on

my terms?

DoIhavetogotomultiplevendorstohave a complete cloud strategy?

4. Enterprise-ready

Doesthevendorhaveahistoryofenter-prise experience in healthcare?

Dotheyoffersolutionsforenterprisecustomers that are distinct from their

consumer offerings?

CanIleveragemyexistinginvestmentsin software and training?

Willmission-criticaldataandservicesbeavailable and supported 24/7?

5. Patient-centered care strategy

Howdoesthesolutionsupportpatient-centered care?

an hcoS checkliSt For SelectinG a cloud SolutionS vendorkeePinG Productivity, clinical SaFety and Security in Mind, hcos Should exPect their cloud SolutionS vendor to helP SuPPort Five key areaS:

Free 30-day trialMicrosoft office 365

30-day free trial for businesses that need full productivity, communication and collaboration tools

with the familiar Office suite, including Office Web Apps.


Table of

Contents

Big Data& the Cloud

BYODto theCloud

Cloud-basedEHRs

FinancingCloud

Transition

GovernmentCloud:

Progress &Problems

HIEsEye Cloud

as Revenue Stream

Privacy & Security

in the Cloud


Advertiser Index

Two of todays most prominent trends in healthcare big data and cloud computing are fated to intertwine in ways that will bolster health data analytics.

Indeed, its already happening at UPMC. The provider has been making big use of the cloud to manage its huge and ever-growing piles of data as part of a long-term partnership with IBM to completely revamp its storage and analytics of huge volumes of patient and research data, all leading up to the medical centers $100 million personalized care initiative, announced Oct. 1.

UPMC has a deployed a dynamic virtualized infrastructure that shortened information backup times by 20 percent and recovery times by half, officials said. IBM helped with storage and server virtualization, enabling the network to be more flexible to accommodate exponential data growth at UPMCs 20 hospitals and 400 outpatient locations. A key part of this is a private cloud that supports mission-critical applications.

Back when UPMC made the first moves toward virtualization in 2005, We probably had a little more than a million unique patient records in our EHR and lab systems, said Christian Carmody, vice president of the Information Services Division at UPMC. Where we sit today, were at 7.3 million unique patient records.

Big data, to be certain. But its not just about volume. The richness of that data has ballooned as well, Carmody added. Weve experienced a tremendous amount of organic growth as weve merged with different hospitals over that timeframe.

As big data gets bigger, the cloud is helping make large-scale analytics manageable. And with the triptych of trends forging ahead, there are opportunities and challenges for healthcare entities to harness their information in new and exciting ways.

By Mike Miliard, Managing Editor of Healthcare IT News

At the intersection of big data and cloud computing: Analytics

Were on the cusp of this concept of big data, this 10-plus years of electronic health record data, financial data, the upcoming use and inclusion of genomic data. Christian CarmodyVice President,Information Services DivistionUPMCListen as Christian Carmody explains the growth of UPMCs data volumes in the past several years.


Table of

Contents

Big Data& the Cloud

BYODto theCloud

Cloud-basedEHRs

FinancingCloud

Transition

GovernmentCloud:

Progress &Problems

HIEsEye Cloud

as Revenue Stream

Privacy & Security

in the Cloud


Advertiser Index

And the need for data storage just keeps going up, he said. Were at probably four petabytes of data today, and we anticipate that at the end of this agreement with IBM, this next four years, that were going to grow to 19 petabytes.

The good news? Weve turned the corner as far as trying to get physicians to adopt technology, Carmody said. The challenge? They are now reliant upon it, and they want more. And that means more data.

Luckily, thats something UPMC has been anticipating for nigh on a decade. We had the foresight and vision to virtualize our environment, Carmody said. We were dealing with issues of organic growth and running out of datacenter space back when we were doing the first deal with IBM.

Now were on the cusp of this concept of big data, which to us is this 10-plus years of electronic health record data, the financial data, and the

upcoming use and inclusion of genomic data into our environment, Carmody added. The combination of all those different elements, being run through a superior analytics program, is what were challenged with as we move forward.

Big data and cloud considerationsMost of the cloud solutions being adopted in healthcare are private clouds, but hybrid clouds are also becoming more accepted, depending on the application and usage pattern, said Greg Caressi, senior vice president, healthcare and life sciences, at Frost & Sullivan. Public cloud solutions are deployed in healthcare, but are more rare, he added.

Infrastructure-as-a-service (IaaS) technology will become increasingly important as the data explosion in healthcare continues to stretch the capabilities and budgets of organizations to manage these petabytes of data, Caressi explained, and as we need to collaborate and share access to healthcare data among a wider range of stakeholders.

Dennis Schmuland, MD, chief health strategy officer at Microsofts U.S. health and life sciences division says too many hospitals sell themselves short by focusing only on the cost-savings of the cloud. Instead, they should be looking at how the cloud can focus on what they do best, rather than keeping the lights on. IaaS will become increasingly important as the data explosionin healthcare continues to stretch the capabilities and budgets of organizations to manage thesepetabytes of data. Greg CaressiSenior Vice President,Frost & Sullivan


Table of

Contents

Big Data& the Cloud

BYODto theCloud

Cloud-basedEHRs

FinancingCloud

Transition

GovernmentCloud:

Progress &Problems

HIEsEye Cloud

as Revenue Stream

Privacy & Security

in the Cloud


Advertiser Index

That could mean collaborative analytics for big data, he said pointing specifically to three areas that are exciting.

One is improving patient safety. A lot of those data streams can be aggregated and analyzed to signal early warnings from oximeters, ventilators, blood pressure, body temperature, heart rate, Schmuland explained. Those early warnings can really predict adverse events well in advance of the condition being serious: detect infections earlier, detect cardiac arrest or a blood clot before it occurs.

A second area is reducing practice variability. Many physicians do not know how their practice compares with others. Big data could quickly enable every physician to see how they compare with best practices and even help provide them with feedback over time, moving toward best practices and reducing variability and improving their adherence to guidelines, he said.

The third has to do with comparative effectiveness research. The challenge with CER is that it takes so much time to do comparative studies: You compare one drug to another, and report and publish results, Schmuland said. Big data could actually do a lot of comparative effectiveness research based on data that already exists. A lot of this data is currently lost in the system.

Three fine examples, sure. But ultimately theres not much limit to what can be accomplished with the affordability and collaborative opportunities enabled by the cloud.

Indeed, it seems we find ourselves at a pivotal moment. Taken together the cloud and big data those two purported buzzwords are setting the stage for huge changes in the quality and cost-effectiveness of care. Which is precisely the situation in which UPMC finds itself.

Back at UPMCThere are more challenges albeit fun and exciting ones ahead.

Then you hear about things like The Internet of Things discrete physical objects, when represented in a virtual Web-like structure where all these different devices will be connecting to the Internet, and well have this additional abundance

Dennis Schmuland, MDChief Health Strategy Officer

MicrosoftBig data could actually do a lot of comparative effectiveness research based on data that already exists. A lot of this data is currently lost in the system.


Table of

Contents

Big Data& the Cloud

BYODto theCloud

Cloud-basedEHRs

FinancingCloud

Transition

GovernmentCloud:

Progress &Problems

HIEsEye Cloud

as Revenue Stream

Privacy & Security

in the Cloud


Advertiser Index

of data coming in, UPMCs Carmody said. We have a unique opportunity ahead of us as far as how we effectively manage, store and enable that data to be transformed into information and knowledge for our clinicians.

Eight years ago, even with nearly one-eighth as many patient records to store as there are now, there was already an explosion of physical servers just taking over our datacenter floor space, he said. We were looking at having to build or lease floor space at another datacenter just to deal with that organic growth.

The decision to virtualize UPMCs infrastructure was appealing, but the process was anything but easy. It definitely took a lot of effort, a lot of time three or four years to go through the transformation to where we were fully up and running on our own little private cloud, Carmody said.

The biggest obstacle was standardization. We needed to consolidate the varieties of platforms and solutions wed previously been supporting for all the different application vendors, and really work with them and reach out to them to push us toward where we could reduce the number of operating systems and databases to a manageable few that we could have confidence in as we moved forward to a virtualized environment.

Calling that a tremendous challenge and a lot of work, Carmody added that the benefits have been overwhelming. Once threatened with having to spillover into another datacenter, Weve reduced our physical footprint, theres actually room to grow, Carmody said, which positions us well for this next expansion into big data.

Today, with the data deluge gathering strength, We are well-positioned to be flexible, to be scalable, and to grow with the computing and storage needs that the enterprise analytics program is going to place on the infrastructure, he said. As our organization grows and introduces and integrates the genomics data with the electronic health record data with the financial and operational data and then crank through those different algorithms and infuse that into the clinicians workflow, the infrastructure is going to be heavily relied-upon. Weve very confident and feel very capable.Weve reduced our footprint, theres room to grow, which positions us well for this next expansion into big data. Christian CarmodyVice President,Information Services DivistionUPMCListen as UPMCs Carmody projects his organizations data growth in the years to come.


Table of

Contents

Big Data& the Cloud

BYODto theCloud

Cloud-basedEHRs

FinancingCloud

Transition

GovernmentCloud:

Progress &Problems

HIEsEye Cloud

as Revenue Stream

Privacy & Security

in the Cloud


Advertiser Index

UPMCs leading-edge datacenter, all in the service of a transformative approach to personalized medicine, is a great example of what a world-class institution with huge financial wherewithal can do with the cloud.

But providers of every size should be taking a careful look at cloud technology as data volumes grow inexorably.

Indeed, far from being intimidating to small hospitals, cloud technology should be looked upon as an opportunity as it will likely be an equalizer between large hospitals with sophisticated IT capabilities and big budgets and smaller facilities that will not be able to keep up without HIT as a service solutions, Frost & Sullivans Caressi said.Both will use cloud solutions, but smaller organizations will be dependent on these solutions for their survival and to keep up with the big hospital systems. n

The expenditure on public cloud is estimated to skyrocket from$91 billion worldwide in 2011to $109 billion in 2012.By 2016, enterprisepublic cloud services spending willreach $207 billion.

Cloud spending set to soar

$91billion

2011

$109billion

2012

$207billion

2016

Source: Gartner

10


Table of

Contents

Big Data& the Cloud

BYODto theCloud

Cloud-basedEHRs

FinancingCloud

Transition

GovernmentCloud:

Progress &Problems

HIEsEye Cloud

as Revenue Stream

Privacy & Security

in the Cloud


Advertiser Index

Sponsored content

Digitizing medical images and electronically storing them for easy retrieval

and sharing have done wonders for timely, well-informed patient care. The

typical Picture Archiving and Communication System, or PACS, summons

up high-fidelity diagnostic images on a system of viewing stations, reduces

storage to gigabytes on a computer instead of roomfuls of films and allows

multiple clinicians to view the same images as long as the system reaches

to their care settings and the data center doesnt go down.

But todays proliferating volumes of fat image files, and demands to share

information for patient care across facilities and specialties, are stretching

PACS to the max. Provider organizations need to convey medical images

not just to clinicians working in designated care settings but also to refer-

ring doctors wherever they practice, new sites added from mergers, and

on-the-go docs relying on mobile devices such as tablets. If fire or flood

strikes the data center, or the PACS application goes down, the images go

down with it and create costly, care-compromising complications.

Disaster recovery Plan in the clouDUsing the cloud to store a second copy of imaging data at least, or central-

ize all image archives from many locations at best, makes sense if provid-

ers are intent on keeping information secure, accessible and safe from di-

sasters or down time, says Barbara White, director, AT&T ForHealth Cloud

Solutions. Such approaches are beginning a wave of adoption, and the

crest of the wave is going to be a true cloud-based, vendor-neutral archive,

an active archive of the medical images.

A big benefit is as basic as survival of the information, something get-

ting short shrift amid many other IT development priorities. In a survey of

health data management by Bridgehead Software published in June 2012,

65 percent of respondents said data volume was increasing year to year

and PACS applications were cited as the biggest source of that growth. Yet

only 26 percent of those in that survey reported they had a robust, tried-

and-true disaster recovery plan in place, says White. I see no better use

case for the cloud for medical imaging than having your disaster recovery

copy of medical images in the cloud.

storing images in the clouD:strategies for security, accessibility anD Disaster recovery

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Table of

Contents

Big Data& the Cloud

BYODto theCloud

Cloud-basedEHRs

FinancingCloud

Transition

GovernmentCloud:

Progress &Problems

HIEsEye Cloud

as Revenue Stream

Privacy & Security

in the Cloud


Advertiser Index

Sponsored content

Hospitals may have a second copy but sometimes in the same data center

or one in close proximity and similarly imperiled by disaster. Or its on tape

and merely backed up consequently not accessible to clinical operations.

Even with a continuous second copy maintained in a separate location,

the application is still what makes the images accessible and sharable,

says White, and typically the recovery site doesnt include that. If your

application is sitting in the first data center, how useful are those

[recovery] images?

AT&T customers are opting to have their second copy, or even their third,

be cloud-based. Besides putting data well out of harms way, they can use

a cloud-based viewer that provides on-demand, as-needed access to im-

ages if the PACS viewer goes down for any reason, White says. The diag-

nostic viewer, cleared by the FDA and available through a partnership with

Calgary Scientific, ensures clinical continuity.

central image rePository for acosThe same set of functions that make this AT&T Medical Imaging and Infor-

mation Management product optimal in recovery situations also powers a

strategy to make the cloud the central repository for all images, as provid-

er organizations form larger and more diverse accountable care organiza-

tions and seek to route all clinical information through electronic medical

record applications.

Having one view of the clinical archive across the entire enterprise that

supports image enablement, thats huge because at that point all the

images for [one patient] are in one location, White points out. If Im a

radiologist or cardiologist and I need to access all the images, I can go to

one repository and not two different systems thats going to show me all

your chest images, your CT scans, your cardiac echo, your complete medi-

cal history in one centralized archive.

The archive includes images from cardiology, mammography and other

hospital departments as well as outlying diagnostic centers and physician

practices producing them. Where AT&T has integrated its service with

EMR or health information exchange vendors, images can be launched in

context directly to those applications along with all the other data that

doctors need to see in one place. The service also receives updates of

demographic information, including patient name changes, medical record

merges, and procedures associated with each stored image.


medical imagingin the cloudLearn why cloud services may be the solution to your health-care organizations medical imagine challenges.

Executive Summary

The wealth of electronic data generated by the U.S. healthcare system presents a paradox for

healthcare providers. Cloud services offers healthcare an attractive solution, helping hospitals

scale with ease, better manage resources, and provide fluid access and sharing of medical images

across organizations, departments and providers achieving a connectedness that supports

healthcare organizations patient care goals. Learn why cloud services may be the solution to your

healthcare organizations medical imaging challenges.

Medical Imaging in the Cloud

Disaster recovery...continued

12


Table of

Contents

Big Data& the Cloud

BYODto theCloud

Cloud-basedEHRs

FinancingCloud

Transition

GovernmentCloud:

Progress &Problems

HIEsEye Cloud

as Revenue Stream

Privacy & Security

in the Cloud


Advertiser Index

Sponsored content

security benefit: accessing, not DownloaDing imagesFacilitating security and efficient IT management, images arent sent physi-cally to the destination. The AT&T process provides a view into the archive; the hospital authenticates authorized users through a standard called light-weight directory access protocol, or LDAP. The customer maintains policies over access and permissions for usage. The important thing, says White, is that youre not waiting for files to download, youre simply accessing those images.

Access can be in the handiest places. A hospital can provide a physician seeing a patient on referral access to images without being in the sphere of a PACS or even on staff at the referring entity. A radiologist can view an image through the PACS viewing station, but an orthopedist on staff at another hospital can be authenticated and given access to view the same images via the FDA-cleared viewer and cloud route.

By following a surgeon into the operating room, the cloud takes the im-ages closer to the point of care, says White. A physician can pull up an image on a tablet computer during the procedure, and if a question arises when viewing it, a colleague can be contacted through a secure email message with the image and a quickly jotted query. They can do a consult together, she says.

a new moDel for image managementPACS have been around long enough that health systems are faced with re-placing outdated systems with tapped-out archives. At the same time, health reform is spurring consolidation of separately developed IT infrastructure in hospitals, including disparate PACS networks banging together. Its a big management challenge as well as a capital cost to create storage and access solutions for a larger, heterogeneous norm of healthcare enterprise.

AT&T can supply the continuously updated structure for that challenge and a pay-as-you-go approach that enables provider organizations to get up and running without upfront capital investment. PACS will certainly continue to be a part of the healthcare IT enterprise for managing the radiology workflow and for providing the readers and viewers for the radiologists, says White. The model were introducing is central location of the images, image-enabled EMRs, imaging exchange, cloud-based imaging archive.

Thats the growth strategy for expansion of the images role in healthcare.

13


Table of

Contents

Big Data& the Cloud

BYODto theCloud

Cloud-basedEHRs

FinancingCloud

Transition

GovernmentCloud:

Progress &Problems

HIEsEye Cloud

as Revenue Stream

Privacy & Security

in the Cloud


Advertiser Index

From the hospital to the home and everywhere in between, mobile devices are entering the healthcare fray with unbridled enthusiasm. Theyre being used by providers to capture data at the point of care and to keep the lines of communication open no matter where the doctor is, and theyre being used at home to record and send vital health data back to the caregiver and, in turn, to send important healthcare management information back to the patient.

By the very nature of their size and mobility, these devices be they tablets or smartphones are ill-equipped to store healthcare data. Most providers, in fact, have a strict rule that no sensitive data resides on a device.

Thats where the cloud comes inMobile lends itself to cloud computing, said Peter Tippett, chief medical officer and vice president of health IT at Verizon, which recently launched a portfolio of cloud-based storage solutions tailored specifically to the healthcare market.

Were just starting to see this swing to cloud-based communications, added Ash Shehata, Ciscos senior executive director for healthcare in the Americas, who sees the cloud as an amazing opportunity to distribute content.

The cloud environment is ideal for mobile healthcare, Shehata said. It will be designed out of the gate with innovation for wireless devices.

Bring your own device to the cloud Mobile and telehealth technologies are enabling a new era of care and cloud providers are rushing to cash in with products and services targeted specifically for health organizations unique needs.By Eric Wicklund, Editor, mHIMSS.org

Mac McMillanPresident & CEO

CynergisTek

If we begin to balance convenience around dissemination of data with the actual practical clinical requirements by using technologies that enable connectivity and only store data on the devices that are able to protect it properly, we can greatly reduce the magnitude of the risk.

14


Table of

Contents

Big Data& the Cloud

BYODto theCloud

Cloud-basedEHRs

FinancingCloud

Transition

GovernmentCloud:

Progress &Problems

HIEsEye Cloud

as Revenue Stream

Privacy & Security

in the Cloud


Advertiser Index

Its a market in need of watching. According to a recent analysis by Manhattan Research, digital health activities are moving quickly away from the home desktop computer and onto the tablet

and smartphone. From 2011 to 2012, the advisory firm found, the number of U.S. adults using mobile phones for health information and tools jumped from 61 million to 75 million, while tablet activity during that time period almost doubled from 15 million to 29 million users.

mHealth proponents say cloud-based services are especially attractive because they can centralize storage and data analysis, pulling those expensive and space-consuming processes out of the device. That, in turn, makes the device more manageable and cost-effective, important factors to take into consideration when marketing to the public (or to healthcare in general). And that is exactly whats prompting the big telecommunications players like AT&T, Intel, SAP, Verizon, Dell and Sprint to promote cloud services.

Nowadays, almost any mobile-enhanced healthcare announcement includes the word cloud somewhere within the press release, almost to the point of ubiquity.

The cloud figures prominently in Polycoms newest development, as one example of many. The San Jose, Calif.-based developer of unified communications platforms has launched the RealPresence CloudAXIS Suite to enable cloud-based telemedicine consults between several parties and on different kinds

Proponents say cloud-based services are especially attractive because they can centralize storage and data analysis, pulling those expensive and space-consuming processes out of the device.

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of applications. Using the new technology, a physician in his or her office can host a meeting with a patient on Facebook as well as the patients family on Skype and a specialist on Google Talk or some other business video application. The new platform is designed to extend enterprise-grade video collaboration beyond the walls of the largest healthcare institutions and enable providers of all sizes and capabilities to collaborate.

Telehealth technology is commonly used between non-affiliated healthcare entities, said Ron Emerson, Polycoms global director of healthcare. With the development of accountable care practices, he said, providers are finding it necessary to extend patient care beyond the walls of the hospital, to remote clinics and the patients home.

Everyone can now be connected in one meeting place, he said.

Another use of cloud-based storage lies in care management for people with chronic conditions, such as diabetes. Telcare, a Maryland-based developer of mobile monitoring solutions for diabetics, is marketing a cellular-enabled blood-glucose monitor that automatically transmits a users blood-glucose readings to appropriate caregivers, ranging from physicians to family members. The data is stored on the companys HIPAA-compliant cloud server.

One of the chief concerns with mobile devices and cloud-based storage is privacy and security. While most devices in the healthcare environment are designed so that they dont store information, the danger still exists that sensitive data can be accessed, diverted or mistakenly made public. Most cloud providers insist on stringent device security that may include two-factor authorization or the

In smartphones, Windows could pass RIM to be #3 player, and could be same size as Apple in units by 2015.

By 2015, tablet shipments will be 50% of laptop shipments

BYOD on the upswingWhats been a long time coming will happen in 2013 when mobile devices surpass PCs as Web access tools and tablets equal laptops in sales.

2015

Source: Gartner

By 2015,over 80% of

handsets in mature markets will be smart

phones. 20% of those will be Windows phones.

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ability to seize control of a device and remotely wipe it clean of all information.

In a recent commentary, Mac McMillan, president and CEO of CynergisTek and chairman of the HIMSS Privacy and Security Task Force, explained that mobile devices need to be configured so that clinicians can review and act on sensitive information, but that information must rest on a secure server.

The first step in making this data-centric, common-sense approach to mobile device security work is to get people to recognize the difference between needing the sensitive data on their mobile device and simply wanting it on there out of convenience. This is made more difficult and more important as the mobile device industry continues to focus on allowing access to data anywhere, anytime (the idea of bring your own device, or BYOD), McMillan wrote. If we begin to balance convenience around dissemination of data with

the actual practical clinical requirements by using technologies that enable connectivity and only store data on the devices that are able to protect it properly, we can greatly reduce the magnitude of the risk. The proposed EHR implementation standard and certification criteria for encryption of devices that connect to EHRs and retain ePHI after termination of their session will certainly heighten this need.

The issue has caught the attention of Washington, too. This past June, Sen. Al Franken, D-Minn., introduced legislation that would require encryption for all portable devices containing personal health information. He also called on Health and Human Services Secretary Kathleen Sebelius to improve existing medical privacy regulations.

It is imperative that HHS use its regulatory authority to safeguard patient data and secure patient trust, Franken wrote in a letter to Sebelius. I urge you to issue long overdue, statutorily required guidance on the minimum necessity standard, which governs the type and amount of protected health information that entities can share. I also ask that you continue to take steps to address the security of protected health information that is stored on portable media, like laptops. n

Ash ShehataSenior Executive Director

for Healthcare in the AmericasCiscoWere just starting to see this swing to cloud-based communications

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GoinG above and beyond compliance mandates

As the HITECH and Accountable Care (ACA) acts continue to shape the

transformation of the U.S. healthcare system, healthcare providers are

looking for solutions to help them reduce costs, operate more efficiently

and support the delivery of high-quality care required by this major trans-

formation. In the face of lower reimbursements and limited resources,

healthcare providers are seeking information technology (IT) alternatives

that dont require upfront capital investment and enable them to concen-

trate on their core competency of healthcare delivery and not IT, according

to Kurt Hagerman, director of global compliance for FireHost, a leading

provider of secure cloud infrastructure as a service (IaaS).

Cloud infrastructure has become an attractive option for healthcare orga-

nizations for a host of reasons, Hagerman pointed out.

Thecloudoffersrapiddeploymentandnearlyinfiniteresource flexibility for server memory, processors, and storage.

ThecloudgiveshealthcareandserviceprovidersahomefortheirWeb applications and internal IT systems at an attractive price point.

ThecloudturnsITintoanoperationalexpenditure,moreinlinewith the way IT is consumed.

Thecloudeliminatesthetediumofengaginginalengthyprocurement cycle or contracts to buy more equipment.

Security, protecting patient electronic healthcare records, and upholding

HIPAA compliancy are the most common concerns and often deterrents

for healthcare organizations to adopt cloud environments.

The essence of our business is contained within the

information we collect from the Web, so protecting it

thoroughly and maintaining HIPAA compliance is critical,

says Carlos Navarro, information systems manager at QualSight.

overcominG privacy and security barriers inside and out

Whiletheclouddeliversmanybenefits,thebiggestchallengehealthcare

security-based cloud infrastructure:

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service providers face is ensuring the cloud infrastructure can deliver

adequate privacy and security. Securing health data is a shared endeavor

among healthcare IT administrators and cloud vendors.

When considering public cloud infrastructures, healthcare

service organizations should seek a knowledgeable and

responsible partner, who can help clearly define each partys

responsibility to compliance with HIPAA regulations,

Hagerman said.

Given the disparate service offerings among cloud solutions, its not un-

common that healthcare and service providers find it difficult to decipher

the varying levels of security available from different hosting providers,

Hagerman said. He advises healthcare and service providers to confirm

that the cloud infrastructure provider has the security controls required to

appropriately protect health information and meet HIPAA requirements.

For example, IaaS providers should protect data in transit and at rest as

well as provide assurance as to where the data is stored and ensure that

the data doesnt leave its designated location. As a standard procedure,

FireHost will sign a the Business Associate Agreement (BAA), which is a

required document for covered entities that will be sharing health informa-

tion with a service or third-party provider.

Withperimetersecurityandapplicationprotectionnottypicallyfoundinother public cloud infrastructures, FireHosts public cloud infrastructure

provides an enterprise-grade private or dedicated cloud experience for

all of our customers as a standard. Managed security controls within the

FireHost environment are built natively into the infrastructure as a service

architecture, to provide technical controls healthcare providers need to

meetHIPAAauditorrequirements.Wereprovidinginfrastructureasa

service that goes beyond HIPAAs standards, from the physical data center

site selection, through the networking and hypervisor layers, and down

to the operating system layer where we handle security patching,

Hagerman explained.

the first hitrust certified secure public cloud

FireHost bears the distinction of being the first hosting provider to be

certified by the Health Information Trust Alliance (HITRUST). HITRUST, a

collaboration of healthcare, business, technology and information security

leaders and organizations that has received guidance from the Department

overcominG privacy...continued

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of Health and Human Services, focuses on information security as a core

component to the successful adoption of healthcare IT. HITRUST developed

the Common Security Framework (CSF), which is a certifiable information

security framework that incorporates standards and regulations, including

HIPAA and the HITECH Act, allowing entities that create, access, store or

exchange personal health and financial information to do so while meet-

ing requirements to ensure the security of that information. HITRUST also

developed an audit program around the framework and certify IT audit or-

ganizations to conduct assessments against the CSF. They certify provid-

ersasbeingHITRUSTcompliant,Hagermanexplained.Wearethefirsthosting provider to receive designation and certification from HITRUST.

After intensive research, we found no other secure cloud

hosting company on the market that can beat FireHost,

with regard to overall protection and performance.

says Carlos Navarro, information systems manager at QualSight.

protectinG confidential data is Job one

Hagerman noted that the issues FireHost is trying to solve for all of its

HIPAA customers, which include Johns Hopkins University, Duke University,

3M, CVS, QualSight LASIK, and others, has been around helping them meet

the technical security requirements for protecting their healthcare data.

They are healthcare research and provider organizations, not IT security

professionals, he said. FireHost built its cloud infrastructure with secu-

rity as a core principle. FireHost IaaS was purpose-built with security as

part of the DNA of the infrastructure, versus an add-on or an afterthought

in the infrastructure, and every client receives quantifiable protection,

Hagerman said.

FireHosts cloud infrastructure gives its users granular administrative con-

trol over the data in the form of:

Role-based,logicalaccesscontrolssuchasvirtualprivatenetwork (VPN) access protected by a Secure Socket Layer (SSL) connection

Anti-virusprotection Logmonitoringandmanagement Vulnerabilitymonitoring Periodicserviceaudits andmore

Preventative measures such as business continuity configurations are read-

ily available, and users can generate reports on the status of data protec-

tion on demand, via FireHosts secure customer portal.

the first hitrust...continued

brands that trust firehost

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roi with cost avoidance

The return on investment for safeguarding patient information in a cloud

infrastructure is calculated in a number of ways, according to Hagerman.

WhereasFireHostisstaffedaroundtheclockwithhighlyqualifiedsecurityprofessionals, healthcare providers may wish not to make data security

a core competency. Year over year, Verizons Data Breach Incident Re-

port shows that hosting systems in-house is riskier to undertake, points

out Hagerman. Outsourcing hosting requires less resources and time and

provides healthcare IT stakeholders access to immense expertise as well as

easy access to the latest varieties of software and hardware through your

cloudhostingprovider.Withserversbeingreplacedapproximatelyeverytwo years and the lifespan of technology growing ever shorter, leasing

only what you need becomes ever more attractive.

Even more vital, a secure, professionally managed cloud infrastructure

provides a level of insurance against data breaches and the associated

costs such as generating and sending out notifications to affected patients,

providing credit monitoring services to those patients for a period of time

and sometimes fines. The most critical threat is loss of brand and end

user trust, Hagerman said. Most companies consider brand damage to

be the number one reason for proactively protecting themselves from

cyberthreats. Indeed, for healthcare providers, staying out of the front

page of the newspaper and the evening news is perhaps the best reason to

implement a security-based cloud infrastructure.

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Cloud. Its the ephemeral buzzword making the health IT rounds these days.

The business case for healthcare organizations is about sharing risks and rewards and rules, and get-ting a lot of work done efficiently and usually at a lower cost, said Jonathan Bush, CEO of Athena-health. It takes the level of attention that you can pay, the level of capital you can bring to something as an individual, Bush explained, and multiplies it by the number of individuals who agree to do it the same way as you, but have a third-party do it.Indeed, think of the cloud as a golf course, Bush urged, during a recent Maine visit.

You can have a pretty nice golf course yourself in Maine if you happen to want to buy 200 acres, and have 82 lawn mowers. But, if you get one other guy, the cost of your golf course, of course, just dropped in half, Bush explained. You just saved $10 million on your $20 million golf course. You made $10 mil-lion dollars by just agreeing to golf the same course as one guy.

Taking the analogy further, Bush suggested that a hundred or a thousand golfers who pay $100 a round or more would bring down the cost of the $20 million golf course quickly.

But you have to agree that youre going to use the same holes in the same places as the other guy, he said. In a way, thats a cloud. The cloud has a certain pull today one may say, stickiness. Its a new name for an old concept application service providers (ASPs), managed host-ing, or software as a service (SaaS). And its catching on with physician practices, community hospitals and even some of the integrated delivery networks

How the cloud is transforming EHRsConsidering the cloud computing model akin to a golf course explains a lot and the analogy is best made by none other than Jonathan Bush. By Bernie Monegain, Editor, Healthcare IT News

Jonathan BushCEO

AthenahealthIndeed, think of the cloud as a golf course.Listen to Jonathan Bush explain what EHRs have in common with golf courses.

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that might be inclined to create their own private clouds.

The reason: Theres more data, more work and more IT than ever before.

Add to that the need to archive medical images in a safe and efficient way, the requirement to have a plan for disaster recovery and the growing field of personalized medicine, and theres a global market poised for 20.5 percent compound annual growth rate from 2012 to 2017, according to a report from Marketsandmarkets.

Physicians have long been accustomed to host-ing critical software applications on servers in the office, wrote Rosemarie Nelson, a principal with the MGMA Health Care Consulting Group, in a recent blog on KevinMD.com. That is how theyve ac-cessed practice management systems the informa-tion technology (IT) backbone of medical practices for 20 years or more.

Cloud computing, Nelson continued, represents a paradigm shift in IT management. The cloud makes it possible for you to grow and expand rapidly and generate efficiencies and cost savings by paying as you go for the services you use.

On-premise vs. hosted EHRs Stand-alone electronic health records still rule the day among the 55 percent of physicians that have adopted an EHR due to their faster response times and lower maintenance costs, but their web-based brethren were already catching up as of 2011 and will likely continue gaining ground on their ease of access and lower up-front costs.

59% Stand-alone EHR

41% Cloud-based EHR

Source: Centers for Disease Control and Prevention/National Center for Heath Statistics, July 2012

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The new normalThe paradigm shift is in full swing, as Jamie Coffin sees it. Coffin is vice president and general manager, healthcare and life sciences for Dell, which runs cloud-based EHRs from the likes of Allscripts, Cerner or NextGen. Coffin contends that most healthcare organizations dont have the expertise in-house to manage the hardware and applications.

With the new security and privacy regulations around HIPAA compliance and having to encrypt every drive and the things theyre having to deal with now are astronomical for a physician practice, Coffin said. Dave Nesvisky, executive director of healthcare for NetApp, agreed that IT is not a core competency for physician practices. So, if you need something that has a lot of capability and a lot of reliability, and you dont have a lot of staff, it really lends itself to being put in the cloud, he said.

Kathy Grise, program director, IEEE Cloud Computing Initiative, said that increasing numbers of practitio-ners are leveraging the cloud for storage, access, and management of EHRs and related data.

Top advantages include lower IT costs, Grise said, but more importantly, the cloud provides easier accessibility to the physician and staff regardless of their location.

Top advantages include lower IT costs. But more importantly, the cloud provides easier accessibility to the physician and staff regardless of their location.Kathy GriseProgram Director

IEEE Cloud Computig Initiative

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The real question is not cloud versus on-premise. Its open versus closed. Aneesh ChopraSenior AdvisorThe Advisory Board CompanyListen to Aneesh Chopra discuss the differences between open and closed clouds.

Wrong questionTo Aneesh Chopra, who served as the first chief technology officer of the United States, and today is a senior advisor with The Advisory Board Company, a healthcare think tank, the real question is not cloud versus on-premise. Its open versus closed.

As the country shifts its focus to value over volume, EHRs, too, will have to change to accommodate a wide range of tools to better connect with patients perhaps with text messages or Facetime video chats, Chopra said.

The idea is to extend the value of my EHR into these other workflows that are necessary to meet our goals if we are moving to the value-based care delivery system, Chopra explained. So having an open EHR that more seamlessly interfaces with

third-party apps is probably the bigger question for providers today.

But for healthcare organizations interested in open EHRs that can connect to the growing ecosystem of applications if you value the need for diversity and third-party apps that can effectively plug into the EHR, it is easier to do that with applications in the cloud, Chopra explained. Not necessarily required, but it is easier.

Cloud providers like Dell and NetApp and others including Verizon, IBM and AT&T strive to be efficient for their clients and for their own enterprise.

Do I create this big infrastructure with tons and tons of servers? Nesvisky asked rhetorically.

With the way NetApp works, Nesvisky continued, its really been optimized for a virtualized infra-structure, which means you can run a lot fewer serv-ers at a lot higher utilization. That reduces the foot-print, power consumption, need for management, and makes the entire thing a lot more efficient.NetApp has architected what it calls an agile data infrastructure, he said. It takes advantage of com-puting power to create virtualized infrastructures that are ultra-efficient.

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Dells Coffin added that healthcare organizations just have to make sure they move the right things to the cloud. Cloud is not about the cloud. Its about how you use cloud as an enabler to make more efficient IT. Its very difficult to have the best privacy and secu-rity in a small IT shop, Coffin asserted.

Vendors take care of that, or at least they claim. Dells data centers, for instance, handle security for customers. We have a full-time HIPAA security officer, Coffin added. All they do is look at our environment to make sure we maintain the highest levels of HIPPA compliance, and we go over the top because we have so much healthcare data.behind our firewall.

Hospital trendsHelping organizations become more efficient can be a byproduct of cloud computing.

Three quarters ago, Dell started a new offering in the cloud MSite, dedicated to Meditech. Now we have over 60 customers in the Meditech cloud. Thats a very small portion of the Meditech hospitals, but its a very fast trend compared with any other offering weve ever brought in the market.

One of those Meditech customers is Kings Daughters Medical Center, a community hospital in Brookhav-en, Mississppi. Carl Smith, IS director at Kings Daugh-ters, was happy to give up control of the hospitals Meditech machines.

Not having to support our Meditech servers onsite gives us more time to devote to our other hardware projects and installing new Meditech applications rather than focusing on hardware maintenance, backup and recovery, he said, in a recent case study published by Dell.

MSite has also greatly enhanced our disaster recovery readiness, Smith added. We were recently audited and it was nice to present a comprehensive report on our disaster recovery strategy through MSite, which was well-received by the audit company.

Dave NesviskyExecutive Director of Healthcare

NetAppTheyll provide the services to other hospitals, clinics and practices in their sphere, in their ownership. Thats really catching fire.

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NetApps Nesvisky said hes seeing a big uptick in private cloud where a hospital will essentially serve as the cloud provider to their community of interest. Theyll provide the services to other hospitals, clin-ics and practices in their sphere, in their ownership, Nesvisky added. Thats really catching fire.

With the emergence of ACOs, hospitals are buying practices like crazy, Nevisky explained. Theyre all becoming part of the IDN so they can control the entire environment. It becomes a cost-effective way of doing business for the IDN to provide all the in-frastructure, the EHRs, the workflows and everything to all the providers in their network, so they can do exactly that, they can share the records, which is obviously moving clinical information and sharing it with patients as part of meaningful use.

Its also tapping into those same economies of scale Athenahealths Bush described.

Sharing resourcesBush returns to the golf course analogy and the idea of agreeing to play by the same rules.

If you get lots of people to agree to compute the same way, to manage information processed the same way, and to agree to the same set of rules, he said, the amount of money I can spend on each little rule is orders of magnitude hundreds of times than any one of my users could ever justify spend-ing on the same thing.

So, Athenahealth is able to spend $500 finding out exactly why a $5 claim was denied.

No doctor in their right mind would have their staff do that, Bush said. But if I can figure out the root cause of that, and build a rule so no doctor ever gets that $5 claim denied, ever again, times millions and millions of those claims across 35,000 doctors bam, thats a bargain for me.

So, Bush continued, thats the idea of the cloud. nJamie CoffinVice President & General ManagerDell Healthcare and Life Sciences

With the new security and privacy regulations around HIPAA compliance and having to encrypt every drive and the things theyre having to deal with now are astronomical for a physician practice.

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Sponsored content

Apixio, with its big data platform, data analysis tools and cloud computing, is enabling tomorrows medicine today.

Silicon Valley is looking to harness modern data science to find efficiency and value in the 20 percent of the U.S. economy that arguably needs it most: healthcare.

Indeed, technologists widely agree that healthcare is anywhere between 20 and 30 years behind in IT implementation, particularly when it comes to using data to drive value in business. As much as 90 percent of the patient clinical record is unstructured. And in this unstructured data the clinical narrative lies information that is critical for care quality, reim-bursement and population health management. But this data cannot be accessed, computed upon, or analyzed by existing clinical workflows or analytic tools.

Thats the state of healthcare today were trying to operate on this in-formation, make sense of it, and extract valuable insights when most of its not structured, Apixio CMO Darren Schulte, MD, explained. The clinical text is effectively hidden from the vast majority of mission critical systems in healthcare organizations, which makes many processes related to qual-ity or care improvement much less effective.

Silicon Valley-based startup Apixio is already changing that. Apixios Clini-cal Knowledge Exchange (CKX) Platform, HCC Optimizer, Patient Analyzer

and Population Analyzer tools help providers and plans to mine patient data regardless of the format so they can better manage their patient pop-ulation, to accurately report on quality of care, bill accurately for services performed and improve patient care.

Quality measuresIn the shift toward value-based healthcare, big data is more than just mountains of information; its an important technique for mining data in the clinical narrative that can precisely reflect the true state of the patient, thus improving compliance with quality measures.

Harvesting big data to optimize value-based clinical care


big data reveals crucial Hidden information in Healthcare systemsHealth Technology Use Case

www.apixio.com Knowledge-driven Outcomes Copyright 2012 Apixio, Inc.

Big Data Reveals Crucial Hidden Information in Healthcare Systems White Paper Health Technology Use Case

Industry Challenge Technology leaders in healthcare know that managing risk for a population requires a highly informed, data-driven approach to tracking the care of patients. The challenge is that coded data from administrative sources falls far short of faithfully representing the clinical history of a patient. Studies show that more than 63% of the key clinical information about patients is missing from the coded data in Electronic Health Record (EHR) systems. What is needed is a way to harness the entire clinical history of each patient, including the crucial information that is contained in narrative and scanned documents. Furthermore, this information must be assembled from all sources into a clear, seamless presentation, so that care managers can efficiently monitor their patient cohorts, and clinicians can quickly and easily retrieve the results they need to make confident decisions.

Apixio Solution The solution is Apixios Clinical Knowledge Exchange (CKX), a smart HIE that assembles clinical information from multiple sources and extracts key diagnoses, procedures and results from text and scanned documents. The result is a complete, electronic view of the patient that can be understood easily by both humans and quality reporting systems. Powered by the CKX, the Apixio Patient Analyzer performs a clinically intelligent search of a patient's entire history, and presents the results conveniently within the user's EHR.

Big Data Analytics Under The Hood The Apixio CKX uses Big Data technology to process all incoming data and make real-time querying of structured data, textual documents, scanned documents and administrative data a reality. All incoming textual data, including text extracted via Optical Character Recognition (OCR) from scanned documents, is analyzed, structured and meta-tagged as soon as it comes into the Apixio Hadoop cluster, making it immediately available for patient-level and population-level queries. With access to over 50 million clinical documents, containing 5 billion discrete clinical findings, CKX is able to use Big Data Analytics techniques to attach meaning to almost all incoming data, regardless of the source. The following case study describes how the CKX and Patient Analyzer are being used by an ACO to reduce its risk and increase its operational efficiency.

Coded 37% Narrative and

scanned 63%

Sources of Key Clinical Data

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Apixios CEO, Shawn Dastmalchi, describes big data as leveraging robust computing power to identify data-driven insights for better value and better quality of healthcare using information whether it is coded or unstructured, as with the clinical narrative. This analysis can support near real-time results, such as when a doctor is seeing a patient and needs to understand the patients full record to make treatment decisions.

A typical health system of say 200,000 patients, with 200 providers, for instance, could generate as much as 10 terabytes of data over 5 years, and of those 10 terabytes 90 percent is not coded or structured, its text in one form or another.

Apixio has created a platform for big data analytics that really enables us to derive key clinical knowledge from the entire patient record, Dr. Schulte said.

Apixio adds knowledge to unstructured data through indexing and meta-tagging so that different analytic techniques can then be applied, such as text-mining for diseases, procedures or other relevant patient informa-tion. Meta-tagging recognized concepts in a data stream can be useful in a flexible data model for many different analytic purposes, Dr. Schulte added. Managing and analyzing such data requires the kinds of tools used by Yahoo and Facebook. Doing so in the cloud, we can take advantage of elastic computing, so we can grow as we need to, either for results to be returned in real-time or for batch processing and the cloud enables us to recruit more computing power to do that.Dr. Schulte pointed to the case of one client, where Apixio helped improve performance on a mea-sure such as diabetics in need of a particular screen every year for kidney disease, a test that may be conducted but not always coded.

Apixio showed a two-fold improvement in that health systems perfor-mance on that measure simply by mining the data in the clinical narrative and determining that those particular tests were in fact done for diabetic patients but they were not appropriately coded for meaning Apixio essentially created a clearer picture of how well that health system was providing care for their diabetic patients.

So Apixios approach is mining those texts in various different ways to understand the facts about the patient that can be related to quality mea-sures, Dr. Schulte said. Measurement of care quality is obviously critical for many different reasons. Its the starting point for any health system, provider, or even a payer to know how they are managing patients, wheth-er they are achieving the desired quality of care, and, if not, how to inter-vene so that their care gaps are appropriately addressed.


advanced text mining improves medicare advantage codingIndustry Challenge: The HCC Coding Problem

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Transition

GovernmentCloud:

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acos and medicare advantage Unstructured data is also a rich source of information that can be mined for billing purposes and shared savings. Simply put: Providers have to dem-onstrate sufficient compliance with quality measures to achieve shared savings within public and private accountable care organizations.

The alternative to Apixio is to make doctors and others perform chart abstraction to ensure that certain data elements for quality measures are captured within the EHR. This is not a viable option, especially as the population and measure set grow in size. The other option, of course, is to hire armies of coders who literally sift through charts to find that specific piece of data that indicates, for instance, that an older individual received the recommended colorectal cancer screening.

A health system still has to report upon these quality measures And if services provided are not coded in a manner that can be computed upon, then its absent from the results and it looks as if the physician didnt do what he or she may have already done and documented.

In the case of documenting conditions for risk adjustment, whether for Medicare ACO arrangements or Medicare Advantage plans, as much as 40 percent of patients conditions go un-coded every year and for programs that set risk adjustment for cost basis or for capitation payments that cre-ates the dual-problem of both underreporting for shared savings calcula-tions and being underpaid for care delivered. In one client study, Apixio found an average annual amount of $913 per patient remained un-reim-bursed in one year for Medicare Advantage patients due to poorly coded conditions which were documented in the medical chart.

Whereas a typical solution is to throw bodies at the problem, our ap-proach is to bring modern data science and big data to solve the problem, better make use of data to best measure risk adjustment for payment purposes, Dr. Schulte said. Particular to this case, is the HCC Optimizer, Apixios revenue reimbursement optimization tool.

HCC Optimizer, built upon Apixios big data platform and text mining, en-ables large providers to understand the conditions within a patients charts and determine which of those conditions have not been coded.

Apixios computer algorithms mine unstructured information for relevant conditions documented in a manner required by Medicare. These condi-tions are compared to coded data, revealing coding opportunities, which

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Table of

Contents

Big Data& the Cloud

BYODto theCloud

Cloud-basedEHRs

FinancingCloud

Transition

GovernmentCloud:

Progress &Problems

HIEsEye Cloud

as Revenue Stream

Privacy & Security

in the Cloud


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Sponsored content

are then presented to users in a prioritized order with supporting encoun-ter notes in a Web based tool.

That creates the opportunity for a health plan or provider to then code for those conditions and, by doing so, it achieves two things: One, you can appropriately get paid for those patients and, two, you can better manage those patients because you understand how sick they are, Dr. Schulte said.

risk-adjustmentAt the heart of the third use-case is a reality ubiquitous to healthcare: Physicians cannot effectively treat patients if they dont have the entire picture of their record.

If the information sits in a doctors note in a clinical record you dont know how sick patients are, Schulte said, so you cant manage a popula-tion of patients or coordinate care.

Beyond reporting quality measures and billing appropriately, doctors who understand how sick their patients are can also manage them better - talk with them when theyre not at the clinic, get a care manager or others to help them, to be sure they avoid coming back to the hospital or going to urgent care.

Thats really the medicine of tomorrow, I hope, which is proactively managing patients and not just dealing with them when they show up at the doctors office, Dr. Schulte said. But going through charts patient-by-patient to understand all the issues is not scalable when managing a population.

So its really bringing to bear whats in that non-coded information, not only for quality but for management, risk, and reimbursement, Schulte added.

In all three cases, computing on that data is a big differentiator for Apixio, Schulte continued. If you dont have a platform that enables you to use parallel or distributed computing, youre going to take days or weeks to return results, even months if youre looking at data that is textual in nature. Weve been able to collapse that to provide near-real-time results. Furthermore, our big data approach allows us to represent the entire patient record mathematically so we can take a holistic approach in filtering out inconsistencies and optimizing for specific applications.

Indeed, big data and modern science techniques can get the healthcare in-dustry where it truly needs to be in terms of understanding how to achieve better outcomes and more efficient healthcare.

And that unstructured data in clinical notes, nurses notes, and elsewhere in patient records takes 50 times more computational power than analyz-ing coded data making for a data processing problem that takes the likes of Silicon Valley to solve.

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Table of

Contents

Big Data& the Cloud

BYODto theCloud

Cloud-basedEHRs

FinancingCloud

Transition

GovernmentCloud:

Progress &Problems

HIEsEye Cloud

as Revenue Stream

Privacy & Security

in the Cloud


Advertiser Index

While other industries have blazed a trail to the cloud, many healthcare executives are still trying to figure out how the model can benefit their business.

So we talked to folks in the know about cloud computing to find out what it means to the healthcare industry, which costs to look out for, and what to expect in terms of cost and return on investment.

Six experts offered suggestions and shared their own experiences to help healthcare CFOs and IT departments make sound choices about moving to the cloud or not.

Q: What expenses are associated with transitioning to the cloud, and what are the most common hidden costs?

Tony Vitelli, director of managed services, Infor: There are costs necessary to facilitate the transition to the cloud, but they are quickly recoverable and can provide an attractive ROI. Depending upon the application, up-front costs may include a migration project and all that those entail (testing, data validation, etc). In many cases the application will not change with a migration to the cloud (no end-user effect). Also, by timing these moves to previously planned hardware spend, we find that the initial investment needed can be significantly lower than continuing with the status quo.

With the proper amount of due diligence and planning, hidden costs can be greatly minimized or even eliminated. As mentioned, by timing your move to the cloud with previously planned activities, the cost of migration can usually be accomplished with existing budget. Even in cases where an existing contract may not have an out clause, changing

A virtual roundtable of cloud experts weighs in on the hidden costs, lesser-known benefits, and disadvantages of cloud computing for health entities.

By Stephanie Bouchard, Managing Editor, Healthcare Finance News

Financing a transition to the cloud

By timing your move to the cloud with previously planned activities, the cost of migration can usually be accomplished with existing budget. Tony VitelliDirector of Managed Services Infor

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Table of

Contents

Big Data& the Cloud

BYODto theCloud

Cloud-basedEHRs

FinancingCloud

Transition

GovernmentCloud:

Progress &Problems

HIEsEye Cloud

as Revenue Stream

Privacy & Security

in the Cloud


Advertiser Index

business requirements may still allow for an attractive ROI. Regarding security, this is always a concern, with due diligence and proper architecture you can be comfortable that your data is safe.

Henry Soch, leader of clinical technology, Sg2: Total cost of ownership (TCO) of cloud services is difficult to determine since thereare many costs that are not factored into most vendor TCO models. Healthcare systems should carefully consider the following factors when trying to determine TCO for cloud computing services: Internet connectivity and bandwidth costs; integration with other healthcare organization applications;

interface challenges with legacy EHR and business systems;

data migration costs to the cloud-based services; staff productivity impacts and training requirements;

duplicative software licensing requirements to

support mobile users; and change management issues and related costs.

Uptime guarantees and other service level agreement costs will impact the overall TCO and must be considered in all arrangements with vendors. With EHR, and other critical computing platforms, 99.999 percent availability is necessary.

Guy Fardone, chief operating officer, Evolve IP: This is a very complex question to answer given the vast amount of cloud s

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