Short Paper Proc. of Int. Conf. on Advances of Information & Communication Technology in Health Care 2011
Impact of Cloud Computing and Open Source Software on Healthcare Imaging H. Derouiche1 and F. Bodendorf2 1
Chair of Information Systems II, University of Erlangen Nuremberg, Germany Email: Haithem.Derouiche@ wiso.uni-erlangen.de 2 Chair of Information Systems II, University of Erlangen Nuremberg, Germany Email: bodendorf@wiso.uni-erlangen.de
II. RELATED WORK OR LITERATURE STUDIES
Abstract— Cloud computing will gain a higher relevance in medical image processing. Increasing cost pressure for clinical units and new efficient methods will pave the way to hosted services for diagnostic image analysis. This will result in new business models provided also by new market players.
Actual studies related with the application of the cloud technology in the healthcare context are either analyzing the mobility aspect of such a deployment [6], the business aspect of patient-centric healthcare within the cloud [7] or the migration of current healthcare solution to the cloud like a PACS system (Picture Archiving and Communication System) [8] or a medical image archive hosted in the cloud [9]. None of the actual publications analyzes the impact of the cloud technology neither on the healthcare imaging market nor on the strategy and business of established big medical imaging companies.
Index Terms— Cloud, Healthcare, Imaging
I. INTRODUCTION The current major trends and developments in healthcare will introduce a short-term radical change. The steady competition and cost pressure moves the health care to become a challenging market. This will deeply impacts all participants like care provider, healthcare industry and the adjunctive IT-Fields. Healthcare imaging will be sustainably changed by reason of cloud computing, cloud storage, cloud collaboration and their new pay-per-X business models [1]. The shortage of the IT-Budgets in the healthcare sector will continue to increase. The technology research company Gartner calculates the costs of the IT comparatively to business volume of the healthcare worldwide with an average of 3.7% [2]. Investments in new IT technology and infrastructure are often put on hold in order to save money. This is one of the major reasons for the slow penetration of IT in healthcare. Indeed, the C-Level of the care provider, commercial and the IT unit agrees that IT should not only be considered from the cost perspective, the reality shows that the small investments are the second big hurdle after the missing interoperability of the systems[3]. An analysis made by the management consultants Alex & Gross show that the cost pressure and the drive to increase productivity lead to a negative impact on the IT-Budget of the healthcare provider [4] and therefore also influences directly the IT imaging market like the radiology. In parallel to these cost saving trends, the amount of healthcare information and images are increasing rapidly. The need for a personalized medicine and data exchange between all stakeholders in the care process, emphasis the demand for interoperability between the IT systems and the collaboration between different and complex clinical IT business processes [5]. One of the biggest hurdles for a fast technology adoption results from the RASP-requirement – Reliability, Availability, Security and Privacy. © 2011 ACEEE DOI: 02.ICTHC.2011.01. 3
III. MATERIALS AND METHODS A. Method The method used within this paper is based on the development patterns distilled from the evolution similarities of adjacent IT fields within the cloud context [10] and the development path of the OSS (Open Source Software) [11] as well as the relationship between the two types of developments. Linking both patterns and amending them with healthcare specific obstacles result in defining a new nonconventional approach to analyze the development pattern of healthcare imaging in the cloud computing context. The aim is to outline development similarities with a sustainable and proven pattern approach. This is a new methodology to simulate key changes in the healthcare domain in order to analyze the impact on the key stakeholders as well as on the market. The novel is based on the identification of key parameters and thereafter the application on healthcare imaging including the simulation of all pattern-related changes in a totally new domain using a well-proven approach. B. Materials To apply the method mentioned above, there is a need to set the corner stones and the characteristics of all involved topics to be able to quantify and to qualify the impact of cloud computing and OSS on healthcare imaging. - Characteristics of Medical imaging software: Medical Imaging enfolds image viewing/visualization and editing, image management, reporting and distribution. It assists the radiologist with indication specific workflows and smart algorithms to a better and faster diagnosis [12]. Anatomical and functional data are provided by interfaces to a wide range 173
Short Paper Proc. of Int. Conf. on Advances of Information & Communication Technology in Health Care 2011 of modalities like MR, CT and angiography systems. The Imaging-IT includes also the multi-dimensional rendering of the images and the automated reconstruction of anatomical structure as well as the computer aided detection and diagnosis – CAD. It uses different pattern recognition algorithms to support the radiologist by detecting hardly recognizable pathological regions of interests in organs and their surface [13]. - Capabilities of the cloud technology: Cloud computing is becoming more and more a disruptive trend in the software virtualization and data storage outsourcing area [14]. The data access occurs only via the internet regardless of the geographical location. Software is not anymore installed on the local infrastructure but accesses and executed on demand directly in the cloud [15]. The resource virtualization is one of the key elements of the cloud technology. Physical resources are dynamically pooled and can be mapped – if needed- to dedicated software. Consequently, medical providers are not anymore obliged to install and maintain huge hardware resources onsite which results in better resource usage and cost reduction and optimization. - Cloud computing as a Trend: The significance of cloud computing can be perceived from the current “challenges” in the IT market as well as from the big investments of Google, Microsoft, IBM and Amazon. These and other companies drive the development of cloud computing since years. Conventional computer loses more and more significance and are replaced by new flexible and dynamic “on-demand” infrastructures. The main drivers for this development are the cost reductions. Current fixed costs of the IT-departments can be turned into variable expenses. Companies do only pay for infrastructures per usage and therefore they can adjust their expenses to their current needs and save costs with higher flexibility. Software and Infrastructure installation, customizing and configuration are done with fewer efforts within the cloud. Customers can run all applications on their home computer and mobile devices without need for great computing power. Furthermore they can use their hardware for longer periods of time instead to follow the current hardware exchange cycles. Smaller hospitals and care provider can start using advanced healthcare it since the investment costs for software and hardware infrastructures are lower and the fix costs can be transformed in manageable running costs based on usage and resources. Cloud computing provides also a development platform where solution provider can develop and deploy dedicated and customer specific solutions without an on-site customizing and down-times. The variety of healthcare IT services based on customer’s specialty, size and workflow preferences can be combined as needed due to the cloud modular conception. - Cloud computing in healthcare: The adoption of IT in healthcare is restricted by means of high investment volumes and missing IT affinity. Consequently, cloud computing presents an interesting alternative for all healthcare institutions. By implementing all needed IT Hardware and © 2011 ACEEE DOI: 02.ICTHC.2011.01. 3
software in the cloud, the usage of advanced healthcare IT like medical Imaging become very simplified. The only prerequisite is a fast and secure internet connection. “Cloud computing is very attractive due to the fact that it hides the complexity of the technology from the users” [16]. Besides that, customers do not need to keep IT-administrators onsite since all the IT, with exception of the terminals and mobile devices, are virtualized. Each care provider can access his IT services using his credentials regardless of time and location.
Figure 1. Private and Public Cloud in Healthcare
Cloud computing enable the steady growing collaboration needs across all care providers. It replaces the current uncontrolled growth of complex networks and integration systems for a smoother and a more efficient cooperation. Data Security is one of the major discussed topics in this context since care provider apprehend the fact that their data are stored somewhere in the cloud and it can be accessed by non-authorized persons. Furthermore they are apprehend to give away the control of the own data. An approach to overcome all these concerns is private cloud. A private cloud proceeding can be made with a “healthcare” cloud with dedicated resources and restricted access where policies are created and controlled by the customers themselves. IV. DISCUSSON AND RESULTS A. Medical Imaging in the cloud Cloud based imaging; image processing and storage are in an early stage of a promising development in healthcare IT. Main reasons for the slow adoption of these technologies are the limited bandwidth of the networks and the old unsuitable investment models of the care providers. Nevertheless, the following should be considered: - The majority of the radiology reading use cases, a two dimensional images are sufficient for the radiologist and therefore small data amounts should be transferred. - eServices can be easier configured and customized in the cloud to customers’ requirements. Software updates and fixes can be done without any downtime. Healthcare IT running as eServices in the cloud can communicate without data loss due to better interoperability assured by the SOA (Service Orientated Architecture) and WOA (Web Oriented Architecture) paradigms. - Standardization of the image format based on DICOM (Digital Imaging and Communication in Medicine) is very advanced and can be handled by the majority of the healthcare IT 174
Short Paper Proc. of Int. Conf. on Advances of Information & Communication Technology in Health Care 2011 provider. - Care provider can book eServices “on-demand” and to unsubscribe from them when not anymore needed. - “Pay-per-use” business models allow the care provider to achieve a better and costs efficient investment strategy. - The market entry barrier for small healthcare IT provider is very low. Using the cloud eService market, new comers can offer their software with very competitive prices to the care provider. Looking to this in a worldwide scale, price erosion can be predicted. Cloud based image processing includes also the CAD (Computer Aided Detection). Medical images (i.e. Lung images from a computed tomography) are automatically analyzed after the acquisition from the scanner and potential findings (i.e. lung nodules) where market and shown to the radiologist. This is a very computationally intensive algorithm that suits the cloud computing and its huge computing power. Furthermore, a radiologist who uses CAD eServices does not require a real-time response for their request. A minor time gap is acceptable which qualifies CAD eServices also for a cloud computing deployment. Cloud storage for radiology images and other medical data provide a unified “enterprise-like” content and data management platform. The advantages of such a usage are: - Care providers have no need for their own onsite hardware for LTS (Long-time-Storage) which can grow to several terabytes depending from the local legislator. - Cloud based eServices and algorithms can access directly the data stored in the cloud without need for a time consuming data transfer. - Easy access to the data for statistical investigations and epidemiological analysis across all medical content. - Information and data migration between different cloud providers is much easier and can be done on-the-fly without any downtime for the clinical users. As open topic, the regulatory and data security questions should be clarified based on the local law and guidelines of each country where the care provider is working. Teleradiology, where radiologists are working across borders, shows that such topics are resolvable [17]. Beyond that, the data transfer speed marks a very important aspect as the size of medical data is in general very big. Nevertheless, between the year 2000 and 2010, the transfer speed has nearly being doubled each year. It can be assumed that this trend will be carried forward.
presented in their latest publication “Commercial Adoption of Open Source” the fact that the border between commercial software and OSS are becoming more and more blurry [19]. One of the major issues of the OSS- IT provider is the reachability of the customers and the building of a worldwide service organization like the commercial pedants [20]. “Aycan Digitalsysteme GmbH” represents one of the new companies that are specialized in medical imaging based on OSS. They adapt the OSS software like “Osirix” to get the CE-label (Communauté Européenne) and an FDA-Approval (US Food and Drug Administration). The second important simulation result is the offering of OSS based eServices in the cloud which facilitates for small companies such Aycan the acquisition of customers, to penetrate new markets without a huge service organization since their eServices are managed centrally in the cloud. Customers which are price sensitive consider such offers as a real alternative to the commercial healthcare software. Small and Medium sized DICs (Diagnostic Imaging Centers) have the biggest growth potential in the medical imaging market. Their radiologists pay for special applications huge sums even when these are used for very rare medical cases per year. On the other hand, these special applications present the items with the biggest margin for the IT companies in comparison to the normal applications which are subsidized and sold with a very competitive price [21]. Offering healthcare IT Services in the cloud will have a very big impact on the business models. Customers only pay the software per usage and get the latest updates without any additional payment. Customers can select which service to use from which company based on the quality/price ratio and are not constrained to buy medical imaging software ahead. This behavior will have an immediate influence on revenues of the current big players in healthcare IT. The third key result of the used methodology in this paper is distilled from the pattern results themselves which lead to a very new strategy in the healthcare context. It is the cooperation and the collaboration between research institutes and universities with the OSS companies. In comparison to the commercial companies with huge R&D resources, OSS companies cannot effort to spend big amounts for researchers to develop special software based on deep medical knowledge. Evidently they will extend the open source idea to provide open and extendable interfaces for plug-ins to allow the research institutes to develop the special eServices for their own research. On the other hand, these research institutes get an incentive and are paid directly from the care provider per use. This double strategy enhances in one hand the research budget of these institutes and helps them to share their knowledge across the globe and to get feedback; on the other hand, the OSS companies can rely on these plug-in’s to close the feature gap compared to their commercial pedants. The USP (unique selling proposition) of the established healthcare IT companies is becoming assailable and their market power is about to crumble. Nevertheless, there is no need to be afraid regarding the presence of the current big healthcare IT since their portfolio
B. Simulation results: Impacts on the healthcare market Applying the development patterns distilled from the evolution similarities of adjacent IT fields on the identified key parameters (potential of cloud technologies, reachability of OSS) results in a simulation of changes in the Healthcare Imaging market in the near future. The first simulation result is the considerable number of Healthcare IT provider which focuses more and more on commercial solutions which are built upon Open Source Software (OSS). Their data protection and security policies are approved by international known authorities [18]. The market research group 451Group © 2011 ACEEE DOI: 02.ICTHC.2011.01. 3
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Short Paper Proc. of Int. Conf. on Advances of Information & Communication Technology in Health Care 2011 is comprises besides the software also the scanner and other medical devices. It can be asserted that the new comers in the medical imaging market will results in a price dumping loop which will deeply impact the business models, the organization structure and the revenues of the established big players.
[6] C. Doukas, T. Pliakas, I. Maglogiannis, “Mobile healthcare information management utilizing Cloud Computing and Android OS”, Engineering in Medicine and Biology Society (EMBC), Annual International Conference of the IEEE. 2010. [7] Henry H. Chang, Paul B. Chou, S. Ramakrishnan, “An Ecosystem Approach for Healthcare Services Cloud,” icebe, pp.608612, 2009 IEEE International Conference on e-Business Engineering, 2009 [8] J. Philbin, F. Prior, P. Nagy, “Will the Next Generation of PACS Be Sitting on a Cloud?” Journal of Digital Imaging Volume 24, Number 2, 179-183, NY, 2011 [9] T. Chia-Chi, J. Mitchell, C. Walker, A. Swan, C. Davila, D. Howard, T. Needham, “A medical image archive solution in the cloud”, Software Engineering and Service Sciences (ICSESS), IEEE International Conference, 2010 [10] R. Mikkilineni, V. Sarathy, “Cloud Computing and the Lessons from the Past,” wetice, pp.57-62, 2009 18th IEEE International Workshops on Enabling Technologies: Infrastructures for Collaborative Enterprises, 2009 [11] K. Nakakoji, Y. Yamamoto, Y. Nishinaka, K. Kishida, Y. Ye “Evolution patterns of open-source software systems and communities”, IWPSE, New York, 2002 [12] M.J. McAuliffe, F.M. Lalonde, D. McGarry, W. Gandler, K. Csaky, B.L. Trus, “Medical Image Processing, Analysis & Visualization in Clinical Research,” cbms, pp.0381, 14th IEEE Symposium on Computer-Based Medical Systems (CMBS’01), 2001 [13] K. Doi, “Current status and future potential of computeraided diagnosis in medical imaging”, British Journal of Radiology 78, S3-s19, 2005 [14] R. Klar, E. Pelikan, “Stand, Möglichkeiten und Grenzen der Telemedizin in Deutschland”, Bundesgesundheitsblatt, Gesundheitsforschung Volume 52 – Number 3, pp. 263-269 Springer, Heidelberg 2009 [15] C. Baun, M.Kunze, J. Nimis, S.Tai “Cloud computing – Webbasierte dynamische IT-Services. 1. Auflage, Springer Heidelberg, 2010. [16] R. Buyyaa, C. Yeoa, S. Venugopala, J. Broberga, I. Brandicc, “Cloud computing and emerging IT platforms: Vision, hype, and reality for delivering computing as the 5th utility”, Future Generation Computer Systems, Volume 25, Issue 6, Pages 599616, June 2009. [17] J.L. Tyler, „The healthcare information technology context: a framework for viewing legal aspects of telemedicine and teleradiology”, System Sciences, Proceedings of the 34th Annual Hawaii International Conference 2001. [18] J. Mundhenke “Werttbewerbswirkung von Open-Source Software und offenen Standards auf Softwaremärkten”, Springer, Berlin 2007 [19] A. Mathew, “Eclipse open source executive strategy summit”, CAOS, THE 451Group, 2009 [20] D. Dinevski, P. Inchingolo, P.Krajnc, I. Kokol “open Source Software in Health Care and Open Three Examples”, University of Maribor, Maribor 2010. [21] A. Khalid “Cloud Computing: Applying Issues in Small Business,” icsap, pp.278-281, 2010 International Conference on Signal Acquisition and Processing, 2010
CONCLUSIONS The current development of cloud computing in the healthcare context will have a big impact on the medical imaging IT market and on the established big players. This trend has both positive and negative effects. On one hand the availability of cutting-edge and best price healthcare IT solutions for the DIC and the care providers. On the other hand the rapid price erosion and the impact on the established healthcare IT provider like organization restructuring, changing business models and the shrinking of their worldwide presence. The new comer in the medical imaging IT market will not give away all the cost benefits to their customers. However, they will be able to have a very aggressive go-to market strategy based on their cost advantages. Their only USP is their head start. This will results in a big number of imitators with a “me-too” strategy since the entry barrier for healthcare IT in the cloud is very low. FUTURE
WORK
A further open point that still has to be analyzed is the radiologist’s price elasticity of the demand of such kind of software. It should be investigated under which conditions, prices and business models the majority of the DIC are willing to give up the partnership with the established companies. Another research topic might be the changes of organizational setup and the business models and processes of the established big healthcare IT players regarding these new kinds of competitors. REFERENCES [1] D. Dean, T. Saleh, “Capturing the Value of Cloud Computing”, The Boston Consulting Group’s Technology, Media & Telecommunications practice and the Information Technology practice, 2009 [2] Gartner, “IT Ausgaben der vertikalen Märkte,” Feb 2009. [3] J. Fähling, J. Köbler, M. Jan, H. Krcmar “Wahrgenommener Wertbeitrag von IT in deutschen Krankenhäusern.”, Lehrstuhl für Wirtschaftsinformatik, TUM Garching, 2008. [4] D. Scholz,”Keankenhaus- IT muss sparen- Outsourcing nicht gefragt.” In CIO Feb. 2009 [5] G. Schicker, “Koordination und Controlling in Praxisnetzen mithilfe einer prozessbasierten E-Service-Logistik”, Gabler Verlag, Wiesbaden, 2008
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