From I.T. publisher TechTarget: "Cloud computing is a general term for anything that involves delivering hosted services over the Internet.

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1 Before cloud computing, there was software-as-a-service computing, which was a lot like its predecessor the application service provider model, which bore many similarities to remotely-hosted apps, which was akin to its predecessor, Web-based computing. So, what is cloud computing? Definitions, often wrapped in marketing lingo, are flying all over the Net, and while they don't clearly define cloud computing and what makes it different, they sure make it sound good. From IBM: "Cloud computing changes the way we think about technology. Cloud is a computing model providing Web-based software, middleware and computing resources on demand." From Greenway Medical Technologies' explanation of its new cloud-based electronic health records hosting service from Dell Inc.: "Dell's cloud-based health information technology solutions simplify information, access, management and archiving for medical professionals and health care organizations." From research firm HealthCare Performance Management Institute of Bethesda, Md.: "Cloud computing enables on-demand network access to a shared pool of configurable technology resources (such as networks, servers, storage, applications and services)." From I.T. publisher TechTarget: "Cloud computing is a general term for anything that involves delivering hosted services over the Internet." However, a cloud service has three distinct characteristics that differentiate it from traditional hosting, the definition adds. "It is sold on demand, typically by the minute or the hour; it is elastic-a user can have as much or as little of a service as they want at any given time; and the service is fully managed by the provider (the consumer needs nothing but a personal computer and Internet access)." TechTarget takes a shot at differentiating cloud computing from previous iterations of Internet-based hosting, but some users of what's being termed "cloud computing" pay for the service not by time, but by transaction, such as per diagnostic imaging study. That brings us back to square one, searching for what really makes cloud computing different. Defining moment David Canellos is CEO at PerspecSys Inc., a cloud computing security vendor. But even he has a degree of difficulty separating the cloud from other hosting mechanisms. For instance, he was using itunes years ago, but considers it a cloud application. "Cloud is delivery of service over the Internet," Canellos says. "To me, if you've got a hosted service and Internet through a browser, that's the cloud. Facebook and Gmail are cloud. What's the difference between Google mail and Yahoo! Mail that we've had for years?" The difference, he believes, is evolutionary. Canellos and other cloud computing users generally agree that the fundamental difference from past hosting iterations is that the cloud is the next-generation version that

2 can take more advantage of the maturity of the Internet and its now-widespread broadband and wireless connectivity, Canellos says. "Technology is more advanced, apps are richer and there are more devices to access apps. The term 'cloud' reflects the ubiquitous and mature level of today's Internet in our personal and professional lives." The cloud is more sophisticated technology than its predecessors, says Greg Feld, director of the cardiac electrophysiology department at UC San Diego Health System. He's also the founder and a board member of Perminova, vendor of a cloud-based cardiac surgical information system, which is used at UC San Diego. Feld has used application service provider model and SaaS-hosted information systems, and says cloud systems truly are next generation. With older hosting arrangements, users often had to refresh screens when moving to another search or function. And, ASP or SaaS vendors didn't always monitor their infrastructure performance and add servers before issues arose, whereas cloud vendors are better at continuously observing capacity and correcting as needed, Feld says. Cloud vendors also can pull data from multiple systems and present it in a similar format. A consistent look and feel of a cloud system is a big difference to clinicians, Feld says. He estimates only 10 to 15 percent of hospitals have some type of cloud system, but expects the technology to be very common within five years. Perminova is a relatively new vendor with two clients, UC San Diego and Mount Sinai Hospital in New York. It's just better? Gerald Harmon, M.D., a primary care physician and medical director at Greenville, S.C.-based Palmetto Physician Connections, a Medicaid plan, doesn't know if cloud computing is fundamentally different, but it's clearly more accessible than earlier hosting arrangements. "From a user standpoint, I find it easier than it was two or three years ago. Connections are more stable, the service is faster and it's more secure." Palmetto uses cloud-hosted case, utilization and disease management software from MedHok Healthcare Solutions LLC of Tampa, Fla. Harmon can run reports identifying patients with a particular medical condition, such as asthma. Applying analytics He then can apply the vendor's analytics software against pharmacy and emergency department data to find high-risk patients who have been emergency departments more than twice in a year or fill more than four prescriptions, and target these patients for specialized prevention and treatment programs. The search engine is fast, Harmon says. "I type in diseases and patients pop right up, almost in real-time." Further, the software is more user-friendly. He previously used data management software that was slow, required users to crunch the data themselves, and then figure out how to use the information. Consequently, Harmon views what he has now as a cloud-based service that is superior to what previously was available. "It's like getting time on an IBM mainframe in the old days."

3 But with off-site hosting of information systems comes some discomfort with not having those systems on the premises. "If I don't have an Internet connection, I'm dead in the water," he notes. "All our data is off site and that makes us nervous. We haven't has an outage, but the potential is there." Robust debates That's why as Harmon's 12-physician practice is preparing to select an electronic health records system, the physicians are in a "robust" debate about whether the EHR should be on-site or cloud-hosted. Harmon's OK with the cloud system as long as the hosting servers are in the United States and the data therefore is managed under U.S. laws. But he does face a generation gap: some older colleagues are balking at a hosted system, even if a standalone EHR would be pricier and require hiring an I.T. staffer. Recently, "we've had more meetings on I.T. than on how to treat disease," he says. Rick Perez, administrative director of radiology at Winthrop-University Hospital in Mineola, N.Y., has his own idea of what cloud computing is. If nothing else, the cloud makes accessing applications a little easier, he says. To get to hosted applications, he previously entered user names and passwords into the hospital's intranet, the virtual private network and then the application. With a new picture archiving and communication system being installed that vendor Carestream Health will host via the cloud, one username and password via a dedicated VPN gets him in the system. But there are larger business-related differences in cloud computing, as well, Perez notes. With previous hosting arrangements, providers may have to pay for upgrades, or had a specific number of licenses for users. The cloud-based PACS comes with a site license and a pay-by-the-study financing arrangement. There also is an "openness" to cloud computing that enables support for features that previous hosting iterations didn't have, Perez adds. For instance, to have 3-D viewing of images, radiologists with the hospital's legacy PACS have to log into a specific server. Now, 3-D support will be inherent in the new system, which also will provide full access to PACS functions at home and via mobile devices. "You may not be able to enter data from certain mobile devices but you can access it," Perez says. "I'm sure that will change over time as everything else changes." Still, cloud computing is new for the radiology department and while Perez is confident the technology is ready for prime time and the uptime guarantees sound good, it's still unknown how well it will work. "It performs well under testing, but how will it work under a full load?" Merge and cloud Medical imaging software vendor Merge Healthcare in late 2011 introduced the first phase of its new cloud-based hosting service.

4 Launched at the annual Radiological Society of North America conference in Chicago, the service, called Honeycomb, initially enables providers and patients to access their images and reports, which are sent to patients via a Merge-provided personal health record. Later in 2012 will come a disaster recovery service where a second copy of the data will be hosted in an alternative location. Dell Inc. is the hosting vendor for Honeycomb. Merge CEO Jeff Surges previously led Extended Care Information Network, which offered a database that held hospital census data and directories of post-acute care facilities, enabling hospital discharge planners and social workers to search for and communicate with long-term and extended care services in their regions. Allscripts bought the company in ECIN used the application service provider computing model, Surges says. "If you toured our data center, there was nothing there. You had to drive to SunGard, which hosted the database." It's fundamental He says the computing model was an ASP because ECIN set up point-to-point connections with the proprietary database and an interface engine. Cloud computing is fundamentally different, he adds, because all entities access the same centralized source. There are good and bad aspects of adopting a technology that is relatively new to health care, Surges cautions. Cloud-hosted medical images and reports will be important in helping providers achieve later stages of electronic health records meaningful use compliance as patient engagement measures become more pronounced. That should increase provider interest in the service as they won't face the daunting tasks of managing terabytes or petabytes of imaging data, or the resulting cost pressures, if they outsource the storage and retrieval. The bad side: Any applications used for diagnostic purposes need Food and Drug Administration approval, which can cause delays before bringing them to market. Seeking Security in the Cloud There are 18 identifiers in a patient record that need to be protected, says David Canellos, CEO at PerspecSys inc., a Bolton, Ontario-based cloud computing security vendor. And if that record is in a cloud computing system, health care organizations don't have the same control of the data than if it was in their own network on their own premises. PerspecSys sells software that segregates sensitive data, keeping it out of applications hosted via the cloud. it houses that data on an organization's network so it never leaves the premises. What remains in the cloudhosted applications are "replacement values" or dummy data, either encrypted values or tokens--a randomly generated value. A proxy server translates requests for data. So, a provider would request John Smith's Social Security number from a cloud-based record and the value for that number, XYZ, is a reference point that is transmitted to a PerspecSys server behind the organization's firewall, which then translates XYZ to the SSN and pulls the number. PerspecSys serves multiple industries and expects nearly 20 percent of revenue to come from health care by the end of 2012, compared with five percent a year ago. providers and payers, Canellos advises, need to understand some issues with data control that cloud computing users in other industries have experienced.

5 Some cloud customers have found it difficult to change vendors because the incumbent is holding their data hostage, so ensure that contact language clearly gives data ownership to the client organization. Further, data migration and abstraction tools in the cloud are not fully matured, so it can be tough to get all of your data with a high level of integrity if vendors are switched.