Health-1.Cloud Computing in Indian Healthcare Sector

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Proceedings of ASCNT-2011, CDAC, Noida, India, pp

Cloud Computing in Indian Healthcare Sector

Praveen Srivastava, Rajiv Yadav, Priti Razdan

Abstract

The term Cloud Computing used to denote the use of cloud or internet based computers for variety

of services. As definitions evolved and got refined, Cloud Computing now implies the user

experience moving away from in-house data centers into remote applications running in a cloud ofcomputers. Users of the cloud are not concerned with the inner workings of the remote application

and only see and use the services being requested, without control of the technology

infrastructure to make it happen. This provides a great opportunity for the healthcare sector in thecountry, since one of the main deterrents to IT adoption in this sector has been the high upfront cost.

CDAC, Noida has taken an initiative to resolve this by moving its well established e-Sushrut

Hospital Management Information System (HMIS) into the cloud computing architecture. We are

now in the process of rolling this out in seventeen district hospitals in Rajasthan, five hospitalsassociated with SMS Medical College in Jaipur, Regional Institute of Medical Sciences in Imphal,

and GGS Govt. Hospital in Delhi. This paper presents the architecture and implementation of this

system and discusses its strengths and weaknesses.

Key Words: Cloud Computing, Healthcare, Electronic Health Record (EHR), HMIS

1. Introduction

The technical foundations of Cloud Computing include Service-Oriented Architecture (SOA) and

Virtualizations of hardware and software. The goal of Cloud Computing is to share resources amongthe cloud service consumers, cloud partners, and cloud vendors in the cloud value chain. Cloud

Computing is likely to benefit a number of sectors and health being one of them. In a cloud

computing scenario, the beneficiary (hospital) would use the HMIS as a Service and does not need to

undergo the challenges posed by technology, administration and implementation in computerization.The focus of the beneficiary just needs to be the service, which is available on demand.

Technologically challenging tasks of designing, implementing and maintaining a Data

Center/Server, Databases, and Application etc are all eliminated and is left to such service providersof IT industry. The remote Data centre(s) maintained by an HMIS solution provider would host the

Application for the hospital and maintain the same. This would literally provide HMIS solution as a

service and not as a system to be maintained by the hospital.

With healthcare providers looking at automating processes at lower cost and higher gains cloudcomputing can act as an ideal platform in the healthcare IT space. A number of hospitals could share

infrastructure with large number of systems linked together. By this pooling the hospitals

automatically reduce the cost and increase utilization. The resources are delivered only when they

are required. This also means real-time availability of patient information for doctors, nursing staffand other support services personnel from any internet enabled device.

Considering the above, we are presently working on the e-Shushrut HMIS solution, currently

working in the Post Graduate Institute of Medical Educ ation and Research, Chandigarh into a

version suitable for offering as a cloud computing solution (Megh Shushrut or MS). This is expectedto cater the needs of the state for the State of Rajasthan, Government of National Capital Territory


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Delhi and North Eastern States, in the very near future. The proposed HMIS implementation in these

cases is planned to be state wide and there is a general realization that it will be very costly to buildseparate hardware and software infrastructure in all the hospitals across the state.

MS is proposed to be launched as Software as a Service (SaaS) model where different modules likePatient Registration, Out Patient Management, In Patient Management, Patient Billing, Laboratory

Information System and EMR are deployed as service. MS itself, will be is running on the

Centralized Data Center provided by state. In case the state data centre is not ready, it can run fromthe data centre maintained by CDAC. This data centre can act as a disaster centre for the State Data

Centre as well.

The Application has been configured so that each hospital can have access to their data. In that way

patient EHR is being maintained at the centralized data center. Various reports can be generated

from the combined data of all the hospitals from State Data Center. This will be very useful in earlydetection of communicable disease like Swine Flu, Dengu etc; spreading across the state.

This paper presents the architecture and implementation details of MS. It is organized as follows.Section 2 describes the architectural set up at the data centre. Section 3 gives the connectivity plan

between any hospital and the centralized server. Section 4 gives the typical computing and

connectivity requirements in the hospital. Section 5 describes the fail-over system, in case ofcommunication failure.

2. Architecture/ Setup at Centralized Data Center

The requirement of the Centralized Data center is to create secure, state-of-art facility to store the data /

information available in different hospitals and to provide access to users in a secured manner, as per theirroles and privileges.

The key envisaged features are

Highly secured state-of-art Data center.

Highly secured and fast data transfer/ transaction between hospitals and repository.

Consolidation of data from different hospitals.

Analysis and verification of consolidated data.

Defining Unified Identity Management, controlling logical and physical access.

Uniform IT security and governance policy.

Secured access of data as per pre-defined privileges and roles.

Fig 1 gives the architecture of the Centralized Data Centre. It consists of:

Server Farm, Network Services, Databases, SAN storage Area.

Computing and network infrastructure (cabling, fiber, and electronics).A communication room where all WAN equipments are kept and fiber terminated.

Environmental control and HVAC systems.

Fire Detection and Suppression systems.


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Power distribution, generation and conditioning systems - Uninterruptible Power

Supplies, generators.Physical security and access control prevention, allowance, and logging.

Housing all critical ICT infrastructure and applications under a unified and secured

environment.Network Operating and Control Center (NOCC) for enterprise management.

Figure 1: Architecture of Centralized Data Centre of MS

3. Connectivity between Hospital and the Server

The connectivity between the central server and the hospitals is one of the major components of the

MS architecture. Fig 2 gives structure of this. A Virtual Private network (VPN) is established

between all hospitals and the data centre using physical network links between them. This is

achieved by sourcing the services from an Internet Service Provider (ISP). For the purpose ofredundancy, services from multiple ISPs could be sourced as shown in the figure.

When multiple data centers could be connected (e.g., the SDC and the CDAC Data Centre), they canseamlessly be integrated into this structure. Each DC will become one node of the VPN. This will

facilitate better redundancy and availability.


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Figure 2: Connectivity between Data Centre and Hospital

4. Connectivity and Computing Infrastructure at the Hospital

Fig 3 gives the typical connectivity and computing infrastructure in a hospital. 3(a) gives the

facilities required at the local data centre and 3(b) gives the structure of the hospital LAN.

AC 3 ton

10 Ft

W

D

`

10 FT

1 2 3

PP

PP

Server & Network Racks

FT

FMS/

Resource

Room

10

FT

10 FT

20 Ft

20 Ft

D=Door

W=Window

Fig 3(a): Typical Layout of Local Server Room at the Hospital


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It consists of

Servers, Rack, Network Services, Databases.

Computing and Network infrastructure (cabling, fiber, and electronics).

A communication room, where all fibers are terminated.Fire Detection and Suppression systems, Access control System.

Power distribution, generation and Air conditioning systems - Uninterruptible Power

Supplies, generators along with a Resource Room for FMS Services,Network Operating, Monitoring and Control Center.

Fig 3(b) gives the structure of the typical hospital LAN. Note that depending upon the physicallayout of the hospital, substantial amount of CAT-6 cabling might be required. The computing

infrastructure at the hospital will typically consist of thin clients, printers, bar code readers, etc.


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Fig 3(b): Typical Network Layout in the Hospital

5. Fail over system in case of communication failure

One of the major difficulties in implementation of a remote computing solution in a hospital is the

possibility of failure of the communication link between the hospital and the remote Data Centre.

The corresponding loss of service would cripple the critical functions within the hospital.

MS takes care of this by providing two local servers in the hospital as indicated in Fig 3(a). Duringnormal operations, they act as a backup store of critical data base tables at the central server. This is

achieved by a low priority DEMON process that runs between the systems synchronizing the


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updations of the critical tables in the DBMS at the central server. In case of a communication failure,

a downgraded version of MS, which provides the same look and feel functionality of the criticalfunction is initiated from the application server in the local data centre. This will be powerful enough

to handle all the critical operational functions in the hospital, till the connection is re-established. At

this time, the Tables are again re-synchronized and the system is switched back to the remote server.

6. Advantages

The use of cloud computing solutions like MS will help in eliminating the time and efforts needed toroll a healthcare IT application in a hospital. It will help in standardizing the infrastructure for

healthcare IT solutions in contrast with the current highly diversified scenario. It ensures availability

of hardware with high end servers, huge data stores, bulk licenses and cost-effective utilizations of

infrastructure for the health sector. The investment costs are distributed across hospitals and thus getreduced for each hospital. Service Provider take over the headache of patching, upgrading, fixing,

scaling, software and hardware and managing data security and backup.

Cloud can allow providers to focus less on managing IT and more on delivering better care. It can,for instance, be used to migrate e-mail, collaboration and other traditional applications also into the

web. It can also be used to share information seamlessly and in near-real-time across devices and

other organizations.

Agility improves with users able to rapidly and inexpensively re-provision technologicalinfrastructure resources. An additional benefit of cloud computing is that the Peak-load capacity

increases. Reliability improves through the use of multiple redundant sites, which makes it suitable

for business continuity and disaster recovery.

Security is often as good as or better than traditional systems, in part because providers are able to

devote resources to solving security issues that many customers cannot afford. Sustainability comesabout through improved resource utilization, and more efficient systems.

For smaller hospitals and physician practices, in particular, cloud-based applications can beextremely cost-effective. These organizations typically dont have the IT staff, required to support

new technologies; and the cloud removes the burden of hiring internal IT staff to maintain and

service in-house infrastructure for mission-critical applications, such as email. In the cloud model,

providers only pay for what they use.

The EMR which is a crucial part of the HMIS is data storage intensive. Compared to locally-housed

resources, cloud services typically improves security because SaaS providers will be able to devote

resources to solving security issues that many customers cannot afford. By implementing high-levelencryption across connections, as well as housing the data in a dis-aggregated and encrypted

structure, the cloud implements all the security requirements. Access to medical data is tightly

controlled.

A patients EHR data might be shared between practices taking care of that patient. This can beeasily achieved by having the SaaS model in place. With the cloud hosted EMR, the government and

the medical fraternity will be able to have access to state wide medical information of the people,
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across the country. This facilitates analysis of the patterns of illness and mitigation plans. The

medical fraternity can also utilize the data to improve the medical methodology.

Laboratory results forms a crucial part of the patient treatment. Using cloud the patients laboratory

data can be centrally stored and shared between practitioners taking care of that patient and thepatient directly.

7. Disadvantages

Security is one of the main concerns of Cloud Computing. This makes it necessary to maintain a

secure, safe, and authorized environment for the prevention of information leakage.

Another drawback with Cloud Computing approach is, that at the end user loses control over theremote servers, their software, or their security factors. A huge amount of data gets accumulated in

these central servers over the years and it may eventually be difficult (or even impossible) to migrate

massive amounts of data from the provider.

8. ConclusionThere is a tremendous promise for cloud computing infrastructure in the healthcare industry and isan ideal tool to leverage computing power at low cost. Cloud computing would help hospitals to

achieve more efficient use of their hardware and software investments and to increase profitability

by improving the utilization of resources to the maximum. By pooling the various healthcare ITresources into large clouds, hospitals can reduce the cost and increase utilization as the resources are

delivered only, when they are required. Cloud computing will serve as the foundation for much of

the work in areas, such as record sharing, analysis, and diagnostics. The cloud computing model is

suited to healthcare applications due to the volume of dynamic and diverse sources of information.Cloud computing can help clinicians and hospitals to coordinate and exchange information more

efficiently. The use of cloud computing architecture helps in eliminating the time and efforts, needed

to roll a healthcare IT application in a hospital.

9. Acknowledgement

This paper is based on the Arogya Online Project sponsored by RHSDP, NRHM and RajCOMP in

Rajasthan. We are grateful to them for providing us an opportunity to convert this idea into an

implementation. Variations of the system are now being implemented in GGS Hospital in Delhi and

RIMS, Imphal. We are grateful to them as well. We are grateful to all team members concerned for

their timely help and encouragement towards the development and Implementation of HMIS under

cloud model.

9.0 References

[1] B.S. Bedi, S. Rajasree, P.K. Srivastava, HIMS Solutions in Government Sector- Opportunities and

Challenges, Proceedings ofASCNT -10, March 2010[2] Rajiv Yadav, S. Rajasree, Implementation ofHMIS Using State Data Centre, Proceedings of ASCNT -09,March 2009[3]Snevely, Rob, Enterprise Data Centre Design and Methodology, Sun Microsystems,

Prentice Hall, 2002

[4]Cloud Computing: An enabler of IT in Indian Healthcare Sector. Study Report by ZinnovManagement consulting


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[6]Cloud Computing in Healthcare, E.Sujith http://www.frost.com (L.A on 11-03-2011)

10.0 About Authors

Mr. Praveen Srivastava (Sr. Project Manager) currently is working with Health

Informatics Group of CDAC Noida. He has 17 years of IT Experience, out of which 10 years in Health

Informatics domain. He is closely involved in Design and Development of e-Shushrut HIMS Software of CDAC

Noida. MCA from Madan Mohan Malviya Engg College, Gorakhpur, he is also topper of M.Sc (Maths) from

Allahabad University.

Mr. Rajiv Yadav has graduated in Computer Science & Engineering from

Marathwada University Aurangabad (Maharashtra) in 1995. He has also completed his Diploma in Advanced

Computing from C-DAC. Since 1999, he has been associated with Centre for Development of Advanced

computing. In his career span of more than a decade, he has had the opportunity to serve in various group

of CDAC, Presently he is associated with the Health informatics group of CDAC & Managing the Health

Informatics Project in Government & Public Hospitals.

Ms. Priti Razdan has graduated in Electronics Engineering from Pune University

in the year 1994. Since 1997, she has been associated with the Health Informatics Group of C-DAC. In her

career span of more than a decade she has had the opportunity to be exposed to the in depth workflow ofGovernment as well as Super specialty Indian hospitals. She is currently pursuing M.Tech-CSE from Amity

University, UP.

Health-1.Cloud Computing in Indian Healthcare Sector

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