This document discusses how cloud computing technologies can be applied to electronic health records (EHRs). It provides background on government programs and regulations driving healthcare organizations to adopt digital health records, such as the HITECH Act and its "meaningful use" incentives. Both opportunities and challenges of cloud-based EHR systems are examined, including concerns around data privacy, security, and vendor lock-in. Examples of EHR vendors offering cloud-based solutions are also presented. The summary concludes that healthcare organizations should carefully consider how cloud technologies can help meet regulatory requirements while addressing the unique security and other needs of digital health information.

1. HEALTHCARE IN THE CLOUDS
Gail Wilcox
CSIX Cloud Computing SIG
September 10, 2010

2. SCOPE
Assumptions Constraints
Audience has basic cloud computing Addresses only EHR cloud technology
knowledge
Most “health records” are still paper HITECH separate from other CMS
based incentive programs
Eligible health caregivers will use only Does not cover Electronic Medical
certified Electronic Health Records Records (EMRs) and Personal Health
Records (PHR) **
**PHR contains information regarding an individual’s medical history, e.g., vaccination history, lab
test results, allergies, medications, surgeries, family history. Google Health and Microsoft
HealthVault are the two best-known PHR services.
Property of CSIX Cloud Computing SIG 9/10/2010, Page 2

3. Healthcare in the Clouds Overview
• Foundation
• Technology
• Vendors
• Summary
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4. Healthcare in the Clouds
Foundation
Setting the Stage
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5. Property of CSIX Cloud Computing SIG 5

6. American Recovery and
Reinvestment Act (ARRA)of 2009
• Signed into law February 17, 2009
• Economic stimulus package intended to create
jobs and promote investment and consumer
spending during the recession
• Set forth $789 billion in economic recovery
programs
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7. Health Information Technology for
Economic and Clinical Health (HITECH) Act
• Part of ARRA
• Sets requirements for being compatible with the
security and privacy regulations of the Privacy Rule
• ARRA allocates $19 billion for health providers and
hospitals who demonstrate 'Meaningful Use' of
electronic health records (EHRs)
• Established programs under Medicare and Medicaid
to provide incentive payments for the 'Meaningful
Use' of certified EHR technology
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8. Healthcare Overhaul Legislation
• Patient Protection and Affordable Care Act (PPACA)
• Signed into law March 23, 2010
• Most expansive social legislation enacted in decades
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9. PPACA Vision
• To transform America’s healthcare system in
an effort to improve
– Quality
– Safety
– Efficiency of care
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10. Differences Between EMR and EHR
Electronic Medical Record (EMR) Electronic Health Record (EHR)
A collection of patient information from A collection of patient information from
one organization, e.g., hospital, family many sources, including hospitals, family
practice or community care facility physicians, pharmacies and laboratories
A record of a single period or episode of A record of lifelong interactions with
treatment or care healthcare providers
EMRs are the foundation of an EHR An EHR is composed of many EMRs
EHR
EMR EMR
EMR EMR EMR
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11. 'Meaningful Use‘ Partnership
• Office of the Secretary for the U.S. Department of
Health and Human Services
• Address privacy and security protections under
HITECH Act
– Centers for Medicare and Medicaid Services (CMS)
– Office of the National Coordinator for Health
Information Technology (ONC)
– Office for Civil Rights (OCR)
Property of CSIX Cloud Computing SIG 9/10/2010, Page 11

12. 'Meaningful Use' Partnership
• CMS and ONC developed standards,
implementation specifications, and
certification criteria for EHR technology
• ONC is the main resource/driver to the entire
health system
– Charged with coordination of the adoption of HIT
– Promotes nationwide HIE to improve health care
• Regional offices
• Office for Civil Rights
– Health Insurance Portability and Accountability
Act (HIPAA) Property of CSIX Cloud Computing SIG 9/10/2010, Page 12

13. Health Information Exchange (HIE)
• HIE is the transmission of healthcare-related data
among facilities, health information organizations
and government agencies according to national
standards
• The purpose of HIE development is to improve
healthcare delivery and information gathering
• To meet ‘meaningful use’ requirements, HIE
technology must enable reliable and secure transfer
of data among diverse systems and also facilitate
access and retrieval data
Property of CSIX Cloud Computing SIG 9/10/2010, Page 13

14. The Nationwide Health
Information Network (NHIN)
• NHIN is a set of standards, services and policies that
enable secure health information exchange over the
Internet
– Will provide a foundation for the exchange of
health IT across diverse entities, within
communities and across the country, helping to
achieve the goals of the HITECH Act
– Enable health information to follow the consumer
and be available for clinical decision making
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15. CMS Incentive Program
• CMS released the incentive payment program final
rule on July 13, 2010 (definitions in place)
• The programs begin in 2011
• Five-year period to adoption
• Incentive program will provide incentive (bonus)
payments to eligible professionals and eligible
hospitals as they adopt, implement, upgrade or
demonstrate ‘meaningful use’ of certified EHR
technology
Property of CSIX Cloud Computing SIG 9/10/2010, Page 15

16. ‘Meaningful Use’ Medicare Eligible
Provider EHR Incentives Example
Adoption
Year Goal Incentive Totals* Penalties
2011 • To electronically capture health record $44,000 - 2011 None
data in coded format $44,000 - 2012
• To report health information
• To use that information to track
clinical conditions
2013 • To guide and support care $39,000 - 2013 None
processes and care coordination $24,000 - 2014
2015 • To achieve and improve performance and $0 - 2015 1% cut in Medicare
support care processes and key health forward payments
system outcomes
2016 2% cut in Medicare
payments
2017+ 3% - 5% pending
overall adoption rate
Property of CSIX Cloud Computing SIG 9/10/2010, Page 16
* Plus 10% for Health Professional Shortage Areas

17. Meeting ‘Meaningful Use’
Objectives
Term describing dedicated, regular use of an
EHR to carry out about two dozen activities
VENDORS PROVIDERS
Assured system they
Ensure systems deliver ‘Meaningful acquire will support
the required capabilities Use’ achievement
Property of CSIX Cloud Computing SIG 9/10/2010, Page 17

18. 'Meaningful Use' Activity Grouping
Charting Order entry (e.g.,
meds, labs, radiology
tests, referrals)
Communicating
with patients 23 – 25
and third parties Clinical decision
Activities
support
Quality and
performance
reporting
Protecting patient
confidential
HIPAA information
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19. Healthcare in the Clouds
Technology
Concerns
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20. Cloud Computing Healthcare Definition
• The term "cloud computing" describes the
practice of storing all data, software, and
hardware off-site, with the system accessible
to hospitals, patients and providers via a web
browser-based login
• Hospitals could share infrastructure and
reduce costs with vast numbers of systems
linked together
• Vendors could introduce new pay-as-you-go
models based on use of CPU hours, or gigabits
consumed and transferred
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21. Why Choose Cloud-Based EHR Models
• Let expensive hardware installation, data storage,
and application hosting be someone else's
headache
• EHR system is immediately available to any
Internet-connected computer in the world
• Overall healthcare and operation costs decrease
• Meet government EHR transformation
requirement
• Allows patients to become more involved in their
healthcare
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22. Electronic Health Record in the Cloud
THE
DARK
SIDE
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23. Bertman’s Ten Reasons Why Cloud EHR is Bad
• Trusting the service provider
– Come to grips with no physical file to touch
– Someone else has control over file
• Not knowing where data is stored
– Broken into chunks and stored in multiple locations
• Not knowing exactly who has access
– Read SLA carefully (care givers, cloud IT personnel,
etc.)
– Patient anonymity
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24. Bertman’s Ten Reasons Why Cloud EHR is Bad
• Cloud service companies can change or disappear
– GE Healthcare 30 day notice
• Cloud medical record storage is not cheap
– $300-$800 per month versus less expensive client-
server software
• Privacy rights not readily understood
– Cloud services companies control and monitor at
will
– How much information caregivers and patients can
see
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25. Bertman’s Ten Reasons Why Cloud EHR is Bad
• Ad-based cloud services present new issues
– Caregiver influenced by ads that are tracked,
targeted and monitored carefully
– Compromise patient privacy/quality of care
• Inherent slowness of web-based systems cause
problems
– Multiple screens
– Problems finishing patient notes
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26. Bertman’s Ten Reasons Why Cloud EHR is Bad
• Subject to poor Internet Service quality
– Service and power outages, acts of God
– Patient care can be compromised
• Cloud EHR systems are prime targets for hackers
– Sensitive information (health, financial)
Property of CSIX Cloud Computing SIG 9/10/2010, Page 26

27. Black Hat Security Conference
Lessons Learned
• Cloud offers less legal protection
• Client does not own the hardware
• Strong policies and user education required
• Do not trust machine instances
• Rethink your assumption
Property of CSIX Cloud Computing SIG 9/10/2010, Page 27

28. Cloud Developer Challenges
• Cannot rely on homogenous computing
environments
• Web-based software must account for
different operating systems and hardware
• Cloud computing strength is scalability
– must function under enormous bandwidth
loads and millions of simultaneous users
Property of CSIX Cloud Computing SIG 9/10/2010, Page 28

29. Hospital Cloud Challenges
• As hospitals make more use of cloud
resources, expenses can rise exponentially
• One desired capability is to link ultra-secure
private clouds with cheaper public offerings
– an EHR system that could pipe into a data
transfer alternative during peak usage hours
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30. Healthcare in the Clouds
Vendor
Highlights
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31. EHIT Vendor Exponential Growth
• Growth from mergers, acquisitions, partnering
and new start-ups (Yes, even Walmart)
• Careful what you buy
– Perform due diligence
– Seek out the wisdom of early adopters
– Make sure vendor is CCHIT compliant
– Seek guidance from ONC local regional office
– Choose wisely based on business and clinical
needs
Property of CSIX Cloud Computing SIG 9/10/2010, Page 31

32. Certification Commission for Health
Information Technology (CCHIT)
• Independent, nonprofit 5011(c)3 organization
• Federally recognized certifying body
• Certification is a requirement of state eHealth
programs and private sector pay-for-
performance programs
• Over 250 products certified
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34. Why Doctors Flock to Practice Fusion?
• Completely web-based, with live phone
support, and it is free
• 'Live in FiveTM' program allows users to be up
and using the EHR in less than five minutes
• No software to install, sales contracts to sign,
consultants to pay or hardware to buy
• Users do not have to be a technology expert
• Just sign up and start charting
Property of CSIX Cloud Computing SIG 9/10/2010, Page 34

35. Salesforce Meets Practice Fusion
• In 2009 Salesforce invests almost $10 million
• Salesforce will get a minority stake of the
ad-based revenues
• Salesforce’s “cloud-computing” model makes
sense for doctors’ offices, which are typically
small businesses without much of an IT staff
• Practice Fusion already uses that model
• Under the deal, Practice Fusion’s
product will reside on Salesforce’s cloud
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36. EHR Screen Shot
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38. Epic Systems and Apple
Mobile Phone-based EHR Application
• Haiku is available on Apple’s AppStore
• Haiku works on both the iPhone and iPod
touch
• Conducted a trial at Stanford Hospital and
Clinics
Property of CSIX Cloud Computing SIG 9/10/2010, Page 38

39. HAIKU
Provides authorized clinical users of
Epic’s EHR with secure access to:
• clinic schedules
• hospital patient lists
• health summaries
• test results
• notes
Supports:
• dictation
• in basket access
Screenshot shows the patient’s
problem list, contact info, photo
and points to an allergies list
Property of CSIX Cloud Computing SIG 9/10/2010, Page 39

40. Healthcare in the Clouds
Summary
• Meet ‘Meaningful Use’ requirements
• Stay current on government regulations
• Determine if cloud technology is right
• Vendor selection
• Embrace change
• Understand special needs in healthcare
– Security
– Certification
Property of CSIX Cloud Computing SIG 9/10/2010, Page 40

41. HEALTHCARE IN THE CLOUDS
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