Learning Objective

1B2. Articulate characteristics of the information and communication technologies (e.g., infrastructure,servers,web services,storage) that support the healthcare environment

The term “n00b“, is a computer-geek term for newbie, or someone without much knowledge of IT. The fastest way to look like a n00b is to not understand cloud-based and local computing models.

Locally Installed Apps

Many apps are downloaded (in their entirety) to your computer or smartphone and simply run on your local device. For example, I downloaded and installed Microsoft Word to my phone and my laptop. It does not need an internet connection, or connection to any other computer to run. In this case, Microsoft Word is a locally installed app (or application) on my phone and laptop. If you look on your computer or phone and identify apps that can run without the internet (e.g. in airplane mode), they are likely to be a locally installed app.

Generally speaking, EHR Vendors do not make locally installed, standalone EHRs, -even for single providers.  The primary reason is that even in single provider practices, there is a need to access the EHR by multiple people, and in multiple locations.   For example, the front desk staff still needs needs to schedule patients from the front desk, a nurse or assistant needs to enter vitals, and the doctor needs to simultaneously use the EHR.  A locally installed, standalone EHR one one  computer, (or each of them)would make this kind of data sharing difficult.

Internationally, there is a tiny niche application for locally installed EHRs when internet access is absent or unreliable, and patients are served by a single (often visiting) provider.


Data centers house servers that do most of the computing work

A server is defined as a computer that provides centralized access to an app or a service. Servers are the main component of nearly every commercial computing environment, and perform all of the work behind the scenes.  Servers can be much more powerful than a personal computer, and are often linked together (called a Cluster) , to perform like a a single supercomputer.

IBM’s Watson supercomputer is 90 servers tied together in a cluster

IBM Watson (of the Jeopardy! work)  is  is made up of a cluster of ninety IBM Power 750 servers,  with 2880 POWER7 processor cores and 16 Terabytes of RAM.

Personal computers are more well-rounded in capabilities compared to servers. Enterprise business applications such as EHRs can sometimes be too large, or require too much processing power, to be installed on a laptop or personal computer.  Servers are specially designed for  a specific task, such as application sharing or data storage.  You wouldn’t want to play Minecraft (at least not with a lot of mods) on a typical server.

Servers use a lot of electricity, produce a lot of heat, are noisy, and take up a lot of space; so the places that house servers (called data centers) are specially constructed.

Using servers instead of locally installed software on every end-user computer solves three problems:

  1. Data is kept in once place (the server) and everyone is looking at the same data.
  2. The application is only in one place(the server), so updates and maintenance are simpler
  3. It may be easier to ensure security on one system (the server) rather than all of the end user systems.
  4. Servers can be much more powerful than end user systems
  5. Shared resources such as servers, have less unused(wasted) hardware and are more efficient.


Client Server Apps

Some apps installed on your laptop or phone may require access to a server to work. For example, have you ever opened your email app, your calendar app, or a multiplayer videogame and the app would not work properly because it could not connect to the server? This type of app is called a Client – Server app architecture. The part you installed on your computer (or phone) is the Client , and it needs to communicate with a Server for it to run properly. Most EHRs are Client-Server apps. For example, both Epic and Cerner EHRs require a client app to be installed on the workstation computer. The client app handles the user interface, but it must be in communication with the server app that does the heavy lifting.

Technically, apps that you access through a web browser (like HealthITBook.com) are still client-server architecture. With web-apps, the client program is not installed ahead of time, it is quickly downloaded by the web browser each time you use it. For example, your go-to mail client such as Gmail is technically a client server app in your web browser. However, a growing number of people in the industry are calling web-based apps Cloud Computing.

Cloud Computing

Cloud computing 'feels' like you are using your own servers, but you are accessing virtual servers running on real servers owned by someone else

Often healthcare providers do not want to maintain their own data center full of servers, or they are a small practice and do not have the space, money, or other resources to maintain the EHR and database servers adequately. Perhaps they often want to focus on their core business of healthcare, and not invest too much institutional resources into IT. Perhaps they also do not have the time required  to set up a server room and servers, install, and test an EHR in their own facility.

Outsourcing your servers and apps in this way, and still accessing them as if kept locally, is called cloud computing. Cloud computing is sometimes also called software as a service, or SAAS, meaning you don’t buy the app, you simply pay to access and use it.

Cloud computing vendors provide a variety of cloud based services, including:

  1. File storage (e.g. Google Drive, iCloud )
  2. Complete cloud-based appsv(e.g. AthenaHealth EHR, Gmail)
  3. Smaller cloud-based services that are not complete applications (e.g. transforming a street address into latitude and longitude, performing face recognition on a security video stream)
  4. Complete virtual computers (see next)

Cloud services also provide virtual servers and virtual desktop computers . You access these virtual computers using a regular keyboard and monitor, but the computer only exists virtually, inside of another massive and distributed computer system.

Cloud computing puts the burden of IT infrastructure, maintenance, and security on the cloud vendor, not your organization. With cloud computing, your app and data are still on physical computers somewhere, but you don’t know where and it largely doesn’t matter. As long as you have a robust internet connection, you can access your apps and data as if there were on a computer in your basement. Cloud computing vendors often choose data center locations based on low cost electricity, and proximity to the highest speed / greatest bandwidth networks of the internet, often called internet backbones.

Choosing Between a Cloud server or Local Server

In some ways, the cloud computing vs physical computer decision is similar to a lease vs buy decision. The major advantages of using cloud-based computing systems instead of your own physical servers are:

  • Low upfront cost
  • Vendor-supplied maintenance and security
  • Less required IT infrastructure

Disadvantages of cloud computing include:

  • The reliance on vendors for everything
  • Higher costs over the longer term
  • Compliance details
    • cloud services provider must sign a HIPAA business associates agreement,
    • cloud services provider must be able to guarantee the required auditing and access controls
    • cloud services provider must be able to ensure that patient data in the cloud remains on servers that are physically within the United States.
Only a n00b says 'cloud' when you are really downloading from a single server.