Cloud computing: Evolution of the species?

So I'm registering for the Gartner Web Innovation Summit, and I'm seeing two major, broad themes: Web 2.0 (which I understand) and Cloud Computing (which I don't).

From the look of things, everybody and their dog is "computing in the cloud"...except me. How did I get so far behind?

As I've studied up on the technology, I've been reminded of this classic (but obviously modified) drawing:




(I'm probably infringing someone's copyright, but I can't find out who the owner is...let me know if you find out.)

Here's how I see the (possible) evolution of application hosting (assuming that you manage your own servers):

1. Self-hosting
   Here, we get some Internet connectivity within our office space, grab some IP addresses, build some web servers, and announce ourselves to the world. When it's time to deploy or update the application, we sit on a stool in front of a keyboard and monitor and use an A/B switch to choose which server we want to work on.
2. Co-location (Phase 1)
   In this stage, we move our servers to a hosted environment, where the data center provides power and Internet connectivity. Aside from that, it all works the same: Every time a server needs to be refreshed, or the application needs to be deployed, someone drives to the data center, sits on a stool in front of a keyboard and monitor, etc.
3. Co-location (RDP)
   Now we're getting high tech: Instead of running to the data center all the time, we use RDP (if we're running Windows, or some equivalent technology if we're running something else) to hit our servers remotely. But we still own all of the equipment, and we have to get it in there somehow (perhaps using a 3rd-party IT resource).
4. Cloud computing
   Here's where it gets kind of...um...cloudy for me. Those nuts at Google, Amazon, and Microsoft (among others) are using virtualization on steroids to offer...well, heck, I don't know what! But instead of selling servers or hosting space, they're offering these funky units of computing time like "EC2 Compute Units". Wha...?

Is this where application hosting is going? The idea is pretty amazing: These huge players build megaservers that can host dozens or hundreds of virtual servers, and then they provision them out like web sites or SQL Server instances.

If your business suddenly doubles, you don't hop on a plane to install a bunch of blades in your data center. Instead, you fill out a form online asking for a bunch of EC2 Compute Units, then deploy your app. If traffic falls, you just decommission a few servers, and your invoice reflects the drop in usage.

Anyway, it's cool stuff. To be honest, I don't see AdvancedMD moving into this space any time soon, but it may be a fun spectator sport.

Who "owns" patient data?

One of the first hurdles that we had to clear as a SaaS company was the objection of providers who were accustomed to keeping their data within their offices. We called it "storing data in the broom closet", since in many offices the actual physical location of their server was no more secure than a utility closet. While the data was certainly NOT secure, it was accessible, or at least perceived as such.



In fact, there are many problems with that arrangement, among them:

• Dismal disaster recovery (DR) options. I once heard that 60% of magnetic tape backups are unusable, although that number may be high. More conservative estimates vary between 10% and 50%. Within medical offices, where there generally is no dedicated IT staff, I would lean toward the higher estimates.


• Lack of security. It would be easy for a disgruntled employee to unplug a few cables and carry the whole server out the door, or just bring in a laptop and wirelessly copy data from the server.


• Risk of physical damage. Hundreds of medical offices were devastated by Hurricane Katrina, for example, and permanently lost huge amounts of irreplaceable patient information.

So, over time, our customers have accepted the fact that they are better off letting AdvancedMD keep their data for them, as long as we provide methods (standard data exports, ODBC access, etc.) for them to get access to it.

Now doctors are being faced with more dispersal of patient information, in the form of electronic prescribing systems, RHIOs, HIEs, PHRs, etc. I'm not a doctor (obviously), but I have to believe that this new sharing of data is a little disconcerting for some.

In the Summer 2008 issue of JHIM, Richard D. Lang, EdD, writes in "Blurring the Lines: Who Owns the Medical Data Home?" (HIMSS membership required) about the very objection that we used to face, but applied in a slightly different way.

Dr. Lang says:

Healthcare IT is evolving from a physician-centric model to
a collection of disparate patient-centric applications where
all constituents contribute to a mélange of databases that
serve people and processes in many different ways. By electronically
diffusing the traditional patient record, this new model blurs
the long-established medical data home.

As a true SaaS company, AdvancedMD assumes ownership of the provider's physical data, even though conceptually the data remains the property of the provider. Similarly, if a practice contracts with a billing service, the lines of ownership become further blurred, as the billing service assumes ownership of whatever data it needs to effectively bill for the practice's services. In that scenario, the billing service contracts with AdvancedMD, not the providers, so we are an additional level removed from the actual healthcare practitioner.

For eight years, we've proven that this data model can work, and, in fact, it works extremely well. It almost seems natural that, over time, patient information will continue to be further dispersed among interested parties that play a role in the patient's care.

As a patient, I kind of like the idea of spreading my information around, as long as it's secure. The next time I need to see a PCP and can't even remember who I saw last, wouldn't it be great if my new doctor could access my medical history without me having to remember it?

I have to believe that AdvancedMD's customers are better prepared for this "brave new world" than those who are still stuck in their broom closets.