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Cloud adoption well underway but barriers exist

Monday, 3 December 2018  
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Picture: Healthcare Holdings Ltd head of digital health Lloyd McCann (see below). editor Rebecca McBeth asked the country’s 20 DHBs what cloud services they are using for non-clinical and clinical data, whether they have plans to increase their use of cloud and what they see as the main barriers to cloud adoption in healthcare. editor Rebecca McBeth reports.


Cloud technology is supporting key clinical and non-clinical applications in New Zealand hospitals and all DHBs have plans to increase their use of the cloud.


The Ministry of Health’s website says “the use of cloud or hosted services is a viable option for funders and providers of health and disability support services (health agencies) because of its cost and convenience.”


DHBs previously needed an exemption to use public cloud services, but in April 2017  the MoH reversed this policy, saying "the Ministry’s earlier concerns about the privacy and security of personal health information stored or processed offshore have been greatly allayed".


The Department of Internal Affairs is also working to accelerate the rate of cloud adoption by government agencies, saying it should be utilised in preference to traditional IT systems, and it has negotiated commercial agreements with public cloud services AWS, Microsoft, Oracle and HPE.


However, while there are many benefits to moving to hosted cloud services, barriers still remain.


Why the cloud?


Independent technology consultant in health, Alin Ungureanu, says that while many health providers say they are going to move to cloud hosted services, the real question they need to think about is why and what transformation is required?


“What outcome do you seek?” he asks.


For many the answer is financial, as moving to an operational opex cost model is seen as cheaper or as solving financial constraints. However, Ungureanu says cloud adoption is not simply an answer to a financial equation as it can and should deliver many other benefits.


Chief among these is the ability to manipulate data in a way that would require huge resource and capital investment if it weren’t in the cloud. There are also benefits around availability and security.


“The main barrier to cloud adoption is that there isn’t a true understanding of what cloud really means, and because of that there is no true understanding of how it can be used and the benefits it can deliver,” says Ungureanu.


Data security asked all 20 district health boards what they see as the main barriers to cloud adoption in health. A key issue cited is the need to protect the sensitive data they hold.


Legislation, and a lack of accredited clinical cloud providers – vendors approved for patient identifiable data – is also a challenge, some say.


“Security and risk assessment to comply with needs and policies, such as privacy, patient data, locality/data sovereignty/security of information at transit and rest on a case-by-case basis can be a timely and resource heavy process,” says MidCentral DHB’s response.


Canterbury DHB cites the need to ensure, “that we continue meet our social, cultural and legal commitments to protect the information we hold on behalf of our community”.


Other DHBs talk about the responsibility of data governance and stewardship, and safeguarding sensitive information.


Cabinet has directed agencies to comply with the Protective Security Requirements (PSR), which classify all health data as ‘in confidence’.


They are also guided to comply with the New Zealand Information Security Manual (NZISM), which sets security controls that must or should be applied to information considered classified ‘in confidence’.


New Zealand has IAAS providers that are certified as being compliant for health data, such as Revera, Datacom and IBM.


Ungureanu says that should be sufficient, “but there are issues around cost and because of those issues, everyone comes up with excuses around legislation etc.”.


He believes the true benefits of cloud technology come with the adoption of a hybrid approach that uses global cloud solutions to utilise the economy of scale of the public cloud, and local solutions to ensure survivability of applications and data during a large-scale event.


Typically, the public cloud offerings are all hosted outside New Zealand. However, the sensitive nature of health data and legislative requirements in New Zealand mean many organisations prefer to use a local provider as this is perceived as keeping the data under their control.


Assessing the threat


Lloyd McCann is head of digital health at Healthcare Holdings Ltd, which earlier this year signed a contract with InterSystems to implement its TrakCare Electronic Medical Record system and with New Zealand-based cloud computing company Umbrellar for hosting on Microsoft Azure.


Once deployed it will be New Zealand’s first fully cloud-hosted EMR.


As part of the organisation’s cost benefit analysis for moving to the cloud, McCann says they looked at the cost of securing its data to a similar standard as Umbrellar/Microsoft and other providers’ offers and concluded they would need to employ at least two security specialists to offer a similar level of capability.


He says data is just as susceptible to attack whether it is kept onsite or in the cloud.


“There are hundreds of evolving cyber-threats and we decided it pays to have someone whose core business is to secure data, where you need to be up with the play as much as possible,” says McCann.


Ungureanu says the security necessary for health data is the same nationwide and he believes a national solution would make sense in a country of four million people, rather than 20 DHBs all coming up with their own solutions and processes.


“The threats to healthcare data are the same countrywide, with the vulnerabilities varying by DHB based on the technologies and systems they use,” he says.


“It doesn’t matter where my data is, it requires the same level of protection. It’s irrelevant to me if it gets compromised at a specific DHB or at a national level or by a private provider.


“A lack of understanding and skills and constraint of funding leads to taking some risky and arbitrary decisions as opposed to being able to enable outcomes required in health, such as sharing information and enabling clinicians to see the data required to take decisions.”




The costs associated with the different commercial models for cloud services also feature highly when it comes to barriers cited by the DHBs.


Traditionally ICT is capital funded and cloud hosting means moving to an opex model, with potentially high service establishment and transition costs. Enabling environments to be cloud-ready is also an expensive business.


“Health is a resource-constrained sector with competing demands for capital investment and a history of delayed replacements. Moving to subscription-based models will speed up investment, but this comes with increased operational costs,” says one DHB.


McCann believes people need to get more creative about how to fund these types of projects.


“The traditional funding model for many providers has been heavy upfront investment (generally capex) and then hefty maintenance and support contracts,” says McCann.


“Just because we have done something in one way for long periods of time doesn’t mean we can’t do things differently now, particularly when many of the organisations we’re now partnering with and consuming services from have a smorgasbord of different approaches we could potentially exploit.”


Legacy systems


New Zealand DHBs have massive technology debt, with a reliance on legacy systems that are generally not cloud-native, as well as ageing infrastructure.


This issue of current systems not being cloud-ready is a key barrier for DHBs.


“Existing vendor roadmaps for current clinical systems do not include a SaaS cloud operating model in the near- or mid-term vision. They are either on their long-term horizon or yet to be planned,” says one DHB.


Ungureanu says that while moving to the cloud can be cheaper than replacing infrastructure, if the systems are not cloud-native the true benefits are not realised with the move.


“The transformation required to move to native cloud services is huge, but that’s not required if you just move like for like,” says Ungureanu.


McCann acknowledges the issue of legacy systems not being cloud-ready is a problem, especially in the Auckland region where more than 1600 applications are being used in healthcare. He says this is why the hybrid approach is likely to remain prevalent in healthcare.


Organisations may choose to move most of their strategic and critical applications into the cloud and keep others onsite if the technology is not cloud-ready or there is a compelling reason to do so.


“That’s likely to be where most healthcare providers will end up,” he says.


He says some organisations in the US that moved applications to the cloud are now pulling some back to onsite arrangements, though these still tend to leverage private cloud approaches.


“We have to assess each individual use case on its own merits and decide on the best environment or approach, but we are light on capability to do this in health,” McCann says.


Resource and capability


DHBs need to balance the migration effort to cloud infrastructure alongside the provision of business as usual and other system enhancement activities. Resource capability in this area is another issue.

McCann says, “This type of resource or capability is not easy to find, so a key lesson is that we need to engage with and be prepared to pay for the required skills and resources early on in our projects”.


Ungureanu says innovation comes from use of the data, not simply moving it to the cloud.


“The transformation process is not just about the infrastructure, but the consumption of those new capabilities. You need smart people to be able to access and manipulate the data,” he says.


“The business cases are to replace the infrastructure, whether cloud or not cloud, but they should focus on the transformation.”


However, he says the DHBs are doing the best they can with the little money they have as the vast majority is going towards just “keeping the lights on”.


“The business must continue to operate and this is not a small task while you need to replace or transform your technology.”


Embracing risk


McCann says it is probably easier for MercyAscot to move all clinical data to the cloud because the organisation is implementing an entirely new PAS/EMR.


“But that shouldn’t deter organisations from looking to adopt this approach – you have to apply the business case model to it,” he argues.


This includes looking at cost and strategic benefits such as enhanced security and reliability.


“We (the sector) have got to increase our appetite for risk,” McCann tells


“There’s risk, but you have to put that into context that risk already exists and exists with our largely paper-based environments.


“We need to advance the conversation on how we manage risk as providers and funders and, most importantly, ensure we have the public/consumer voice in the discussion as well.


“It’s a shift, but we have to recognise the current system is imperfect as it is, so we have to be realistic about new risks and manage them appropriately.”

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