Delving into the rapidly growing industry of cloud-based services, Paul De Raeve of the European Federation of Nurses Associations (EFN), gives us an insight into the world of ‘cloud’.
There is increasing interest across healthcare industries and providers on the use of cloud-based services to improve the cost-efficiency of continuity of care, with a specific focus on citizen-centred health services and systems’ interoperability. As cloud computing becomes the ‘new normal’ for many areas of business, European healthcare providers cannot fully benefit from it. European Union (EU)-level deployment of these technologies has not yet taken place. The lack of an EU scalability is undermining impact on quality and safety.
In this context, this article aims at exploring the concept of ‘cloud’, its relationship to healthcare, how healthcare might benefit from its scalability, associated risks, the importance of the EU-level Electronic Health Records (EHR) design for integrated and cross border care, an initial mapping of currently operating healthcare clouds.
A reality check
Over the last 5 years, my colleague has had the opportunity to work as a nurse in three different care settings: secondary care, in a Healthline/dispatch centre, and in primary care. For keeping the patients’ records in the hospital, it had to use a mix of Electronic Patient Record System (EPRS), bedside paper-based notes, and electronic systems for recording observations. The EPRS was used by nurses to access the medication chart, doctors’ notes and personal comments including patient’s assessment. Information provided by healthcare professionals varied greatly between wards and professionals, some being comprehensive while others were vague.
In the context following the economic crisis of 2008, in which resources were reduced to the bare minimum, there was a notable lack of guidance as of what should be in a note. My colleague included on the patient records the ABCDE formula (Airways, Breathing, Circulation, Disability, Exposure), together with psychosocial, mobility, and independence assessment details of care provided, as well as nursing care plans. This experience shows that the lack of a standardised data-collection system resulted in duplicated records and some other observations were recorded using systems other than the EPRS.
Moreover, if the observations were read without the clinical context (e.g. information that patient is a COPD patient) they could unnecessarily alert the clinician that was overseeing the observations of patients on the ward. These findings are aligned with those of Baumann et al. (2018). The latter reported fragmentation of health records caused by the simultaneous use of electronic and paper records by nurses, hence increasing time spent on record keeping. In addition to that, the study found that the full implementation of the EHR system was linked to a reduction of time spent on documenting – a 12% decrease in physicians multitasking after the implementation of the EHR, hence improving patients’ safety and decreasing the risk of medical error.
The experience from the secondary care employment period shows that all patient records were managed through a stationary computer. This led to all the above-mentioned problems, as well as a delay in the input of information due to having fewer computers than needed. The whole system would have worked better if the nursing workforce has had a unified outline of the nursing note, this would assist in ensuring the continuity of care and handovers among nurses. Access to portable devices would have made a tremendous difference. The nurses could have used device-to-device (D2D) to provide input (i.e., observations, regular notes, and bedside notes) in one single digital system.
In the third clinical practice setting, the EMIS (Egton Medical Information Systems) is used. It provides access to standard templates for chronic conditions, general consultations, and referral templates. This is useful for seeing a patient as it ensures a well-structured consultation. EMIS also allow for electronic prescribing and incorporates decision support system (DSS) in the form of alerts in case of identified contraindications, drug interactions, or dosage errors, which reduces the number of prescribing errors (Campanella et al. 2011).
The EMIS is a user-friendly system, that allows to audit chronic conditions, to prescribe, to monitor infectious diseases, and provides easy access to the health history of the patients. It does, however, have a disadvantage: not all community practitioners use the same system, and it is not compatible with the local hospital EHR, an issue identified and discussed by Kruse et al. (2018).
The story line of these experiences is that nurses need to be able to access a minimum of citizens/patients’ data to guarantee the quality and safety of continuity of care: demographics, a summary of current and past health problems, allergies, medication list, family history, psycho-social history, and ideally, also the latest test results when relevant to patients’ conditions (e.g. in case of patients with chronic diseases). If these data could be accessed electronically, and in portable devices (e.g., like an EHR in a smartphone) that would be of great support for the nurses and citizens/patients. Although standards for the EHR structure are commonly introduced, a pragmatic care summary record is needed to support frontline nurses in continuity of care.
Within this context, the International Classification for Nursing Practice (ICNP) provides an agreed set of terms that can be used to record the observations and interventions of nurses across the world. ICNP, linked with SNOMED CT, provides a framework for sharing data about nursing and for comparing nursing practice across settings, ensuring safety and enhancing quality by facilitating improved information management to support more effective clinical decision making. In many EU Member States, ICNP is integrated into the EHR and as such provides the potential to deliver to citizens information that meets their needs and supports their preferences (Hardiker, 2016; ICN, 2018).
The concept of ‘cloud’
Firstly, there is not an agreement among scholars on what is ‘the cloud’. In the Lexico dictionary (2019, powered by Oxford University) alone, we can find six different definitions of the term as a noun, ranging from “a visible mass of condensed watery vapour floating in the atmosphere, typically high above the general level of the ground” to “a network of remote servers hosted on the Internet and used to store, manage, and process data in place of local servers or personal computers”. A close definition of the latter can be found in the Cambridge Dictionary (2019), “a computer network where files and programs can be stored, especially the internet”. These two definitions have elements in common, including the lack of a precise description of what “the cloud” in IT might look like.
The aim of this article is not to fill this terminology-gap nor to come up with a new more inclusive definition. Instead, it will take as its point of departure the two above-mentioned definitions and complete them throughout this article. Moreover, this article will draw on the developments and innovation achieved in digitalisation by the two ongoing EU-financed H2020 projects on EHR that started in at the beginning of 2019, Smart4Health and InteropEHRate, both working to empower the citizen and unlock health data, using a bottom-up approach for EHR Interoperability, both encourage an open science approach.
For the sake of clarity, this article differentiates between two types of clouds: private ones, also known as corporate clouds, in which the cloud infrastructure is housed and maintained internally by the end-users themselves, and public ones, those offered for commercial purposes. The commercialisation of the tools as deliverables in Smart4Health and InteropEHRate requires special attention, hence a greater focus will be given to public clouds, especially when citizens share and donate their health data.
Healthcare provision benefitting from cloud-services
Healthcare provision is a field that requires continuous and systematic innovation to remain cost-effective, efficient and timely (Kuo, 2011). All stakeholders involved in healthcare, one way or another, are confronted daily with the same reality: life expectancy is increasing worldwide, which in return have left in many developed countries ageing populations in need of more holistic and additional healthcare services, in a time in which the lack of resources of the EU healthcare systems, in terms of staffing and funding, drive most decision-making processes, and as such also developments and innovations.
This situation imposes increased workloads on frontline nurses who then seek for new formulas to maximise cost-effectiveness and quality of care while continuing working with the traditional approaches as back-up. Dual systems and piloting increase the workload of the frontline nursing workforce. Although the use of clouds to store health data is the soundest of the solutions to tackle these problems (Sultan, 2014), tailed solutions in codesign are needed to lower down the nurses workload.
The cloud-based service that will potentially transform the way current healthcare systems operate and communicate are EHR. An EHR is a digital file containing citizens/patient’s personal data (name, picture, address, age, etc.) and health history (existing diseases, previous surgeries, allergies, blood type, allergies, vaccinations, etc.). One of the drivers of the implementation of cloud services in healthcare is to maximise cost-effectiveness. By using cloud solutions, the return on investment for healthcare providers is higher (Seddon and Currie, 2013).
Traditional paper-based work, which is administrative and consumes a lot of time of healthcare professionals schedule, could be reduced to the bare minimum. Hence, cloud solutions would encourage a shift in nurses worked hours from decreasing administration tasks towards direct patient care. This would be particularly relevant if the different healthcare industries adopt different clouds that are compatible with each other, so solving the interoperability challenges among the systems.
For example, a patient arrives at the emergency room of a hospital and shows her/his ID. Just with that, the nurses would be able to access the EHR of the patient, once access is consented by the patient, and then redirected to the right services, skipping time consuming registration processes and medical tests that are not needed because all the latest information is already shown in the EHR. It goes without saying that the major concern of healthcare professionals is to give good quality care to their patients, making their experience in the healthcare system is as ‘enjoyable’ as possible, with specific focus to patient-safety. The nurses should be put in the driving seat of co-creation designing ‘fit-for-purpose’ solutions, deployable solutions, moving frontline back to direct patient care.
Risks related to cloud-services usage for healthcare operators
The use of IT clouds for optimising resources in the healthcare sector has great potential, but also some risks and concerns associated with it. Some of these might not apply to all clouds, nor all healthcare professionals. After reviewing some literature on this topic, the most common risks are:
- Implementation: moving from on-premises installation to a cloud means changing completely the way work is carried out. Everybody who is part of the healthcare providing team must be on the same page when the cloud is implemented, otherwise, risks such as downtime or improper handling of data arise (Hein, 2019).
- Data privacy and security: a comparative survey by the World Economic Forum and Accenture (2009), comparing Asia Pacific, North America, and Europe, found that the latter was the region most concerned with privacy and security issues. Over 80% of respondents rated it as ‘very serious’. Citizens and professionals who store their data in clouds are concerned that these data might be re-sold to third parties without their consent/knowledge, or even worse, that it might be stolen for fraudulent purposes. These concerns have been existing for as long as the internet has, particularly when personal data is managed remotely by cloud providers who might be operating in many different countries or even continents (Seddon and Currie, 2013; Sultan, 2014).
- Regulatory compliance: the storage and use of personal data, particularly of patient’s data, is strictly regulated in the EU by the General Data Protection Regulation (GDPR, 2016). In this context of increasing regulations, healthcare providers might be reluctant to adopt cloud solutions due to the complexity of these regulations. Hiring an external advisor on compliance is the go-to solution for most healthcare providers, but this also increases the cost of implementing cloud services (Seddon and Currie, 2013).
- Reliability and possible failures: the implementation of cloud-based solutions for healthcare providers only make sense if it substitutes traditional paper-based administration (which is time-consuming and costly). Otherwise, having two parallel systems in place (cloud-based and the former one) might increase the burden of extra work among healthcare professionals and lead to burn-out. However, if healthcare providers rely solely on the cloud for some of its routine operations, the risk of a cloud-failures would pose a huge challenge (Seddon and Currie, 2013; Sultan, 2014). In the healthcare sector operations cannot be interrupted if something fails, and back-up plans are always needed, as the opposite might pose a life-threatening risk for patients.
- Cloud-collapse: IT-associated problems can occur, leading to a possible cloud-collapse. If this happens, the major problem is that the solving of the problem does not depend on the healthcare provider but on the cloud manager, which in public clouds is most likely an external company whose activities might be outsourced.
Therefore, it is argued that for tackling these risks related to cloud-services usage, and the risk of cloud collapse or failure, having an emergency scenario planned becomes a must (this related to risk management). In a setting in which all cloud-services are closed, healthcare professionals cannot afford to postpone surgeries nor to disturb the distribution of medicines due to the IT system being hacked and as such closed down; healthcare services continue to be delivered. Hence, frontline healthcare workers need to be able to manage emergency scenarios of cloud-failure effectively and without disrupting continuity of care.
As for the other four challenges outlined, implementation, security, regulatory compliance and reliability, these can be mitigated or, at least, minimised, with the proper involvement of end-users. If end-users are involved throughout all the phases of cloud-project conceptualisation/design/implementation, they are in a position in which they can highlight the unique characteristics of their working environment and as such technical requirements need to be developed based on the end-user needs. Moreover, they can also assist with EU and national data privacy laws as frontline compliance (i.e., informed consent) are grounded into their daily practice. End-user engagement is key to ensure that the newly implemented cloud-services achieve their objective of increasing efficiency without increasing workload and shortening learning-curves which will enhance trust between the cloud-service provider and end-users.
Electronic Health Records in the EU Member States
There is not a single common EHR system operating across all EU Member States. Instead, some countries have it and some do not, and those who do, often have different EHRs implemented at the regional/municipal level.
An example of a country who has successfully implemented EHR in its national systems is Finland. The coverage of EHR in the country is 100% in healthcare facilities in both the public and private sectors. New functionalities have been implemented continuously in the EHR, such as a national data repository (‘Kanta archieve’) and e-services for citizens. With national data repositories, the EHR data will be available for nurses and physicians regardless of the patient’s location. In 2015, the Finnish Ministry of Social Affairs and Health published a new eHealth and eSocial strategy ‘Information to support well-being and service renewal 2020’, aiming to support the renewal of the social welfare and health care sectors and to foster the active role of citizens in maintaining their own well-being by improving information management and increasing the provision of online services where the role of nurses and other healthcare professionals is crucial. One of the six key objectives set out by this strategy is that by 2020 the system will be smart and the users capable. Measures to achieve this include improving the system usability and decision-support, involving professionals in the system and service development, increasing professionals’ training in information management, electronic documentation, data protection and security.
There is great potential for other EU countries to implement similar cloud based EHR systems nationally. However, it is argued that national context differs due to different population needs.
For example, in Belgium, a country marked by its linguistic difference, several regional solutions have developed, one for the region of Flanders, another for the region of Wallonia, and another for the Brussels region. Although Belgium has a national eHealth plan in place since 2013, systems still do not communicate with each other. Nurses are part of the ‘Medication schematics’, ‘Electronic prescription’, ‘Share in order to collaborate’, and ‘ICT training and support for healthcare providers’, with minimum access to data guaranteed by the federal government.
The case of Croatia is different. It has since 2012 developed a national system providing IT services and basic e-Health functions (‘CEZIH’) including e-Orders and e-Lists, e-Prescriptions, e-Record, national preventive programs, e-Infant and the Croatian Health Insurance Fund portal (HZZO). A National Portal for patients available from 1st September 2016, enhances communication between patients and healthcare providers.
In the Czech Republic, the launch of EHR in the University Hospital Motol started in 2011 with the tool ‘IntelliVue Clinical Information Portfolio’ (ICIP) by Philips, for sectors Anaesthesiology and Intensive Care, with other departments still relying on paper-based health records. The portal collects patients’ data such as admission details, laboratory results, score systems (9APACHE, TISS, Norton, Ramsey, GCS, VAS, etc.), vital functions, X-rays, medical orders, hygiene, fluid balances, infusion therapy overviews, blood transfusions, care for catheters, care for wound (prevention, dressing), nursing report, care plans, and others. It is argued that nurses benefit from using the ICIP because they can expend more time with the patient and less with the paperwork.
For future developments at the EU level, it is interesting to look at Denmark. This country has developed several EHR systems operating at the national level, respecting the regional developments, needs. Two regions use the EPIC system (EPIC is privately held healthcare software company from USA, the core of its EHR software solution is called EpicCare). The other three regions use the Systematic system. There are 98 municipalities in the country using three different systems: KMD, CSC and Systematic (i.e., different EHR solutions provided by different private companies, which are not interoperable with each other). The communication between hospitals and primary care use a national transfer system called MedCom.
In a more centralising vein, Estonia has one online portal, ‘Digilugu’, with citizens having access to their health records and determine who can see their data. On July 2019, e-registration, e-death notification, and an e-vaccination went online. Most healthcare providers do all their documentation work digitally.
France, which developed since 2016 an EHR system called Dossier Medical Partage (‘DMP’). Currently, 4 million citizens are in the system. The DMP is an EHR storing and securing the patient’s health data and allows authorised healthcare professionals to share this information with the patient’s consent and under her/his control. Patients can create their DMP online and healthcare professionals can also do so on their behalf if they consent it.
Finally, Germany, Portugal and Italy have different developments in EHR.
Germany has no operating national EHR system in place, due to the resistance of physicians, who are concerned about data protection issues. However, they do have EHR systems in some federal states, but with limited data. Some health insurers in the country, however, offer their EHR to their clients.
Italy has an operating Electronic Health Dossier (‘Fascicolo Sanitario Elettronico’), a tool containing the citizen’s entire health record. It allows for traceability, consultation and sharing of health data with healthcare professionals. It is established by the different Italian regions and autonomous provinces in compliance with the current national legislation on the protection of personal data. This tool aims to improve the quality of health services and facilitates scientific research in different fields. The tool also assists in health planning, the verification of the quality of care and the evaluation of healthcare.
Finally, in Portugal, all the primary health care providers, and most hospitals have access to EHR, with already some interoperability between different software. Doctors and nurses are the professionals having access to the EHR if the citizen/patient allows it. Patients can access their health data, through the National Health Service platform and the mobile app MySNS. The SNS platform is made up of clinical data collected electronically, in an individual way, produced by entities that provide health care to the citizens within the National Health Service (NHS).
By no coincidence, the two ongoing EU-funded EHR projects, InteropEHRate (led by ENG, Italy) and Smart-4-Health (led by UNINOVA, Portugal, with HPI, Germany, as scientific coordinator) aim at developing an EU platform for citizen-centred health record EU-EHR exchange, paving the way for the full deployment of citizen-centred solutions and services in a digital single market for wellbeing and healthcare, through an easy-to-use, secure, constantly accessible and portable health data and even services delivery approach, thus advancing citizens’ health and wellbeing, and digital health innovation. As such, coordinated action and end-user co-creation will need to guide these EU developments to make deliverables, outcomes, solutions, ‘fit-for-practice’ in all EU Member States, and hopefully even beyond (WHO Europe region). The full potential of the EU EHR will be exploited when different national systems of EHR become interoperable with each other, or when a cross-national EHR system gets implemented in the EU. A more detailed explanation of the above-mentioned projects is therefore needed:
The InteropEHRate H2020 project objective is to realise an open, standardised and unique European extended-EHR to preserve the European assets and professional ways of working, by addressing the current lack of standardisation and security, defining a set of integrated protocols and conformance criteria for mobile apps, supporting secure and portable local storage and backup, released as open specifications.
The Smart 4 Health H2020 project is developing, testing and validating a platform prototype for a citizen-centred health record EU-EHR exchange. This will pave the way for the full deployment of citizen-centred solutions and services in a digital single market for wellbeing and healthcare, through an easy-to-use, secure, constantly accessible and portable health data and services prototype, thus advancing citizens’ health and wellbeing, and digital health innovation.
Cloud-based healthcare solutions that are currently operating
A preliminary mapping of the biggest operating health clouds (displayed in alphabetical order) indicates the importance of competition in the European Single Market:
- Amazon Web Services Cloud (this cloud also operates in other fields other than healthcare);
- Azure for health by Microsoft;
- Apple Health Records;
- Cerner HealtheIntent (a population health management tool);
- Cloud Healthcare API, by Google;
- CloudHealth by VMware;
- GE Health Cloud Platform;
- HealthSuite digital platform by Philips;
- SAP solutions for healthcare (more an app that a health cloud, but it includes a Cloud-based portal for patient applications);
- Vlocity; and
- Watson Health by IBM.
The aim of this article is not to indicate which of these EHR is the best. Nevertheless, that just with a preliminary mapping one can come up with such long of health clouds means a few things.
On the good side, health-clouds and EHR are a growing area of business, which has good and bad implications. That this sector is growing so fast means that the demands of end-users (i.e., healthcare professionals and citizens/patients) are going to be finally addressed.
It also means that the market products from private companies will compete within the single market and those with support from the end-users in co-design will probably see a return on investment due to its deployment scale. The fact that there are so many healthcare cloud solutions also means that healthcare providers are likely to have enough room to choose the service that better serve their purposes.
On the bad side, many healthcare cloud-service providers could enter the competition race because of the initial hype, managing to place in the market products that have not rightly engaged end-users or that do not fulfil the claims they might make. In addition to that, a very wide variety of healthcare cloud-solutions in the market might also lead to confusion for healthcare providers and citizens/patients, as they might not be familiar with this new technology and not know what the best solution for their needs is. Finally, if many different cloud-services are operating in parallel, the challenges for interoperability will probably increase. The interoperability of healthcare clouds and EHR is of interest for the healthcare providers and the citizens/patients, but cloud-service providers have little incentive to implement it.
Co-creation of Cloud-based healthcare solutions
It is key for the frontline nurses that a co-creation environment is the starting base for change. Innovation in health should empower patients and frontline nurses, moving towards an integrated care system based on proactive/empowered health-aware patient/citizen. We need to ensure that the IT tools, and the data revolution support and facilitate the shift towards a resilient health and social care ecosystem, and support nurses to deliver frontline high quality and safe care. It is therefore essential to create fit-for-purpose innovations/solutions for the health and social care ecosystem. Requirements and mechanisms co-designed with the end-user are key to ensure the utility and suitability of the developed solutions. It is important in the requirement phase to provide the IT developers with the nurses’ views and expertise in making the solution fit-for-purpose.
Identifying, assessing, and bringing in good practices examples is key to have a constructive dialogue between the developers and the end-users. The goal is to empower citizens and patients, and in doing so, strengthening patient safety, chronic disease management, diagnosing, home-care logistics, hospital logistics, e-skills, selfcare and independent living. It is key to move towards a system based on needs (unmet needs), safety and quality, including quality of life. Technology needs to help us reaching these holistic objectives.
Therefore, it is key to build trust: citizen and patient’ trust is a central concept in developing digital tools, EHRs, requiring data sharing, therefore, patients and healthcare professionals, in particular nurses, should be more involved in the data sharing governance. Due to the close relation nurses have with citizens (prevention), the patients (care and cure), families and informal carers (informal care), nurses are ideally placed to make IT tools, EHR, trusted by the end-users.
Therefore, nurses are clear that whatever is developed, needs to show an added EU value with clinical relevance. The developed cloud solutions need to respond to patients’ needs and support frontline professionals in care delivery, continuity of care. Involving nurses since the start of the co-design process will lead to the development of tools able to support nurses and allow them to spend more time with patients, increasing the direct-patient care time. Innovation, digitalisation is to support frontline healthcare professionals and as such making sure that the direct patient care gets increased again! Ultimately, tools, processes and resources need to be planned for co-creation and co-design to have return on investment.
Healthcare and digitalisation are high on the EU political agenda. Hence, the EU is funding the Electronic Health Record projects, InteropEHRate and Smart-4-Health, aiming at developing a single EHR system that can be deployed in all Member States, and that it is interoperable with all already existing EHRs.
The added value of the InteropEHRate and Smart4Health projects to the wider project of European integration would be to develop a system of EHRs that can operate across all EU Member States. The outcome of these projects should empower EU citizens, as they would own their own health data and decide when to share it with healthcare professionals.
Moreover, if the citizens/patients become the owners of their own health data, a lot of new possibilities for the interoperability of EHR open. As citizen travel in a borderless EU, they take their personal EHR with them, and use their own health data when needed (e.g., for healthcare consultations or even to continue a treatment abroad). In addition to all these, these two projects are also exploring scenarios in which health data contained in the EHR needs to be accessed in emergency situations, as well the possibility of anonymous health data donation for researchers.
However, when these two projects successfully deliver the outcomes they are currently working on, a question remains: which cloud provider is the best one to host these new EHR systems? Within the aim of this article is not to answer to that question with the name of a single provider, because, among other reasons, by the time these projects have finished the healthcare-cloud providers’ landscape will have probably changed. Nevertheless, this article can already draft a guideline for choosing the best healthcare cloud for the outcome of these two projects:
- End-user engagement is essential. Healthcare-cloud providers who have engaged with end-users from the conceptualisation, design, and implementation phases of their clouds, are much more likely to be compatible with the needs of the Smart4health and InteropEHRate needs. These two projects have end-users (i.e., nurses and other healthcare professionals) in their consortiums for the same reasons.
- Interoperability is a must. Healthcare-clouds that offer interoperability with other clouds also addresses another of the goals these two projects have: creating a system of EHR that is cross-border within the EU. That is, that could be used in all EU countries without special requirements.
- The price will be a key deciding factor. In a market in which most healthcare cloud-providers are expected to be privately own, the price of the services is also going to be one of the key factors determining if that cloud-solution is the best choice or not. Particularly in these times, in which the EU’s healthcare sectors have gone through profound resource-cuts following the economic crisis of 2008.
- Trust is key. If patients and citizens are going to store their personal and health data on a healthcare-cloud, they must rest assured that the provider is trustworthy, secure, and reliable. Otherwise, they will not trust the cloud-solution and will not use EHR.
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Paul De Raeve
European Federation of Nurses Associations (EFN)