New Healthcare Integration Challenges for ISV’s

With new regulation comes new opportunity. New healthcare requirements around the digitization of health information has caused a wide variety of start-ups and services to surface. Innovation is great, but there are very few standards being adhered to, causing a lot of headaches for ISV’s who are working with new customers to implement their systems.

If a hospital, physician, or clinical lab would like to start using a new product or service, that application needs to be able to communicate with older systems that may not be ready for retirement. Who will be responsible for ensuring that the two systems can interface to each other? How much will this cost and what impact will it have on deployment schedules? This typically falls on the vendor and a solutions specialist needs to be brought in.

Take for example a PMS system at a physician practice that now needs to communicate with a scheduling system that resides in a data-center off-site. The physician PMS will need to exchanges HL7 SIU messages with the scheduling system securely, meeting HIPAA requirements for health information exchange.

In order for this to happen, a secure connection between the two endpoints needs to be established, application interfaces need to be built, ports to the firewall need to be opened, and eventually a mechanism for ensuring each endpoint is authenticated must be implemented (See Wikipedia Article under Security Rule). What seemed to be a simple roll-out of a new system now requires professional services, network changes, and protocol conversion if there is a different transport protocol in use.

These integrations and road blocks can increase sales cycles and implementation times, making it harder to sell while decreasing margins for the ISV. Not to mention, the burden this may place on the customer.

Once an integration occurs, it is also necessary to monitor and maintain the network, which requires IT resources that may not have previously existed or may not have the bandwidth to support an increasing number of integration points.

As part of your integration strategy, it is important to evaluate a build vs. buy strategy:

– What will be the cost impact of rolling a VPN and application interface for each endpoint?

– What will be the cost of managing and maintaining that network?

– Who will bear the cost?

– What impact will this have on implementation times and sales cycles?

– As compliance regulations change, how will this impact your solution and margins?

Healthcare interoperability is an extremely important part of HIPAA regulations and a lot of health IT professionals will be focused on it, but as an ISV, connectivity may not be a part of your core offering, making it a distraction instead of an opportunity. If the numbers do not add up, it may make sense to use an application integration service as part of your value proposition to the customer, making implementation smoother, and decreasing network costs.

Application Interfaces: VPNs are not the answer

You have a new application, vendor or hospital that you need to interface to. Everyone in meeting grumbles about how the application interface will be built, where the resources will come from, and who’s budget will take the hit for adding the new partner.

To get started, you start thinking about everything that will need to happen:

1. A new VPN connection will need to be created to bring the new trading partner onto the network… paperwork with the hosting company or telco, network configuration changes, firewall ports opened, etc.

2. Depending on the application or partner you are working with, you need to understand what interfaces you will need support/build, e.g. does the application have a specific transport protocol you are not familiar with, is there a specific message protocol that you will need to convert

3. Specialist that have worked with these types of interfaces will need to be selected and contracted

4. Depending on how many connections you are creating, you may need to bring on additional staff to manage and support these connections

5. If any value added services such as guaranteed delivery or file tracking need to be implemented, this will increase the scope of contract work

6. Each connection will need to be tested thoroughly

VPNs provide the basic necessity of secure connectivity, but they are a unwieldy solution for IT organizations that are faced with deploying many connections and are limited on technical resources, time, and money.

When working with new trading partners, healthcare application interfaces, or vendors, VPNs may not make the most sense for your needs. Think about some of the problems you may face when adding new VPNs and how you can mitigate those pain points:

1. Are there other secure, application connectivity solutions available? If so, do they offer the most basic needs for interoperability?

2. Does the VPN solution offer file-level tracking, encryption, guaranteed delivery and web portals to view message and data traffic?

3. Are there solutions available that do not require changes to the firewall and/or network

4. Is there a solution that will require minimal IT support, reducing the total cost of ownership for maintaining secure outbound connections?

5. Will these connections continue to meet changing government standards for connectivity or will additional work need to be done to keep them compliant?

6. Is there a solution available that does not take weeks or months to implement?

There are many more questions to be answered, but the basic question is “can you find a better way?”. As technology advances and the Cloud becomes a more trusted platform for offering services, it may be time to start seriously evaluating alternatives to VPNs.

Preparing for Health Application Interoperability

2011 is going to see a dramatic increase in the adoption of EHR software and digital patient information exchange will become an even greater priority in order to meet Stage 1 meaningful use requirements.

If you are an IT Manager, this looks like it will require an all hands on deck and a huge shift in how things have been run throughout your organization. Since all patient data will need to be exchanged digitally in a safe and reliable way, you will be tasked with:

  • Ensuring application interfaces can connect internally as well as make connections outbound through your firewall
  • Making sure your IT ecosystems are documented carefully to determine where the holes are in internal and outbound connectivity
  • Allocating resources for managing all new connections and configuring your firewall to accept new connections
  • Dedicating staff to managing the new network; either adding to overhead or detracting from other initiatives within the organization

Some things to think about in 2011 as you prepare to meet these new requirements are:

1. Meaningful Use Incentives: Registration for the EHR Incentive program started on January 3rd:

2. New Infrastructure: New processes will need to be learned as you begin interfacing to all the EHRs, PMS’, HIEs, Physician Groups, Clinical Labs, etc. being brought onto the network.

3. Security: All patient health information will need to be encrypted and transported securely in order to meet HIPAA compliance.

4. Training: Staff will need to be trained and allocated to manage these networks. As your network continues to grow, so will the resources required to support and manage it. Changes in your firewall will need to happen and application interfaces will need to be built.

5. Solution Providers: HISPs (Health Information Service Providers) will need to be selected. Not everything can/should be done in-house, so you will need to determine how to minimize the total impact of these new application interoperability requirements. Your EMR may already provide application interfaces, but it is possible that many of your systems do not support outbound connectivity.

2011 will bring a lot of change for the healthcare industry as a whole, and with that change, progress. Despite the huge burden these new regulations will have on IT departments large and small, the end game will produce a cohesive, secure and reliable patient information exchange that improves the quality of care for all Americans.

Understanding the Direct Project

Looking through some of the recent announcements on the Direct Project, it is not completely clear what NHIN is trying to represent if you are an EMR, Health Care Professional or Health Information Service Professional (HISP).

NHIN’s Direct Project is providing a specification and guidance on how interfaces can be built to exchange information in a secure, encrypted way using “email like” addresses on a network.

This is great! This is not an implementation though.

Health care professionals or ISVs who are looking at the Direct Project to solve their connectivity problems will need to understand that an interface will still need to be built, and encryption and key management will still need to be licensed in order to ensure all data is securely sent and in compliance.

This is a great step forward, and standards help drive adoption and innovation, so we will be excited to see how the trials turn out.


NHIN (The Direct Project): Ready for Prime Time?

NHIN and NHIN Direct (now called “The Direct Project:) are frameworks for creating a standard system through which health care applications can communicate, share information, and connect with one another. And, according to Shahid Shah, in his article titled An Overview of NHIN and NHIN Direct for Software Developers*, “NHIN is far from settled and is not a forgone conclusion for data exchange, so you shouldn’t rest your complete integration strategy on it. In fact, make sure you have other options available to you.”

I don’t want to be too negative on NHIN or those who are striving to make it a production reality, but if you are considering connecting systems leveraging NHIN, you should understand where NHIN stands as a health information exchange solution.

With the HITECH Act, meaningful use (MU), and incentive payments on the line, a lot of organizations are trying to find their health information integrations solutions now, not in the future. As such, below are some weaknesses of NHIN that might be an issue when trying to implement a health care application integration solution:

  1. Still in early stages of testing with users
  2. Many security policies still need to be defined and implemented by the user
  3. Limited documentation for implementation
  4. May require application development for exchange integration, making it a resource intense solution to roll out

Given that there are a lot of new compliance regulations to meet in order to receive incentives, IT resources will be stretched, and anywhere you can implement a solution that does not require a large amount of overhead and technical expertise is going to be attractive. Even if NHIN and The Direct Project were ready for prime time, integrating your systems (which could be dozens per location), will require a lot of resources, time, and money.

In short, NHIN is not the silver bullet for health information exchange, nor is it the solution that companies, health care professionals, and application integrators can count on now.

Messaging in a Box… err, Cloud?

Connecting-the-world-transparentConnecting applications and systems takes time, involves a lot of people and requires training and deployment costs. What if it wasn’t that bad? What if you had an application messaging solution “in a box”? What if that box was a Cloud that allowed you to scale quickly and reduce costs?

Sounds great and it is!

That is what we have been working on here at Cloak Labs and we are proud of the best service that allows you to connect disparate software applications on and off your network in an easy to install, scalable, and cost-effective way.

The Cloak Labs service provides IT Managers and Administrators with a pre-built application network that resides in the Cloud and enables a network to be established in hours in some cases. Traditionally, if someone wanted to establish a connection between two systems, an IT administrator or manager would have to build a network between the two applications and implement an interface engine in the middle in order to allow the two endpoints to communicate.

Let’s review some of the challenges here:

  1. In order to connect two applications on or off the network, personnel needs to be allocated to build those connections,
  2. Hardware will need to be deployed to support the connection(s), also requiring more person hours to deploy, maintain and update,
  3. Connections are rigid, allowing for only point-to-point communication,
  4. In order to implement any value added services, either a 3rd party application provider will need to be brought in, or a RYO (Roll Your Own) solution will need to be built. Either way, this will require more support and more costs,
  5. If the systems do not reside on the same network, it will be difficult to get trading partners to accept connections coming into their network for all the reasons above.

Let’s see how Cloak Labs provides an easy-to-deploy solution to solve this problem:

  1. Cloak Labs is a service so no person hours will be need to be contributed to support the network,
  2. As a service, there is no hardware for the end-user to purchase or support,
  3. Cloak Labs provides a small software client that interfaces to applications, encrypts messages and routes them through the appropriate channels,
  4. Cloak Labs’ service allows disparate applications to communicate without the need for an interface engine,
  5. Cloak Labs provides file-level tracking, guaranteed delivery, and a variety of other built-in value added services, enabling IT managers to meet compliance and avoid customization costs,
  6. Cloak Labs provides reporting tools to increase management’s visibility into application network performance and costs,
  7. Since Cloak Labs is easy to install, bringing up trading partners on and off your network is easy and can be done in as little as 20 minutes,
  8. Cloak Labs leverages the Cloud to scale with usage and provides users a cost-effective, pay-as-you-grow pricing model.

Contact us to learn more about how your organization can build meaningful application interfaces with CloudPrime.

Cloud Computing: A History and Perspective

As a company that leverages Cloud infrastructure to provide cost-effective, scalable and secure application messaging services, I get a lot of questions about how we make the Cloud secure. Before I address this question, I figured it would be interesting to first take a look at the history of Cloud computing. I ask forgiveness in advance for all my gross-oversimplifications.

Grandpa Simpson Yelling at Cloud

The Early Years

Cloud computing first started being described in the 60’s when the pioneers of ARPANET envisioned that people all of the world could connect and access data from each other over a network. Having an interconnected “web” would provide the foundation for distributed computing. Further, John McCarty, a noted computer scientist, proposed the idea of “computation being delivered as a public utility.” (, March 2009), much like it is used today.

Through the 80’s, the concept of a client-server model for operating applications and platforms within an enterprise began to take root and lay a foundation for what we recognize as “the Cloud” today. Client-server systems require that one computing appliance, ideally with a great amount of computing power and capacity, would be able to serve multiple clients (PC’s, terminals, etc.) around the world. One famous example of this in the 80’s was BITNET which connected IBM mainframes in order to send electronic mail to academic institutions around the world. (A brief history of the internet, Internet Society, 2010)

Emergence of Cloud Computing

Although the idea of a “Cloud” infrastructure was seeded in the 1960’s, it was not really until the 1990’s that we saw any semblance of Cloud computing the way we know it today. In the late 90’s, SalesForce pioneered one of the first SaaS (software as a service) CRM applications and boldly labeled their innovated business model as “The end of software” since you did not have to purchase and install an application locally.

Although it appeared that SaaS based software models would be the future of how we used and interfaced with applications, these applications were still hosted in server farms or locally by the companies that published the software. In 2006, launched a new service that would change how we thought about hosted computing and helped catapult Cloud computing into the spotlight.

Cloud Computing Evolved

Amazon’s EC2 environment gives developers and software publishers a way to access what seems like unlimited resources in a “pay for what you use” model. This combination of low cost and scalable server resources made it possible for developers with very little money to develop applications and publish them (very quickly!) for the community to use. While this was a great milestone for developers and just about anyone who has ever used the internet, many people, businesses, and experts did not believe that the Cloud could provide the security and reliability needed to run enterprise grade applications.

While Amazon provides a paid public service (much like the one anticipated by John McCarthy), many users of the Cloud leverage what is called a “Private Cloud”. This generally means that the host of the distributed computing center has created a cloud environment but its resources are not made publicly available. Bringing the Cloud internally allows managers to have more control over security and maintenance, instead of relying on a provider. Private Clouds help satisfy many of the concerns IT Managers and CIOs have around security while allowing them to take advantage of the benefits of Cloud computing. Eric Knorr of InfoWorld has a great article here discussing “Private Clouds”.

Cloud Computing Today

Today, there is a wide range of options for developers and publishers of software when evaluating which Cloud provider they will use to host their applications. Companies like Microsoft and IBM have started offering services providing their customers with “elastic cloud” environments that promise services that are scalable, easy to access, and inexpensive to use. Seeing more and more large players, as well as small and medium size boutique cloud providers enter the market is a signal that more and more companies are adopting the Cloud as an acceptable infrastructure for hosting their data and applications.

CloudPrime Leverages the Cloud

Cloak Labs is a service that leverages* the Cloud for many of the same reasons any other business might. The Cloud provides a scalable, cost-effective and on-demand environment through which we can provide our application messaging services. When people ask how it is that we can leverage the Cloud when it is not secure, the answer is two fold:

  1. We only work with Cloud providers that can pass SAS 70 type II compliance, and
  2. Cloak Labs encrypts all messages over the network, making all data traveling through and stored on the Cloud completely secure

Having an infrastructure that can scale as you grow allows our business to provide a rich and robust service without you incurring large up-front costs or expensive service fees for transferring data between local and hosted applications. You can learn more about Cloak Labs and our services by visiting

  • Cloak Labs runs in the Cloud. An overview of the CP Messaging Topology can be seen here.

Health Care as the New Enterprise — Sort Of

September 14, 2010 / CloudPrime, Healthcare / 0 Comments

uss_enterprise-resized-600When most people talk about “The Enterprise”, they are referring to large corporate establishments. We all know it is a fictional craft sailing through the far reaches of space to “boldly go where no person has gone before”.

[You either hate me or love me at this point]

All kidding aside, I recently engaged in a discussion with a friend where they asked if Cloak Labs works for “The Enterprise”. I am assuming that he meant corporations in the traditional sense, and when I responded that our customers in the Health Care space are enterprise customers, he looked at me with dismay.

When most people hear “The Enterprise”, they think of supply chain management, financial transactions and CRM tools to name a few. Rarely do I hear people mention Health Care (Health Care Networks, hospitals, physician groups, clinics, state agencies, etc.) when describing who their enterprise customers are.

In large part, I think this is due to the Health Care industry historically being late adopters of technology, and thus viewed as an outsider to The Enterprise discussion. With the recent stimulus funding, passing of the HITECH Act and stricter HIPAA compliance regulations, the Health Care industry is consuming enterprise grade applications and systems on a unparalleled scale and quickly is gaining a lot of attention by business and solution providers who wish to pander their goods to anyone and everyone in Health Care.

Where there can be a parallel drawn is to the late 80s (through today), when businesses began leveraging the Internet to connect to other systems within their trading community or across their organization (think EDI, Lease Lines, VANs, MFT, etc.). The Health Care industry is being challenged by a similar problem in that they are required to connect all systems to the health information exchange to allow for secure digital transmission and ubiquitous access to electronic health records.

While many still do not think of the Health Care industry as an enterprise-class market, it is hard to ignore how much focus companies like GE, IBM, and Intuit are putting into this space, signaling that the major players of enterprise grade solutions have a different perspective on what is and is not “enterprise”.

Life is a Health Information Exchange Highway…

John Moore is a much smarter person than I, and his colleagues at Chilmark research know their stuff, and that is why I was so happy to see Mr. Moore discuss HIEs in his Health IT News Blog on August 4, 2010.

John, in greater eloquence than yours truly could deliver, openly discussed the problems with the haphazard way health information exchange is being approached within the healthcare industry.

Yes, we know that there are large numbers of dollars dedicated to establish a free flowing, secure network of health information; and yes, there is a limited timeline. This is not an excuse to achieve interoperability the wrong way, but instead a call-to-action to do it right!

An interesting point in John’s blog is his comparison to private vs. public HIEs and how they are organized. It should not really be too surprising that private HIEs are more efficient and organized. The private sector’s main goal is optimization to increase margins without comprimising quality (hopefully). States don’t really have the same motivations, and typically they work with grants and funding allocated to special initiative programs thatmust be spent, not conserved. This is not a cheap shot at the state HIEs, just an observation of how projects are organized between the two sectors.


Mr. Moore goes on to make a great comparison to the Interstate System and Eisenhower’s vision for an interconnected nation, including a statement that like the Interstate Highway System, “it won’t be cheap”. The current amount of funding for public HIEs is half a billion dollars… that is not cheap!

I think that with the right plan in place, we can solve the connectivity problem in a cost-effective way with a reasonable timeline. Having said that, John is right, that a plan and vision will make HIEs a success and will become a “Symbol of Health”.

Application Messaging Integration: Look into my Portal

Let’s face it, Middleware is not sexy. It is the stuff that literally can be found in “the middle” or lying below the surface of what a general user of software technology experiences. CloudPrime, to many, is just that: a service that allows applications to communicate in a scalable, secure, and cost-effective way. Yep, that sounds like Middleware.

However, what is not typically available through Middleware services, is a portal; a window that allows a user or manager gain visibility into a system. Cloak Labs is an exception to that rule and offers a very detailed interface that allows professionals to have better visibility into their messaging network.

Cloak Labs’ messaging portal provides a variety of features for network managers and users alike, including:

  • Simple, graphical interface for easier management
  • File-level tracking
  • Security Gateway management
  • Message network reporting
  • Exception reporting
  • Network message alerts

Whether you are a Healthcare Application Integrator, EHR Vendor, or Healthcare IT Professional, how you connect systems and manage the messaging infrastructure between them is extremely important, especially in the context of compliance.

The idea behind the Cloak Labs portal is to give Health IT Managers and users more out of their Middleware, and expose as much information as possible, allowing these users make intelligent, well-informed decisions about how they connect systems.