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A M I C R O S O F T W H I T E P A P E R

Health and Wellbeing: faster, more efficient, broader and betterWhy and How Europe Must Reach for Cloud Computing

www.microsoft.eu/health

Health and Wellbeing: faster, more efficient, broader and better

Why and How Europe Must Reach for Cloud Computing

A Microsoft White Paper

Co-authorsPeter Wrobel, Clarity in Science Communication, and Elena Bonfiglioli, Senior Director EMEA Health, Microsoft

DesignChris Jones, Design4Science Ltd

Microsoft would like to thank the following people for theirinput into this document:

Belgian Federal Ministry of Health: Lieve Deschoolmeester, Jan EyckmansEuroRec: Jos Devliesiwantgreatcare.org: Neil BaconOpenLine Consultancy: Jo VerstappenMicrosoft: Julie Anderson, Dorothee Belz, Lisa Boch-Andersen, Jens Dommel, Rüdiger Dorn, Vincent Dupont, Tracey Ferriss, Wendy Frodyma, Alex Gray, Bruna Guimaraes, Mark Lange,Andre Piso, Paul Smolke, Mark Yamartino, Tanya Znamenskaya

© Microsoft Corporation 2011

1 Challenge and opportunity in health and wellbeing 4

2 What cloud computing is, and how it can help 6

3 Vital value from the cloud 12

4 Power to the people: patients and citizens 15

5 Policy recommendations 18

Contents

This paper includes cases and real examples ofcloud computing adoption across the region in thefollowing countries: Belgium, Germany, Italy, Poland,Russia, Sweden, the Netherlands, the UnitedKingdom, and also the USA.

The infusion of intelligence and connectivityinto a wide range of health devices,complemented by Internet-scale services, iscreating a new paradigm for computing. As aresult, a new paradigm for health andwellbeing is emerging. Such new ways ofmanaging information translate into animproved experience for patients, leading tobetter outcomes, more control, moreconvenience, better and broader service, andultimately better value for money.

The uptake of cloud computing by a fewhealth provider organisations in Europe hasshown impressive gains in terms of costefficiency. The opportunity for cloud computingis to match its ability to deliver solid costreduction while improving the quality of careand broadening access to health and wellbeingservices.

HEALTH AND WELLBEING: FASTER, MORE EFFICIENT, BROADER AND BETTERWhy and How Europe Must Reach for Cloud Computing

Europe’s policy makers are faced with anumber of challenges. In times of economicinsecurity and budget cuts, citizens stillexpect a sustainable social security systemthat meets their needs and the needs oftheir children.

Nowhere are the challenges, the pain points,more evident than in health and wellbeing,where shrinking real budgets are set on acollision course with rising health costs andageing populations. In addition, citizens todaywant to be more actively involved in themanagement of their own health and wellbeing.This increases the pressure for innovation andtechnology developments to be driven bypatients’ needs and with patients’ participation.Add to the mix the challenge of ensuring datasecurity and privacy in such a sensitive context,and you have a perfect recipe for systemicstress or emotional debate, in absence ofsubstantive evidence.

In administration, as with most medicines,there is no “magic bullet”. Economic constraintsmean that everyone has to keep their feet firmlyon the ground. And in the past few years a newally has emerged: cloud computing.

The term “cloud computing” describes anew way of working whereby software,computing power, storage – a whole range ofinfrastructures and applications – reside in the“cloud”, that is to say, off your own premisesand accessed via the Internet. Instead of beinga drain on capital and human resources, cloudcomputing enables rapid, agile and cost-effective solutions.

Governments, health ministries, healthproviders – public and private alike – andpharmaceutical companies have started touse cloud computing to address a variety ofbusiness and medical challenges. We aregetting a glimpse of the benefits for physiciansas knowledge workers. As professionals, theyare increasingly getting the right data in theright format at the right time, enabling them toprovide better treatment and preventive care.

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1 Challenge and opportunity in health and wellbeing

“Doctors are competing against time, andthe technology offered by Microsoft helps us

to decrease pre-surgical death rates andprolong people’s lives.”

Vladlen Vladlenovich Bazylev, Chief Doctor, PenzaFederal Center for Cardiovascular Surgery, Russia

The ability to respond more effectively topandemics provides an illustration of thebenefits of cloud computing. The cloudoffering for disaster recovery and businesscontinuity built on the Windows Azure platformhas helped health managers to cope with themassive surges in the public demand forinformation that came with the threat from theH1N1 flu virus – with peak traffic anunexpected 365 per cent higher than theprevious day. Data replication and mirroringusing the cloud creates another layer ofprotection when it comes to managingpandemics and disaster recovery, offeringnew ways of providing resilience, datarecovery and business continuity.

Let’s look at another essential aspect forhealth: collaboration. During Belgium’sPresidency of the European Union, the cloudhelped the Belgian Ministry of Health toaddress the collaboration challenge it faced.The cloud enabled a shared workingenvironment across national ministries ofhealth quickly and flexibly, without having toprocure and install new hardware to meetincreased capacity requirements. The sametechnology is enabling Russian doctors fromdifferent clinics to work together withprofessionals at the Penza Federal Centre forCardiovascular Surgery to get onlineconsultancy and reach a correct diagnosisfaster. And cloud computing is set to


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“The European Union must be an ‘Innovation Union’, a fertile businessenvironment where entrepreneurship flourishes, where small ideas can growinto big breakthroughs, and where the information economy is the growthengine for Europe. This strategy can only be realised when all industryplayers, both major or small, invest in and promote innovation and newtechnologies, such as cloud computing, fostering the sector’s growth andsharing the agenda for innovation and European success.”

José Manuel Barroso, President of the European Commission

The Swedish Red Cross (SRC) is thelargest humanitarian voluntaryorganisation in Sweden. Its workimproving conditions for people requires agreat deal of coordination across theorganisation, especially when respondingto a crisis.

Two important considerations led theSRC adopt the cloud-based MicrosoftOnline Services offering: cost reductionand the need for reliable and up-to-datecommunication.

“We estimate that we will achieve areturn on our investment in the [migrationproject] within two years. Over the nextfive years, we estimate that we’ll besaving approximately 20 per cent inoverall costs,” says Joakim Pettersson-Winter, SRC’s Chief Technology Officer.

SRC no longer pays SEK 250,000 (€25,800) for the push email serviceswhich were not providing the level offunctionality required by the organisation.

The changeover also freed up time for theIT department; the IT staff memberresponsible for managing the previoussystem now has 25 per cent of his timefreed to spend on more strategicdevelopment projects.

Although cost reduction was one ofthe main drivers in the decision to moveto the cloud, the new system also had toimprove communication andcollaboration. “For an organisation likeours, running dispersed operations acrossthe country, Online Services enable fieldcommunications that deliverimmeasurable benefits,” says Pettersson-Winter.

The integrated cloud-based systemallows SRC staff to switch between theirPC, laptop or mobile phone and have allthe information at their fingertips. Sincethe launch, web mail and instantmessaging have gone up by 50 per centin the organisation.

THE CLOUD IN ACTION – SWEDEN

Swedish Red Cross: Flexibility for a distributed workforce

transform the relationship between patientsand healthcare by making personal electronichealth records a practical reality.

Momentum is building around cloudscenarios applied to health and wellbeing. Butthere is still a long way to go. The cloud maybe hailed as a revolution in computing, but asfar as Europe is concerned the revolution hasso far been a quiet one, sometimes evenproceeding unnoticed. This paper looks at theexperiences of early adopters across severalcountries. We aim to stimulate more innovators

to look at the cloud as the emerging enablingtechnology that can unlock Europe’s potentialin health and wellbeing. We recommend thatthe European Institutions and the EuropeanMember States sustain their politicalleadership by integrating cloud computinginto their eHealth Action Plan for the yearsahead, including it as an area of strategicinvestment in the next cycle of CohesionFunds and in the research priorities of theupcoming Common Strategic Framework. Weall stand to gain...


The Internet has long been used as amedium for accessing and exchanginginformation. With the development of cloudcomputing the Internet has becomeradically different: a place wherecomputing happens. Cloud programs,platforms and storage take the strain awayfrom individual organisations and, crucially,have the ability to link and exchangeinformation with smart devices.

Although cloud computing is a recentdevelopment in business operations, it hasbeen around for a long time in the consumerspace. An early example is Microsoft’s Hotmail,introduced almost 15 years ago: an emailservice users could access from anywhere inthe world with an Internet connection and abrowser and which did not require them, or ITdepartments, to invest in and maintain thehardware and software necessary to make anemail service function.

In a sense, cloud computing is the Hotmailidea expanded to cover any type of program,any kind of data, and any kind of user. It really

is that simple. The complexity of cloudcomputing comes not from its basic concept,but from the number and variety ofpossibilities that it offers.

Before the cloudIn the old paradigm, in the health sector as inother areas, organisations run programs ontheir own machines – servers or mainframesthat they must set up and maintain. All theprocessing takes place in-house. All the datais stored on the premises. It may seem like aneat and tidy approach – but there are anumber of drawbacks.

Cost. Doing everything in-house meanspaying for server capacity and programs thatyou might only use occasionally. Paying forstorage you might only need a few times ayear. Diverting the resources of skilled ITdepartments to install, update and maintainsoftware programs on individual machines andkeep those machines running.

Time. The in-house approach means that

every time you want to add a new application(like email, or an online store, or a staffvacation scheduling tool), you have toacquire, install, configure and test a newserver. Whenever you want to use a newprogram it has to be installed or upgradedand tested on multiple machines. Cloudcomputing, by contrast, can be instantly andalmost infinitely expandable.

Ubiquity. Care organisations often have tomanage software in geographicallydistributed environments. But a programmethat enables a number of clinicians indifferent locations to view and discuss thesame patient record, for example, can bedifficult to install if each location is using adifferent system, or if systems and dataformats are incompatible with each other. Orit might require a level of computing powersimply not available to servers or individualdesktop machines in each location. Cloudcomputing can help by making the sameapplication available over a large geographicarea, without the need for “custom plumbing”

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2 What cloud computing is, and how it can help in health and wellbeing

to connect all the disparate systems.

Collaboration. Many organisations have userand beneficiary communities stretching farbeyond their own walls. Physicians and carersinteract with patients in multiples locations andpatients many times must see multiple healthpractitioners. Even governments arecollaborating on particular health projects.Increasingly, organisations and individualswant to share data – but withoutcompromising security or privacy.

Risk. Traditional IT puts all data andapplications in one place. Even modernsystems typically have only a single backup,and that backup often has lower capabilitiesthan the primary system. Cloud automates theprocess of providing multiple, geographicallydispersed backups, meaning that even a


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“All you need is the Internet and youcan start working.”

Jan Eyckmans, Head of Communication, BelgianMinistry of Health

The availability of healthcare data cantransform the ability of healthorganisations to respond to public healthcrises. At the peak of the H1N1 (swineflu) pandemic, one of the big challengesfor health authorities in affectedcountries was dealing effectively with themassive number of people needingassessment and guidance. The H1N1 FluResponse Center(http://h1n1.cloudapp.net), built anddeployed on Windows Azure, allowsusers to take an Emory University-designed flu self-assessment, and thenoffers the appropriate advice.

Users can give explicit consent toshare the anonymous information theyprovide during self-assessment for publichealth, education and research purposes.As a result, apart from the assessmentand advice given to the individual, theapplication also provided valuableaggregated information for assessing theprogress of the epidemic.

The H1N1 Flu Response Center alsoallows users with HealthVault accounts tostore the results of the assessment,combine them with their information

already in HealthVault (such as healthhistory, allergies or chronic conditions),print a summary, or share the resultselectronically with their chosen doctor,again through HealthVault.

Using the Windows Azure platformallowed the application to be deployed tothe cloud and made available to thepublic very quickly. Increased demandand usage were handled effectively bythe scalability features of Windows Azure– without investing in servers and datacentres. The site saw peak traffic on 9November 2009 with 123,746 pageviews – an unexpected leap of 365 percent over the previous day.

“Using Windows Azure we were ableto go from idea to deployment in justthree weeks. As anybody who has builtout data centres can tell you, this is areally incredible timeline. Being able touse our existing skills and all of ourfamiliar tools, such as the MicrosoftVisual Studio development system, wasanother plus. Without all of this, there isno way we could have had the site readyin time for flu season,” says Sean Nolan,Microsoft Distinguished Engineer.

THE CLOUD IN ACTION – GLOBALLY

H1N1 Flu Response Center: A swiftresponse to a massive challenge

Cloud computing offers the EuropeanCommission a unique opportunity tosuccessfully achieve the goals set outin the European Digital Agenda.Particularly in the field of health, thecloud offers the features needed “toequip Europeans with secure onlineaccess to their medical health data by2015 and to achieve by 2020widespread deployment oftelemedicine services”. (Key Action13, Digital Agenda for Europe)

‘Public clouds’ and ‘private clouds’Cloud services can run on infrastructure that is shared withother organisations and companies (so-called “public clouds”)– or developed and maintained on infrastructure dedicated tojust one customer (the “private cloud”). Organisations willmake their choices depending on their development roadmapand timeframe, their own size, the confidentiality of the data tobe stored in the cloud, and regulatory requirements.

The choice between public and private cloud will not affectwhat end users see on their screens, but it will have a bigimpact on cost. While private clouds still offer economies ofscale for large organisations, according to one analysis1, overtime the premium for private clouds can rise to be 10 times ashigh as public clouds.


natural disaster in one area is unlikely to takedown your IT systems.

With the cloudCloud computing encompasses fivecharacteristics3: on-demand self-service;broadband network access; resource pooling;rapid elasticity; and the opportunity to provide ameasured service. And as cloud technologyevolves, another principle is beginning tobecome more apparent: collaboration – asbriefly mentioned in the previous pages.

On-demand self-service. When a healthorganisation needs new computing power, orstorage, or a new programme, it simplyaccesses what it needs from the cloud – or

more specifically, from a cloud supplier. Accessto services is automated, no switches need tobe thrown by human operative, and it does notmatter what time of day or night it is: theservice is there when you want it, and you helpyourself to it. In health, even more than in otherareas, “on demand” becomes a vital valueproposition.

Broadband network access. To reach thecloud you just need to switch on your mobilephone or computer and go to the web – if it canconnect to the Internet, it can connect to thecloud. With the €1.8 billion of state aid fundsannounced by the European Commission inJanuary 2011 to help reach its Digital Agendabroadband targets – including competitively

priced broadband access for all Europeans by2013 – cloud computing is set to become aEurope-wide possibility. As we look atindependent living, healthy and active ageing,and active prevention for Europe 2020, cloudcomputing can help make these visions areality.

Resource pooling is increasingly attractive inthese difficult times. Multiple organisationscan use the same programs, servers and datacentres, and the provider allocates resourcesdynamically according to demand. This canlower the user’s costs considerably, since thesame infrastructure is serving several clientswhile achieving new flexibility and reducingcosts. It can also give users access toprogrammes and infrastructures that theywould otherwise be unable to afford. A recentwhitepaper published by Microsoft1 indicatesthat the benefits of pooling resources intolarge-scale shared clouds can reduce costsmore than tenfold compared with smaller,dedicated clouds and extremely well-run IToperations.

Rapid elasticity. Any system that involveslarge numbers of users demands the ability tocope with huge spikes in the numbers ofpeople seeking to use it, or surges in theamount or complexity of the calculations itneeds to make. And traditional IT systems are

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How the cloud delivers

There are three broad kinds of cloud service. When combined,these are referred to as “IT as a Service”.

With Software as a Service, SaaS, the user simply usesapplications provided by a supplier that run on the provider’sinfrastructure. An example is Microsoft’s Business ProductivityOnline Suite, a set of messaging and collaboration tools. This iswhat the Belgian Ministry of Health used to facilitate collaborationwith the various ministries in the member states, the WHO and itsown highly mobile staff during Belgium’s Presidency of theEuropean Union. The suite includes Microsoft Exchange Online foremail and shared calendars and SharePoint Online for sharingdocuments and portals. Another example is how thepharmaceutical giant GlaxoSmithKline has cut its operational ITcosts by 30 per cent2.

With Platform as a Service, PaaS, the cloud provider hostsapplications developed by the user, or on behalf of the user, usingthe cloud provider’s operating system – much like customprograms developed for Windows. An example is the WindowsAzure platform, a group of cloud technologies that can run eitherin the cloud or on the user’s premises. Image archiving is oneexample of using cloud services to offset the effects of theexponential growth in data and in requirements for on-demandstorage.

Infrastructure as a Service, IaaS, provides on-demand datacentres with servers, storage and networking, typically priced bythe hour. Users can store any kind of data and run whateverprograms they want, but the physical infrastructure is maintainedby the cloud provider.

“For an organisation like ours,running dispersed operations acrossthe country, Online Services enablefield communications that deliver

immeasurable benefits.”

Joakim Pettersson-Winter, Chief Technology Officer,Swedish Red Cross


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most likely to fail at the most critical moments,when demand is highest. Without the cloud,the only solution is to pay for expensivebackup systems that might lie idle for 99 percent of the time. With the cloud, the serviceprovider looks after the elasticity, managingeven large-scale spikes in demand, so evensmall operations can use vast resources only

THE CLOUD IN ACTION – BELGIUM

Ministry for Health: A platform forpolicy development

Towards the end of 2009, Belgium’s health ministry had aproblem. With the country due to take over the Presidency ofthe European Union in July 2010, it had to move quickly to setup a collaboration platform for all the policy documents thatwould be produced during the six-month tenure. Conferences,policies – all needed to be prepared in conjunction withcolleagues in the European Commission, in other MemberStates, at the World Health Organization, and foreignuniversities. To make matters more complicated, the Belgianofficials in charge of the projects would be permanently on themove between different locations in Europe.

Chief Information Officer Lieve Deschoolmeester opted forthe SharePoint platform, hosted by Microsoft. Why go for thecloud? “We didn’t have SharePoint competences in house –not enough to offer it quickly to our users,” she says. “And it ismore cost-effective to pay a licence per user than to have theplatform installed in house. Plus there was the time issue.”Another crucial factor: the assurance that the platform wouldbe online 24/7.

For Jan Eyckmans, Head of Communications at theMinistry, a vital advantage is SharePoint’s ability to deal withchanging texts by tracking changing versions of a document:every revision to a file can be stored – and restored ifnecessary. Versioning, as this capability is called, is especiallyhelpful when several people work together on projects, orwhen information goes through several stages of developmentand review. You can see when a file was changed, and whochanged it. You can also see when information about a file hasbeen changed. For example, if someone changes the due dateof particular item, that information appears in the versionhistory.

“When talking about policy documents, versioning is veryimportant. Otherwise if someone forgets to mail back newversions, everything gets mixed up.” Now, he says, there isless risk of ending up with the wrong version of a text when aminister is trying to explain it.

The project got the go-ahead in mid-December 2009, stafftraining began in April, and all was ready for the start of thePresidency on 1 July. “All you need is the Internet and you canstart working,” says Eyckmans.

Eyckmans summed up the advantages of Microsoft’scloud-based collaboration platform: an elastic system offeringa good price per user; easy to use and to adapt; the flexibilityto work when and where you want; easy documentmanagement and versioning; the ability to involve a broadrange of people in policy making; and finally – no downtime atall.

THE CLOUD IN ACTION – POLAND

ENEL-MED Centrum Medyczne: High-quality patient-centred care

Founded in 1993, ENEL-MED is one of largest private medicalcare organisations in Poland, with ten medical centres, sevendiagnostic laboratories and one general hospital. Over 1000 topPolish companies and over 300.000 individuals use ENEL-MED’scare services each year. It provides a wide range of medicalservices to both corporate and individual clients – from primaryto specialist outpatient care and diagnostic imaging.

Healthcare organisations as large as EMEL-MED have to dealwith a multitude of medical treatments, so they need full controlover information to adjust doctors’ and nurses’ medical rounds,schedule physiotherapy, book patients for planned andemergency operations and visits, and manage lists for incomingand discharged patients – as well as the ability to rapidly set upspecialised consultancy between medical professionals.

“We see an individual in every person,” says AdamRozwadowski, the company’s founder, and to provide high-quality individualised medical services, ENEL-MED was lookingfor a reliable information-sharing solution that could beimplemented quickly across the whole organisation with noadditional capital investment. Cloud computing was the idealanswer, so Microsoft approached ENEL-MED with its BusinessProductivity Online Suite.

The first pilot was set up in just two weeks, in cooperationwith local partner Jade. Medical professionals could see thebenefit right away: nurses were able to use shared calendarsonline to book appointments for patients and doctors, reserverooms and beds for patients, and check the availability ofmedical equipment.

Today, everyone who works at ENEL-MED is using theBusiness Productivity Online Suite to exchange emails, using asingle contact list and booking tool. But this is just the first step:the ambition is to go further, expanding Microsoft’s cloudservices to connect doctors and patients. The idea is to usetelepresence technologies for outpatient care, virtualconsultations and second-opinion meetings between doctorsfrom different specialties to reach one holistic view ondiagnosing and treating a patient.

when they need them, and not pay for themwhen they don’t.

A measured service. You pay for what youuse, and you know what you are paying for –rather like a water or electricity meter. Thisgives organisations detailed knowledge about

where they are spending their money, and withthat the opportunity to monitor and controlcosts. IT becomes an operating expense basedon actual use, reducing upfront capitalexpenditure on servers that has no relation toactual use. That can lead to considerablesavings, especially as cloud services require

effectively no installation costs – the cloudprovider takes care of hardware and software,including updates.

Collaboration. Cloud applications are naturalcollaboration hubs. Since the application exists“in the cloud” and is accessible to anyone with


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How can patients find out which general practitioner or hospitaldoctor is best for them? Traditionally, patients have had noalternative but to follow the advice of another doctor. Thatchanged in the UK in 2008 when Neil Bacon set upiwantgreatcare.org, a website that allows National HealthService patients to rate the care they receive.

iwantgreatcare.org decided to use cloud computing “fromday one,” says Bacon, who notched up 20 years as a kidneyspecialist working in the UK and the US. He cites three reasonsfor going to the cloud: his previous experience with socialnetworking for doctors; the scalability the website would requireas it grew; and being in start-up mode with limited resources.“We needed something that was highly cost-effective but at thesame time scalable at short notice as we brought on new clientsand expanded our services.” And the cloud proved itsresponsiveness when national coverage on BBC television earlyon led to an instant surge to thousands of hits a minute on thesite.

There was another advantage Bacon hoped to reap from thecloud: “absolute flexibility” – not just for the collection of data,but to be able to work with different reporting systems. He citesthe ability to cope with a variety of user platforms, includingmobile phones, and different levels of connectivity.

Bacon’s website is free for patients to use. But it is also usedby healthcare providers to see how well they are meeting theneeds and expectations of patients. These providers work withiwantgreatcare.org to design their own questionnaires andchecklists for patients, helping them to deliver better care andhigher quality-services. With hospitals and primary care trusts,for example, having a variety of enterprise-level computingsystems, iwantgreatcare.org’s cloud interface gets round issuesof compatibility. Everything is done over the web, and there is noneed for the providers to install special systems (althoughinterfaces can be provided where necessary to integrate the

information with existing data management systems).The three years since iwantgreatcare.org was set up have

seen annual increases of 500 per cent in activity on the site.“Many individual doctors are getting dozens of reviews in aweek,” says Bacon. The company has also started working with anumber of medical charities, embedding its solutions into theirweb pages. The idea is that charities can then use theinformation logged by patients to secure better outcomes fortheir own members.

iwantgreatcare.org is currently available only in the UK, butBacon sees the British experience very much as a proof ofconcept that could be rolled out across Europe. Health systemsacross Europe may vary, but the shared principles oftransparency and empowerment are driving a common need toinform people’s choices about the care they receive. “We knowthat our platform in the cloud can be adapted very quickly – wecould roll out a foreign language service in a matter of weeks,”says Bacon. “The cloud makes sense. I can’t imagine any peoplestarting businesses today without going down that line.”

THE CLOUD IN ACTION – UNITED KINGDOM

iwantgreatcare.org: Enablingconsumer choice in health

an Internet connection, all users, all devices,and all locations are equal. Collaboration andsharing data become easy in this environment.

The transition to the cloudWhile the real advantages of cloud computingare becoming more evident, the fundamentalconcerns of any health organisation withrespect to its present and future IT systemsremain. Security, privacy, trust, datagovernance and compliance are suchconcerns. And during times of transition, manyorganisations worry about the compatibility oftheir current systems with new ones, and howto move existing applications to the publiccloud (see Box, “‘Public clouds’ and ‘privateclouds’”), which is shared with other users.


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Founded in 1869 within the walls of Vatican City, Bambino GesùPaediatric Hospital was recognised in 1985 as one of threeresearch centres for children’s health in Italy. “Every year, wemanage 1 million patients,” says Giulio Siccardi, ChiefInformation Officer. “Our doctors save lives, and we need to givethem the best IT solutions in the world.”

But the hospital’s email service was under fire fromclinicians. “I couldn’t send email messages with large patientfiles as attachments, and I couldn’t share my schedules onlinewith colleagues to arrange meetings or discuss patients,” saysMario Zama, Chief of the Plastic and Maxillofacial Surgery Unit.“I perform high-risk surgeries that save lives, and I need toshare information efficiently with the multidisciplinary teamsthat provide care for my patients.”

A change had to be made – and the IT department opted forcloud computing. In November 2010, it registered for theMicrosoft Business Productivity Online Standard Suite, part ofMicrosoft Online Services, signing up for 3,000 seats of theMicrosoft Exchange Online email and SharePoint Onlinecollaboration service. “In one month, we distributed the singlesign-on agent to 3,000 employees’ computers, and there wereno problems. It was fantastic!” recalls Siccardi. The hospital getsthe services for a per-user monthly subscription.

Email and collaboration software hosted in a third-party datacentre and delivered as a service over the Internet has enabled

the hospital to retire its on-premises email software, reduce ITstaff workload, and save money. “We save 60 per cent comparedwith our previous solution. Now we can invest this money inresearch,” says Siccardi. In addition, his department is no longerencumbered with daily email maintenance, saving around 100hours a month.

With SharePoint Online, doctors have a tool to support themultidisciplinary medical team that forms the basis of patient-centred care. They can set up collaboration sites and sharepatient charts and lab results. “The entire plastic surgery unit’ssurgical schedule is displayed through SharePoint Online,” saysZama.

Before the cloud, doctors had been finding their own web-based email solutions, and Siccardi had been worried about theimplications for security and confidentiality. Now, with the cloud-based Microsoft Forefront Online Protection for Exchange,multiple filters and virus-scanning engines help protect thehospital from spam and viruses.

“I can receive patients’ email messages at home or on mysmartphone,” says Zama. “This communication is essential. Withcraniofacial surgery, we are changing the aspect of the face. Thatis a very emotional situation, and I like to talk to the children andtheir families about their expectations and how to achieve whatthey want. Ultimately, this solution helps me to cure and heal mypatients. And healing patients is the best part of my job.”

THE CLOUD IN ACTION – ITALY

Bambino Gesù Paediatric Hospital: Improved care, reduced costs

There are a number of factors thatorganisations must consider when reviewingtheir potential transition to cloud computing,whether private or public cloud solutions. Theseinclude a natural tendency to control your ownIT environment, to maintain security andmanage data directly. This can have advantages– particularly for organisations that have alreadyinvested in building up a robust IT infrastructure– and dedicated private clouds could be asolution.

There is a common perception that directcontrol offers better security or privacy.However, to invest for the longer term and seizefuture benefits, it is important to monitorongoing cloud developments. The already-highreliability and security of public clouds continue

to improve at a fast pace. The considerable security of public clouds

stems from the enhanced scrutiny and expertisethat cloud providers can deploy, and from thefact that cloud systems are automaticallypatched and updated in a timely manner. As wecompare cloud-based solutions to on-premiseoptions, we should not forget that many securityissues arise because in-house systems are outof date, and thus more vulnerable to exploitation.The burden of IT system maintenance iscurrently a major cost for organisations – a loadthat cloud computing can help to lighten.

Organisations need to clarify their specificneeds before they explore whether a public orprivate cloud would be the best solution forthem.


Not every technological advance results inlower costs. But cloud computing bringsthe benefit of unprecedented economies ofscale to IT operations. This is particularlythe case for health-orientatedorganisations, because the cloud allowsthem to concentrate more of theirresources and time on health, rather thanon IT. After all, they are in the healthbusiness, not the IT business.

When applied to health and wellbeing, cloud computing can add vital value byconnecting a wide range of medicaltechnologies and data sources into a seamlesswhole.

For the first time, at this scale and level ofaffordability, cloud computing helps providingpatients, providers and payers a complete andholistic picture of health, enabling a trulypatient-centric approach to medicine. As such,the cloud enables a focus on the continuum ofcare, balancing the priorities from treatmentand cure only to focus also on prevention andlifelong wellbeing.

The cloud is still in its early stages in

Europe, but the experience so far gives morethan a hint of what the technology can deliverfor health and wellbeing organisations – largeand small.

In Sweden, the country’s Red Cross movedto the cloud with Microsoft Online Services in2009 and reckons that it will recoup itsinvestment within two years. Its employees arebenefiting from a system that allows them toswitch between their PC, laptop or mobilephone and have all the information at theirfingertips.

Along with other industries, healthcare isexperiencing an explosion in the amount ofdata being collected from a variety ofdiagnostic and monitoring equipment. Thatdata needs to be stored securely andefficiently – and made available when needed.

Radiology image archives and other typesof health data can take advantage of cloudstorage, with increased capacity oftenavailable in a matter of seconds rather thanthe days or months required to deploy in-house systems. Historical clinical data that israrely accessed is a prime target for archiving

– it could be moved to the cloud storage tomake room for data that is operational andrequires frequent access from clinicalsystems.

Individuals – patients and citizens alike –also stand to benefit. Research published byhealth provider Kaiser Permanente incollaboration with the American HeartAssociation (AHA) in May 2010 showed thatthe use of at-home blood-pressure monitorsand web-based reporting tools that connectclinicians and patients via the Internet appearsto improve patients’ ability to manage theirown blood pressure to healthy levels. Thepatients in the study were connected to theMicrosoft HealthVault cloud platform (seeChapter 4, “Power to the people: patients andcitizens”) and managed their data with a freeonline tool provided by the AHA. At six months,patients in the home monitoring group were50 per cent more likely to have their bloodpressure controlled to healthy levels than theusual care group. Similarly, the homemonitoring group had significantly loweredsystolic blood pressure at six months (-21 mmHg) than the usual care group (-9 mm Hg).

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3 Vital value from the cloud


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“Ultimately, this solution helps me to cure andheal my patients. And healing patients is thebest part of my job.”

Dr Mario Zama, Chief of the Plastic and Maxillofacial Surgery Unit atBambino Gesù Paediatric Hospital, Vatican City

Zorggroep Meander provides care for theelderly and children in a number ofnursing homes and children’s centres inthe Netherlands, along with care inclients’ own homes. It came to JoVerstappen’s Open Line consultancylooking for a quick way of recording thehours of its employers digitally, ratherthan on paper.

The Meander group has about 5,500employees, with 900 “normal” officestaff working from desks and the rest,deskless, providing healthcare. OpenLine realised that the quickest way tomeet Meander’s aims was to provide the

Business Productivity Online StandardSuite as a service, with servers andbackup hosted on Open Line’s premises.This allowed them to add 4,500 newusers – the deskless health providerswho were the main reason for going tothe cloud for a solution.

Three months after Meanderapproached Open Line, the new systemwent live. “Speed is the point,” saysVerstappen, and flexibility. The systemcurrently provides the human resourcessolution for recording hours. Otherfunctions, such as Exchange email andcalendars, can be added later.

THE CLOUD IN ACTION – THE NETHERLANDS

Meander Care Group: Rapid deployment, with flexibility

The cloud is not an all-or-nothingsolutionReaching for the cloud does not mean movingeverything onto cloud platforms. The cloudgives health organisations the flexibility to mixand match. They can and should evaluatewhat makes sense to move to the cloud now,and plan a longer-term strategy to takeadvantage of the opportunities as both theyand the cloud develop.

The bigger the cloud, the bigger thebenefits• Economies of scale result from

consolidating overhead costs, purchasingpower and power efficiency: large datacentres are up to 50 per cent more costeffective than smaller data centres.

• The overall cost of IT is also determined bythe degree to which the capacity isefficiently utilised. Currently, infrastructureis built to meet peak demand. Pooledcomputing improves the utilisation of ITresources and reduces costs by another 50per cent.

• Finally, public clouds, where multiple


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customers share the same application, allowthose customers to divide the costs ofoperating the application and can reduce costsby an additional 20 per cent. This can bringadvanced healthcare applications within thereach of smaller organisations.

Put together, these economies of scale canresult in long-term savings of up to 80 per centwhen comparing large and small clouds.1

That is one reason why, in the US, thebudget submitted to Congress in February2010 committed the country to the use ofcloud computing technologies and to areduction in the number and cost of federaldata centres.

Europe has the opportunity to consider asimilar direction and take up the cloud to helpdeliver on the health measures indicated by theDigital Agenda for Europe. The bigger the savings,the more resources that can be shifted to front-line health care for patients.

Cloud value: reduction in cost of processing

Cloud value: reduction in total cost of operation (TCO)

Cloud value: data centres in public and private clouds

A private cloud is cost prohibitivefor companies with a data centreof up to hundreds of servers.An enterprise with a larger datacentre (more than 1,000 servers)still faces a significant incentiveto choose the public cloud.

THE CLOUD IN ACTION – RUSSIAPenza Federal Centre for CardiovascularSurgery: Collaboration for clinicians

Penza is the fifth largest cardiovascular centre in Russia,carrying out 100 operations a week. With heart disease, a fastand accurate diagnosis can make the difference between lifeand death. The centre is using cloud computing to speed up thesharing of test results and improve its decisions on treatmentand surgery. Audio, video, web conferencing, instant messagingand telephony are integrated via Microsoft OfficeCommunications and SharePoint.

“Doctors can contact their colleagues quickly and discusstreatment options, and make decisions about further treatment,surgical decisions and rehabilitation,” says Oleg Anisimov fromLotsman Plus, which developed the system for Penza. “Locationis not an issue for making decisions, because all communicationis done over the Internet.” Colleagues from remote areas cannow be involved in decision-making. The system also providesthe security and confidentiality that people expect for medicalrecords.

“This takes us to a different level of technology,” saidcardiologist Nadejda Galtseva. “It enables us to keep up-to-datewith state-of-the-art diagnostic requirements.”


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There are many ways in which the cloudcan help patients and their familiesmanage personal health information.Here’s one challenging scenario: How canpatients see their own health data –wherever they are – and both edit and addto their own records, while allowing theirtrusted doctors and specialists to also readthese records, controlling who else can seetheir records and guaranteeing privacy andconfidentiality?

It’s not a hypothetical question. Health andwellbeing are driven by data – informationabout people. The days when doctors wouldnot allow patients even to see their ownmedical records are gone, or going, across

Europe. Increasingly citizens both ill and wellare looking to have access to and control overtheir own health data.

Cloud computing is able to respond to justthis challenge and turn it in an opportunity byallowing multiple users to share information ina secure environment. Imagine a web-basedplatform designed to put people in control oftheir health data. In a move in this direction, acloud-based offering called HealthVault allowsindividuals to open their own, free, account(parents can also open accounts for theirchildren), into which they can upload dataabout their health either manually orautomatically from a range of online health andwellness applications, as well as fromcompatible health devices. The data covered

4 Power to the people: patients and citizens

“A unique opportunity for us to put our patients first by givingthem their medical data, and to empower them to manage theirown healthcare.”

Aurelia Boyer, Chief Information Officer, New York-Presbyterian Hospital, on linking theirown data system with HealthVault.

HealthVault: putting people incontrolHealthVault, designed in close consultationwith health professionals and patients,offers a privacy- and security-enhancedfoundation. This platform allows a broadecosystem of stakeholders – from medicalproviders to health and wellbeing devicemanufactures to health associations – tobuild innovative solutions and services inthe form of HealthVault applications to helpput people in control of their own and theirfamily’s health. Through these applications,individuals can gain greater insights fromtheir data to help them better manage theirown health. If the account holder permits,HealthVault applications also allow healthand wellbeing providers to access theinformation and provide servicesaccordingly.


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includes information taken from blood-pressure cuffs, weight scales, heart ratemonitors, pedometers, blood glucose monitorsand peak flow meters for measuring lungcapacity.

Stepping into the cloud andunlocking Europe’s potentialPopular cloud computing services outperform internalinfrastructure – with 99.9 per cent uptime or better in manycases – so the road to the cloud looks good. But is the cloudright for you?

Step 1: Evaluate cloud services • Analyse the business case for cloud services.• Start by discovering how much cloud computing is alreadytaking place in your organisation or other agencies, andconsider how your existing applications could takeadvantage of the cloud.

• Ensure that you will meet or even exceed regulatorystandards for privacy and confidentiality.

Step 2: Plan for the cloud• Start small – start the journey in a limited scope to confirmthe business case and understand the impact on thepeople, policies and processes in your organisation.

• Plan in phases. The cloud is not an all-or-nothing approach.Some things may make sense today; others will need to beleft for later consideration.

• Know when to make your move. Some cloud strategies payoff over time, so factor in how long it might take to recoupyour investment, and set expectations accordingly.

• Examine the benefits and trade-offs of public and privatecloud solutions, or a combination of the two, factoring incost, security and all other considerations.

Step 3: Integrate cloud services• Look for ways to integrate applications and databases heldon your own premises with cloud technologies to offer moreor faster services.

• Think big – especially if you’re a small organisation orgovernment agency. Cloud services are massively scalable,both up and down. Who else might benefit? Keep potentialpartners in the loop.

• Build a governance structure to measure progress and tokeep all stakeholders informed.

could affect your health. With all theinformation about your medications in oneplace, you can share it with your healthcareproviders. If your pharmacy is connected toHealthVault, you can also import yourprescription history easily and quickly.

Microsoft has recently launchedHealthVault in Europe, starting in the UK andGermany. In the UK, Microsoft has partneredwith MSN Life & Style to provide anapplication called My Health Info that enableswellbeing management, giving individualsinsight into how to improve their health. MyHealth Info helps them monitor their bloodpressure, calculate their body mass index andmeasure the amount of steps they take asexercise.

In Germany, Siemens IT Solutions andServices is introducing a HealthVault-basedoffering called Assignio, targeting fouraspects of personal health. The idea is to help

If you or someone you are caring for takesmultiple medications, HealthVault can help youkeep track of your prescriptions. You can usethe information to check for possibleinteractions or cumulative side effects that

bridge the information gap between citizensand the professional medical and healthcareorganisations that they interact with on anongoing basis.

The key focus for Assignio is to helpcitizens with fitness and wellbeing, prevention,and the management of chronic disease. Italso allows patients to involve hospitals anddoctors that they trust, by sharing theinformation with them. German healthcompany Asklepios, which runs a network ofmore than 100 clinics, is developing “MeineGesundheit” (“My Health”) – a service linked toAssignio that will support patients in managingtheir own health with an application thatmakes medical information – on theirappointments, medication or treatment plans,for example – available in their Assignioaccount.

Trust is essential to a patient-centrichealthcare system. For the system to succeed,participants must be willing to share healthdata. Because health data can be highlysensitive, citizens and healthcare providers willonly share data if they trust that their privacywill be protected. When trust is establishedand data flows freely, everyone benefits.HealthVault has translated these principles intoclear privacy principles, which augmentMicrosoft’s industry-leading corporate privacypolicies and put citizens in control of theirhealth information.


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Footnotes1 Source: The Economics of Cloud Computing in the EU Public Sector, Microsoft, November 2010. 2 GlaxoSmithKline Leads the Way with Microsoft Online Services, Microsoft case study, October

2009.http://www.microsoft.com/casestudies/Case_Study_Detail.aspx?casestudyid=4000005460

3 As defined by the US National Institutes of Standards and Technology, seehttp://csrc.nist.gov/groups/SNS/cloud-computing/cloud-def-v15.doc

4 The Economics of Cloud Computing, Federico Etro, Intertic, February 2011.http://www.intertic.org/Policy%20Papers/Report.pdf

“With Assignio we are able to offer an eHealthsolution for all stakeholders within the healthcareindustry but one where the citizen is at thecentre. The basic principles of Assignio are trustand security; this is extremely important for usand will allow us to add true value to all users.”

Roland Neuhuber, Global Head of SIS Healthcare Siemens

Privacy and security: a question of trust

As online services become increasing popular, protection ofpersonal information continues to garner attention. To achieve theoperational efficiencies offered by cloud computing, participantsmust be willing to share health data. Because health data can behighly sensitive, citizens and healthcare providers will only sharedata if they trust that their privacy will be protected.

With a thoughtful approach, data can flow while continuing tomaintain adequate consumer protections. Microsoft hasimplemented the principle of “privacy by design”, wherebyproducts and services are built from the ground up with securityand privacy features that make it easier for customers to managetheir own confidential information. As a result, when citizens usea service such as HealthVault, they can be confident that they arein control of their health information.

We remain committed to increase the transparency ofprivacy-related information to consumers, and the choice andcontrol mechanisms that are available to them. When trust isestablished and data flows freely, cloud computing can deliverfaster, better, broader and more cost-effective health services.


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Health and wellbeing stand to benefitenormously from the cloud. The global scaleof the cloud will enable the costs ofcomputing to be driven down – at a timewhen health organisations are underimmense pressure to reduce costs.

The cloud has collaboration built into it – andcollaboration is the lifeblood of the healthsector. The cloud makes health data “liquid” bytaking it out of its individual silos and letting itflow at the right time to where it can help thepatient most – under the patient’s control andwith an emphasis on privacy and security.

How, then, can policy makers and decisionmakers ease Europe’s way into the cloud? Hereare a few suggestions across four key areas:

1. Fostering the economics of cloud

computing

• Plan due diligence for cloud readiness.In this tough fiscal environment, governmentsshould be encouraging their own healthorganisations to integrate the cloud into theirinvestment plans and to forecast where the

cloud could appropriately help them savetime and money. This analysis of “cloudreadiness” should be an integral part of EUand national Action Plans for eHealth.Countries should then share and discusstheir analysis with other Member States aswell as with stakeholders in the frameworkof the European eHealth Governanceprocess to ensure faster and moreeffective adoption at European level.

• Cloud computing as an integral partof EU Cohesion Funds. As we aim toachieve more (access and quality) withless (cost), the next wave of Europeansocial and structural funding (CohesionPolicy) should provide incentives forcountries that look to integrate cloudcomputing into health and wellbeing. Thismay require the European Commission tolook for ways to cover funding foroperating expenditures by augmenting thecurrent regime, whereby Cohesion Fundscover capital expenditures only. As Italianeconomist Federico Etro has written,“Organizations can shift from major ICTexpenditure on capital goods to spending

5 Policy recommendations

on operating costs, a change that will havemeaning for more than accountants. Budgetsthat form part of planning and some of theways incentives are structured are likely tochange.”4

2. Awareness raising and capacity

building

• Cloud in health stakeholders’consultation. Governments should stimulatea programme of consultation and awarenessraising with health professionals, healthstakeholders and IT architects and providerson how to obtain additional value from publiccloud infrastructures in a safe and secureenvironment. The newly launched EuropeanInnovation Partnership for Healthy and ActiveAgeing and the eHealth Taskforce are idealplatforms for driving forward suchconsultation, as well as for pilot technologyexperimentation and testing. The EuropeanCommission should consider setting up aEuropean Taskforce for Cloud in Health andWellbeing within this Innovation Partnership.

• Better cloud information for consumersand stakeholders. The European Union

should consider establishing Europe-wideprinciples that would provide consumerswith clear information about what a cloudservice provider is permitted to do with aconsumer’s or business’s information. Thisshould be harmonised at national level aswell. The Cloud Taskforce could help drivethis forward.

• Transparency. Cloud service providersshould be transparent about datamanagement practices and informconsumers, customers, businesses andgovernments about how they are going tokeep their information secure.

3. Security, privacy and data

protection in a cloud environment

• Help data to remain secure. The right toprivacy requires that data be secure. Thatmeans effective and coherent laws and lawenforcement to protect cloud services. Inparticular, cloud service providers shouldhave the legal right of action to protect data.

• Allow data to move safely. Europe needsa comprehensive approach and coherentagreements for data protection, data useand data portability. The new and emergingneeds of patients and health professionalsas well as the opportunities brought aboutby cloud computing in health and wellbeingshould be taken into account in theframework of the current revisions of the

Data Protection Directive 95/46/EC. • Allow data to move freely. We see the

need both to protect information and toempower citizens and patients with healthdata. As health systems shift from a focuson “transactional” care of patients whenthey’re sick to lifetime health management,data needs to be liquid – able to move fromplace to place, and country to country as itis used by computers in the cloud within asecure, private and trusted environment.This aspect stretches outside the EUboundaries. It should be considered in thecurrent discussions between the EuropeanCommission and the United StatesDepartment of Health and Human Serviceswithin the framework of the Memorandumof Understanding on eHealth, as well as KeyActions 13 and 14 of the European DigitalAgenda.

4. Standardisation and innovation

• The market must lead. The maximumdegree of interoperability across programsand countries should be encouraged – butthe market should lead. Standardisationshould still permit the market to innovaterapidly in the early stages of this newgeneration of computing. Discussionsshould also integrate this need to balanceinnovation and standardisation as workfocuses on standard development and

effective deployment. • Supporting the fast pace of innovation.

Both medicine and technology areadvancing at a fast pace. We recommenddeveloping an enhanced regulatoryframework that enables innovation, rewardsexperimentation, and ultimately drives value– by encouraging the dynamic flow of dataacross the health ecosystem within asecure, private and trusted environment. Werecommend that the EU eHealth Governanceprocess take on board this topic, workingclosely with industry and stakeholders.

• Supporting upskilling. Health and careworkers will inevitably be confronted withskills challenges matching the rapidintegration of ICT with their work processes.The European Union’s e-Skills strategy isessential to building the skills to realise theEuropean Digital Agenda. It is not a questionof a one-off investment: general upskillingand retraining has become a lifelongrequirement.

Moving to a focus on lifetime healthmanagement means that we need toprovide tools for citizens to participate inmanaging their health across thatcontinuum. Cloud computing offers usthis opportunity. Let’s take the rightsteps and embrace the cloud to unlockEurope’s potential in health andwellbeing.


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