Then I noticed a trend at a lot of the web sites that I frequent: Microsoft has slowly, and quietly, been positioning itself to jump into the healthcare market.

Consider the following:

• Microsoft has been plowing forward with their cloud and Software-as-a-Service model: Azure Platform, Office Live, etc.
• Microsoft is offering American scientific researchers free access to their new Window’s Azure platform. This should allow centralized data collection for scientists to collaborate on research projects.
• HealthVault is one of the key players in the personal healthcare record (PHR) race. Google Health is the other big boy on the block. Sure, there are other players in the game, but even they recognize the need to acknowledge the dominance of Microsoft and Google.
• Microsoft announced HealthVault Community Connect, which is designed to help hospitals and patients control the flow of data stored in multiple systems.
• The Cleveland Clinic and Microsoft partnered to use HealthVault with the hospitals EMR to track patients with chronic conditions.
• EHR vendors are starting to get on board with the Microsoft platform.
• Microsoft already offers a health information system, i.e. Amalga Hospital Information System. Why isn’t anyone talking about it?
• Take a look at some of Microsoft’s activity at HIMSS 10.
• Microsoft Surface – what a great tool for physician interaction with patients.

• Mobility – at the moment, the only real player in the tablet computer game is Microsoft. I’m encouraged by the iPad and the Adam, but for now there is only Microsoft and Windows XP tablet, Vista and Windows 7. Microsoft will have to do a better job with their smartphone platform, but take notice that they continue to push forward with the concept even though they’re getting trounced by the iPhone and Android devices.
• Microsoft and Philips are collaborating to build clinical decision support tools (CDST).
• Microsoft is already entrenched in numerous healthcare systems across the country, perhaps the world, as an enterprise partner. Windows is still the dominant operating system found on desktop computers in hospitals, and how many millions of healthcare providers already use a Microsoft productivity application, i.e. MS Office, Exchange Server, MS Outlook, MS SQL Server, so on and so forth. This gives Microsoft an extensive user base from which to build an incredibly integrated system.

Further consider that software like our pharmacy information system (PhIS) and BCMA system from Siemens is built on the .NET framework using Visual Basic.NET. Yep, another Microsoft product. How long do you think it will be before other vendors begin partnering with Microsoft to develop and integrate products that will work in the healthcare arena? I’m betting not long.

I’d love to spend a few days in Redmond running around playing with all their toys. I can’t imagine the research and development that goes on behind those walls, but it must be pretty cool. I’m sure we only see a fraction of what they’re working on.

Microsoft may be aging and their bite may not be as vicious as it used to be, but they are still an 800 pound gorilla in the the software industry. And what can an 800 pound gorilla do? You got it, anything it wants.

Looking for patient information wasn’t any less cumbersome. If you needed to read a patient’s history and physical, you went to the chart. If you wanted to look at lab results you had to wait for the lab, or the unit secretary, to print them out and attach them to the chart. If you wanted to see what time a medication was administered, you had to look in the medication administration record, i.e. the MAR. Data was scattered all over the place. Of course, no one thought it a problem because that was the most advanced system available at the time.
Healthcare technology has come a long way, and as pharmacists most of the information we need is much easier to find. Yet here we are still trying to figure out a way to create a unified patient health record that can be used by healthcare professionals not only across the street, but across the continent or world.

While technology has granted pharmacists the ability to fit everything they need in their pocket, the volume of data created, stored, manipulated and reviewed by pharmacists has grown to staggering levels. Unfortunately healthcare continues to struggle with the best way to handle storage of this information in a way that makes it universally accessible. Patient information is often times located throughout many systems; pharmacy, lab, radiology, nursing, ADCs, ADT, etc. While integration among various systems is improving, it’s still imperfect.

Pharmacy organizations like ASHP are working to remedy some of this by developing electronic standards for pharmacy and working to get various groups on the same page prior to moving forward.

In 2009 the ASHP Section of Pharmacy Informatics and Technology published a vision statement on “Technology-enabled practice”.  In the paper several technologies are discussed that can act as a springboard for development of a new and improved pharmacy practice model. My thoughts on the vision statement can be found here.

For this technology to work now and well into the future, pharmacy needs to consider a model that will provide the foundation for centralized data storage as well as easy access to information anytime from anywhere. A data hub that can be accessed via any web-enabled device makes a lot of sense. These things are central to the principles behind the cloud computing model.

One major misconception regarding cloud computing is that it is simply remote storage. While remote storage is a piece of the puzzle, there are many other components that make up the cloud computing environment; software-as-a-service (SaaS), infrastructure-as-a-service (IaaS), platform-as-a-service (PaaS) and some might say data-as-a-service (DaaS). The nomenclature continues with words like “private cloud”, “hybrid cloud”, and so on. It can get very confusing. However, the most important pieces of the puzzle for pharmacy are the ideas of centralized data storage and access to the information anytime, anywhere; IaaS and SaaS, respectively.

Regardless of the nomenclature used, it is clear that cloud computing will become very important to not only pharmacy, but the entire healthcare industry as a whole. Without saying “cloud computing”, the RAND Corporation presented testimony to the Senate Finance Committee in 2008 that addressed some of the benefits of a cloud-based healthcare system. According to the statement: “The hope of many is that the broad adoption of HIT systems with the aforementioned functionality in the United States will transform health care in terms of making it more efficient and effective simultaneously. Efficiency would be enhanced by reduced test duplication, improved drug utilization, better scheduling, reduced paper record handling, and improved claims processing and billing. Effectiveness would be enhanced by reduced errors (reduced handwriting-based errors, for example), reminders to improve preventative care, decision support for better evidence-based practice, improved management of chronic illness, and improved continuity of care for those patients seeking care away from their primary provider (such as was needed to support the mass evacuation that occurred after Hurricane Katrina). Effectiveness would also be enhanced by the quality of care assessment such systems would make possible and by improvements in the evidence base for best practices derived from the analysis of large electronic medical record databases.”

Why? Well if you ask me it’s relatively simple:

• The cloud is sold on demand, sometimes by the minute or by the hour which requires less initial capital from healthcare systems.
• The cloud is elastic, meaning a user can have as little or as much services as they want at a given time. In other words, it can expand like a balloon when necessary.
• The cloud service is fully managed by the provider, meaning the user needs nothing besides internet access. This is a huge benefit when it comes to resources to implement and maintain a system.
• It’s green. How many CIOs are sitting on excess server power waiting for a spike in activity that they’ll never need? I bet it’s a lot. People don’t like getting caught with their pants down. With cloud services, you only use what you need (see points one and two above). This means you aren’t using resources you don’t need.

Advantages of SaaS over the traditional software model include:

• Lower implementation cost
• Lower maintenance cost; no maintenance from the end user
• No additional hardware investment
• No additional supprt resources necessary
• Faster development cycles; no upgrades or patch uploads from the end user
• Access anytime, anywhere with only an internet connection.

And let’s face it, I would wager that customer service and support can have a significant upside in cloud based computing. When a business wants to succeed they do a good job and provide stellar support. If they don’t, they fail. Not the case with on-site IT support in the hospital. When support from the IT department in the hospital is slow or subpar, the only recourse is to fill out some paperwork and hope it improves. To quote from Michael Biehn’s character, Kyle Reese, in the Terminator “That’s what he does. That’s all he does! You can’t stop him!” That’s how a successful vendor will behave. I’m not saying that will always be the case. I’m just saying that it’s possible.

As we continue to develop both new desktop and mobile operating system, i.e. Mac OS X, Windows 7, iPhone, Android, etc, it’s going to become even more important to develop and utilize applications that can be used regardless of hardware or software architecture. This is where SaaS fits. In theory anything with a web-enabled browser can utilize SaaS. How? Well the software runs from a central location and is simply delivered via the browser. I know what you’re thinking, but Citrix is not SaaS; it’s a virtual desktop environment. They’re not the same thing.

IaaS and SaaS are not new concepts. Naming conventions may have changed, and technology has advanced the ideas to new heights, but everyone that has spent any time on the internet has, or is now, using some form of cloud computing. You may be aware of it, then again you may not, but I’m confident that most people reading this blog post have used some form of online storage, social media service, or online application like GMail or Zoho.

For those of you that doubt the importance of the cloud model, understand that companies like Google and Microsoft have invested heavily in cloud computing over the past several years. While this alone doesn’t guarantee that cloud computing will be the future, I would like you to consider this: who drives future technology? I would argue that technology development is driven by whichever way the market is swinging. The idea of cloud computing has spawned a wave of new software and hardware technology. In addition it has generated new ideas for how to store, manage and access large amounts of data like those seen in the healthcare industry. As lofty as the idea may seem, based on what is happening in the world the traditional model of data storage and software distribution is being pushed toward the cumulus.

Take a look at some of the happenings in cloud compuing:

- PHRs are exploding. As evidence take a look at Google Health and Microsoft Healthvault; these are cloud offerings. Information is stored on some far away data farm where you don’t have to worry about security or hard drive failure.

- Microsoft, in agreement with the National Science Foundation, is offering free cloud computing to NSF-supported researchers. Of course it’s via Windows new Azure cloud platform, but it’s still cloud based and it’s free. In addition Microsoft now has its Business Productivity Online Suite, including Exchange Online, SharePoint Online, Office Live Meeting, and Offic Communications Online offered via the cloud.

- Google of course offers Google Apps, which includes Mail, Docs, Groups, Sites, and Video. Who hasn’t used one of the Google offerings?

- DocStoc launched an “iTunes style” online store. Slideshare is another “document sharing” service.

- VMware entered the marked with the Zimbra Collaboration Suite.

- Rackspace and Amazon are just two popular companies battling to gain customers in the ‘cloud’ storage market. Rackspace has a great site if you’re looking for general information on cloud computing.

- IBM is offereing Infosphere, an analytics solution designed to integrated and analyze data from multiple healthcare sources.

- Not to be outdone by IBM, Oracle unveiled Oracle Clinical Development Analytics for life science.

- Earlier this year Fujitsu launched tsClinical, a SaaS based solution designed to support clinical drug trials.

- Humedica offers a clinical informatics platform similar to IBM Infosphere.

- Pharmacy OneSource offers several SaaS products including a clinical servellance tool (Sentri7), intervention tracking (Quantifi) and pediatric dosage software (Accupedia) among others.

- Practice Fusion has been gaining ground with their web-based electronic health record software.

The explosion of cloud based products is consistent with job trends over the past several years (image below). Someone thinks this stuff is a good idea.

Pharmacy is standing on the edge of opportunity to do something special here. We can build a foundation for healthcare that will live far into the future. Gone are the days when proprietary desktop software is the norm. Slow development cycles, the inability to be flexible and costly upgrades and support services are turning companies offering traditional software models into forgettable entities. It’s time to investigate technologies that will provide pharmacists with the information they need in a timely manner on any device from any place in the world. Just a thought.

SaaS is different than the traditional enterprise software model because the provider of the software licenses it to the customer as an on-demand service. The vendor often times hosts the software on their own servers where data is manipulated and returned to the customer for viewing. It’s kind of like renting software.

The beauty of SaaS applications like those from Pharmacy OneSource are that they can be viewed from any device with a web-enabled browser; Mac, PC, smartphone, etc. In addition, the application is owned, delivered, maintained and managed by the provider, limiting the burden on the customer. A by-product of this model is that delivery of the application over the web ensures that the software is always up to date.

The SaaS model appears to be popular in the “business” world at present, but is increasing in popularity in healthcare secondary to its simplified deployment and reduced cost. With advances in cloud computing strategy, better data storage models and faster internet connections I think it’s only a matter of time before we start to see more SaaS solutions in pharmacy practice. And why shouldn’t we? By their very nature SaaS applications lend themselves to use on mobile devices like the tablet PC and iPad, which in turn offers greater flexibility for pharmacists practicing at the bedside. Just a thought.

– This actually makes perfect sense to me. One issue that often comes up when discussing a cloud environment, besides access to data, is speed. We have started using thin clients here at the hospital in place of desktop machines, and there is little doubt that performance has suffered. With the option discussed in the article above, data would move quickly between you and the local environment while in use, but slowly moved into the cloud in the background. I like it.