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vergence in your Enterprise,” David Linthicum describes categories of cloud computing technology. These categories go beyond the traditional software- as-a-service (SaaS) model. What follows is an analysis of how those categories could be applied to a cloud-computing-based, SOA-enabled HIE: Storage as a service:

Rey Currie is Lawson Software’s global director of product management. For more information on Lawson solutions:

This is the remote hosting of HIE data. Stored data within the cloud provides the elasticity of handling storage demands. A benefit here is the outsourcing of disaster recovery backups and restores. Storage takes the form of discrete data and clinical docu- ments created within the HIE framework. Management/governance as a service: Every

exchange will require some type of governance to provide rules of engagement, as well as service level agreements, for HIE participants. Establishing rules concerning service level agreements and consent to access to support the continuity of care between disparate healthcare organizations is a huge challenge to exchange participants and HIE makers. Application as a service: Applications that run on top of the HIE platform allow end users to consume the exchange data. Examples include Web-based clinical results viewers and tools to allow end users to use the exchange. Process as a service: These are the processes that drive the collaboration of the exchange. They include referral management, consent to access, and processes that facilitate collaboration between care providers. For example, HIE profiles can be implemented as a process as a service. Information as a service: Examples include pa- tient demographic information, patient insurance information, clinical results and historical data. This is enriched data that is consumed by applications and exchange processes. Information can take the form of a dashboard for C-level executives participating in the exchange, as well as clinical reports for meeting meaningful-use objectives. Integration as a service: Integration supports loosely coupled entities and applications to allow data sharing between care providers outside and inside healthcare organizations. Examples include the transformation, routing and logging of exchange data. Testing as a service: Whether local or in the cloud, testing is critical. This service includes testing for data validity for EMR interoperability, as well as data quality. Platform as a service: This is the foundation for

building upon the exchange to develop applications, interfaces and processes. It provides the tools to de- velop the exchange platform to run in the cloud. Infrastructure as a service: The infrastructure is just a data center that typically exists on premise but now resides in the cloud. It includes all of the tools to manage, administer and deploy the HIE. Security as a service: These are the tools and mechanisms to fulfill the requirements for HIPAA and ARRA security, including single sign-on, entity authentication, audit trails and encryption of per- sonal health information. Database as a service: This is the data hosting with access to database management tools, providing support for exchange-based clinical patient reposi- tories and warehouses, provider registries, patient registries and clinical document registries. In an SOA model, it is quite possible to have a confeder- ated architecture that allows some database services to reside within the cloud, with others on-premise at an exchange participant’s location.

Some risks to consider Although the benefits of SOA-enabled HIE are

many, there are risks to consider before running out and implementing a cloud-based exchange. In fact, the risks might outweigh the benefits of the cloud- based exchange strategy. At the very least, you need to be aware that:

Internet-based clouds are at risk to security vul- nerabilities. All of the bad things that you hear in the news about credit card hacking, Web site denials of service, identity theft and misuse of classified in- formation are all applicable in a cloud-based HIE. Not all the legacy applications are SOA enabled, which may lead to a higher cost of integration and support. Finally, the tight competition among healthcare entities may be a huge obstacle to collaborative data sharing and the integration of work flows.

Next steps

If you represent a healthcare organization con- sidering options for developing or connecting to an HIE, an SOA-based cloud-computing frame- work provides several advantages over traditional on-premise configurations. It is a viable option to proprietary, on-site alternatives. And it’s not an all-or-nothing deal. There are many architecture and implementation options available to you. Your best bet is to consider the risks and benefits, give careful consideration to what part of the HIE should live in the cloud, and start drafting your project implementation plan.


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