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 of computers. 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 the country, 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 hospitals associated 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 among the 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 providers of 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 cloud computing 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 staff and 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 expected to cater the needs of the state for the State of Rajasthan, Government of National Capital Territory
Proceedings of ASCNT-2011, CDAC, Noida, India, pp

Praveen Srivastava, Rajiv Yadav, Priti Razdan

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 build separate 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 like Patient 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 from the 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 early detection 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 of communication 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 their roles 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 of redundancy, 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 can seamlessly be integrated into this structure. Each DC will become one node of the VPN. This will facilitate better redundancy and availability.

Praveen Srivastava, Rajiv Yadav, Priti Razdan

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.
20 Ft

AC 3 ton

Server & Network Racks

FT PP

10 FT

20 Ft 10 Ft PP

10 FT

FMS/ Resource Room

10 FT

3 D

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 physical layout 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.

Praveen Srivastava, Rajiv Yadav, Priti Razdan

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). During normal 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 critical function 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 to roll 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 get reduced 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 technological infrastructure 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 comes about through improved resource utilization, and more efficient systems. For smaller hospitals and physician practices, in particular, cloud-based applications can be extremely 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-level encryption 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 be easily 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,

Praveen Srivastava, Rajiv Yadav, Priti Razdan

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 the patient 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 the remote 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. Conclusion There is a tremendous promise for cloud computing infrastructure in the healthcare industry and is an 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 IT resources 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 of ASCNT -10, March 2010 [2] Rajiv Yadav, S. Rajasree, Implementation of HMIS 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 Zinnov Management 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 of Government as well as Super specialty Indian hospitals. She is currently pursuing M.Tech-CSE from Amity University, UP.