Enterprise imaging is going to the cloud—but should you go private, public or a hybrid?

By Simon Häger, Market Strategist at Sectra

It is not an understatement to say that the trend for enterprise imaging systems and PACS is moving toward the cloud. The reason? Quite simply, moving to the cloud provides significant new opportunities for healthcare providers. Now that it is time for radiology, pathology, cardiology, and others to take the leap to the cloud, there are several hosting models for you to choose from—public, private and hybrid clouds—which all comes with their own specific characteristics and advantages. Your decision will have a major impact on your future costs and the security and scalability of the solution. In this article, we have listed the pros and cons of each and provided some guidance on how to maximize the benefits of using cloud-based enterprise imaging.

In a previous article, we discussed how to build a business case for moving your healthcare IT system to a cloud-based environment. But there are many cloud models to choose from, and you must decide what model to use. In this article, we explain the difference between private, public or a hybrid cloud models, their pros and cons, and give you some guidance on how to maximize the benefits of using the cloud.

Understanding the different cloud models

Let’s recap the basics. In broad terms, cloud models can be divided into private and public clouds, with the hybrid cloud utilizing parts from both models. The US National Institute of Standards and Technology (NIST) has provided a widely adopted description of the various cloud models[1] , which we have used as inspiration for the description below.

Public cloud

The cloud infrastructure of public clouds is made available to the general public and is owned by an organization selling cloud services. The cloud provider is responsible for both the cloud infrastructure and the control of data and operations within the cloud. Public clouds can differ considerably depending on the vendor. The “true” public clouds are mostly provided by the tech giants, such as Microsoft (Azure), Google (Google Cloud) and Amazon (AWS) and have thousands of tenants. For enterprise imaging systems, we see many enterprise imaging vendors now shifting focus to deliver their solutions through public clouds provided by some of these tech giants.

Private cloud

The private cloud infrastructure is operated only for a single organization. It may be managed by the healthcare system itself or by a third party and can exist both within the hospital’s network or off-premises. The cloud provider is responsible for the infrastructure but not for the control of data. A private cloud structure can be provided by a number of different types of vendors, ranging from individual IT companies to consultancy firms and the enterprise imaging provider itself. The general perception is that private clouds offer a higher degree of control of data because the IT infrastructure is not shared with others as in public clouds.

Hybrid cloud

The hybrid cloud infrastructure is a composition of two or more clouds that remain unique entities but are integrated together, which enables data and application portability. This setup can also involve some on-premises components and offers benefits from both the private and public clouds. In medical imaging, this setup is becoming more frequently used, with some parts of the system being installed in an on-premises or private cloud setting, while other applications, such as speech recognition or image analysis, are hosted in a public cloud environment. However, hybrid cloud models may also increase complexity due to several instances and multiple vendors that need to be orchestrated.

Benefits of moving to the cloud

Before considering different cloud models, you should determine whether your organization is ready to utilize cloud-based enterprise imaging. This may be done by evaluating whether your organization can capitalize on the multiple benefits associated with the cloud. In general, cloud computing offers a lot of benefits in comparison to an in-house IT environment, particularly because outsourcing IT allows physicians to focus on patients rather than on IT concerns.

One of the main benefits of utilizing a cloud infrastructure is achieving elasticity and resilience. The cloud provides a more cost-effective way to scale up your software, compute and storage needs as volumes grow or shrink.

Letting a vendor provide both the software and hardware also means they are responsible for upgrades, which usually are complex and time consuming for the healthcare organization to conduct. This will provide you with access to the latest technology and functionality since it is in both your and the vendor’s best interests to continuously update components and software. Your organization will gain faster and easier access to the latest developments, which in turn will increase the productivity of your operations.

More frequent upgrades also contribute to the security benefits of the cloud. IT security is the core competence of many cloud vendors, which means that it is not necessary for the hospital to maintain full security knowledge in-house. For some areas, you can rely on the vendor’s expertise. More frequent upgrades of firmware and software components, a more patched infrastructure and the vendor’s know-how together with a multi-layered safety architecture provide better IT security than a regular on-premises environment at a general hospital.

Cloud services usually employ a SaaS or “pay as you go” model, meaning you only pay for what you use. This operational-based pricing structure, based on the inherent economies of scale and scalability of the cloud IT infrastructure, aims to provide more cost-efficient utilization of IT resources than a capital-heavy on-premises installation. It removes some of the large initial investment associated with on-premises installations and makes it easier to match revenues with costs. A “pay as you go” model was a great advantage during the pandemic when volumes quickly declined. The cloud also makes it easier for you to scale your system in two ways, both for higher volumes, and to include images from more “ologies” and departments—the latter of which is another clear trend in medical imaging. Increased storage needs and lower costs in the cloud as opposed to on-premises storage are two further factors driving cloud adoption.

Faster speeds are yet another advantage of the latest generation of web-based, cloud-based solutions for enterprise imaging. Instead of waiting a long time before images appear and can be read, large imaging studies can now be opened in less than a second or two. One example is 3D mammography exams where many vendors can now open all images in a study, from the cloud, in less than three seconds. This was given as an example in a report from ITN[2] .

Being stuck with a poor-performing vendor can be devastating. Cloud infrastructures offer opportunities to switch vendor more easily if they misbehave and reduces the risk of lock-in effects in comparison to an on-premises installation. However, it is important to ensure that the infrastructure is built on open source components and that files and images are saved in a standardized format, such as DICOM, XDS, S3, etc. to facilitate a potential future vendor replacement, if needed.

Lastly, utilizing the cloud also helps with easier integration with large EMR systems. Many cloud-based enterprise imaging systems can now easily integrate with most of the larger EMR vendors, most notably Epic, Cerner and Allscripts.

All in all, the cloud provides a lot of benefits, which is why about 90% of new installations in the US seem to be moving to the cloud when replacing their PACS or enterprise imaging system.

Key benefits of utilizing the cloud for healthcare IT

Figure 1. The key benefits of utilizing the cloud.

The pros and cons of public and private clouds

Let’s proceed by evaluating the pros and cons of the different cloud models.

Customization vs. economies of scale

One of the biggest advantages with private clouds is that they offer greater customization capability than public clouds, ensuring both the software and hardware suit specific applications and purposes. The increased flexibility of private clouds can therefore, in some specific cases, offer a lower overall cost by matching its infrastructure and business model to the applications and workflows you have in the organization.

Public clouds are designed more for general purposes, with a focus on achieving economies of scale, and normally do not allow any substantial customization. With that said, public cloud providers can, in general, offer lower costs than private clouds due to their scaling capability and the effect of spreading costs over several tenants.

When it comes to customization, it is important to keep in mind that public clouds usually offer a broader set of services. For general-purpose applications, they offer superior scalability, shorter implementation times, and lower costs. They are often globally available, which enables international health providers to use the same vendor and setup regardless of the country in which they operate. However, when it comes to enterprise imaging and patient data laws, this might also be more of a restriction than a benefit in cases where local datacenters are not available.

Let’s dig deeper into other factors that impact costs.

A deeper look at costs

As already mentioned, public clouds share resources over a greater number of tenants and can thus achieve better economics of scale. Accordingly, they should theoretically be able to offer lower prices to their customers. But this is only valid if you as a vendor buy enterprise imaging as a fully managed service where the vendor assumes the costs regardless of use patterns and workflow. In contrast, if the health provider is responsible for paying the public cloud provider separately, the cost may end up being extremely high depending on how the service is used. For example, some public clouds charge a low fee to upload data, but multiple times more for downloading data. For use cases such as radiology, this becomes extremely expensive because of radiologists’ use pattern of fetching prior examinations, which requires data to be downloaded. Private cloud providers have the advantage of being able to tailor their cloud environment and business model to suit the use pattern and use case of their customer.

Again, the level of customization becomes a contributing factor to how affordable the cloud model becomes for your organization. In some use cases, the increased flexibility in the IT environment and business model may trump economies of scale and provide a lower-cost solution than the tech giants’ public clouds. Therefore, the user pattern of your organization should be analyzed carefully and taken into the equation when selecting a cloud model. However, as mentioned, another way to work around this risk of high costs is to buy enterprise imaging as a fully managed cloud service utilizing a public cloud.

In an evaluation process, a hybrid cloud model may turn out to be the most affordable. In such a setup, the short-term storage and application layer could be handled within a private cloud environment that is designed with the running applications and use pattern in mind. The long-term (“cold”) storage would be kept within a public cloud environment. However, this arrangement creates a challenge when it comes to managing multiple clouds from perhaps multiple vendors. If you choose this path, it is important to buy enterprise imaging as a “full service” where you only rely on one party to avoid getting stuck between vendors blaming each other.

In our calculations, we noticed that some public clouds became too expensive. There was a mismatch between the public cloud provider’s pricing model and the way we uploaded and downloaded data. Our radiologists upload a study once, but often need to look at it multiple times. My advice is to use a cloud with a suitable pricing model.

Radiology Manager at a Swedish hospital running its PACS in a public cloud

Cybersecurity on every one’s minds

Over the past year or so, security breaches have surged to become one of the biggest threats to healthcare organizations. Reducing the risk of patient data theft and improving the organization’s capacity to rebuild its IT environment after a potential attack are just two high-priority areas that healthcare needs to address.

There is still a lot of confusion related to cloud and cybersecurity—both between on-premises and the cloud in general and between public and private clouds. A lot of it boils down to the control of data—who will have access to the data, and who can get access to the data. The public cloud is, by definition, used by multiple tenants, whereas a private cloud is single tenant, and a private cloud is therefore, physically speaking, a more isolated entity. Since this might create a false sense of the private cloud having a higher level of security, one should remember that many security breaches are the result of poor configurations, lost passwords, poorly patched infrastructure and other mistakes that derive from the hospital’s IT environment. Security is all about building multiple layers of security, an area in which many public cloud providers possess superior expertise.

If you as a healthcare provider utilize a public cloud without a fully managed service provided by the enterprise imaging vendor, you need to understand the entire security infrastructure. Using a public cloud without a fully managed service means that some elements of security are typically provided by the cloud provider, while others are provided by third parties. This is in contrast to private cloud providers, which generally have control over all security parameters in-house.

Another thing that is often misinterpreted is that the impact of the US CLOUD Act[4] only concerns public clouds. But it actually stipulates that US cloud providers, both private and public, are required to disclose any data they keep if instructed to do so by a US governmental agency.

Generally speaking, security is expensive and boils down to minimizing risk at the lowest cost, along with reducing the time it would take for operations to return to normal functionality after a potential breach. The larger the cloud, the more they can spend on security. This means that public clouds can generally devote more money and focus to security. In fact, many experts claim that the biggest asset among public cloud providers nowadays is the higher level of security. Mega cloud server companies have large, dedicated IT teams that monitor data security 24/7.

Implementation times vary

The time from decision until you can utilize the system and its applications is normally shorter with public clouds. The private cloud is similar to an on-premises installation, where the vendor first needs to build the environment and make suitable customizations before you can start using the service. This often results in a higher upstart cost for private clouds in comparison with public ones. The longer implementation time is the cost you pay for the higher level of customization that is possible with private clouds.

Performance should not be underestimated

The higher customization of private clouds can, in some cases, result in higher application performance since they can be tailored to maximize speed for specific needs. This is something that is highly dependent on the type of applications that will run in the environment, and whether or not they are designed for a cloud environment—often referred to as “cloud native” applications. Although a private cloud can initially offer a higher performance, this benefit will most likely play a important role in the future given that the hardware and software in public clouds are continuously upgraded.

Redundancy and elasticity

Private clouds have the ability to spread the workload over multiple servers but are limited by the amount of server space the cloud vendor owns or operates. Larger public cloud platforms can scale immediately and are essentially considered unlimited since they have a much greater capacity to scale their servers. This is a great benefit if your demand suddenly increases, for example, in connection with an acquisition of a new hospital.

Public clouds also have the advantage of being able to offer a larger variety of redundancy options and higher redundancy and can thus generally guarantee higher uptimes. Hence, public cloud providers can offer better service level agreements (SLAs) that, if breached, may result in fines as regulated in the contract. For you as a health provider, this might serve as an insurance to cover any extra costs and lost revenue if the system is inaccessible for a period.

To summarize, optimizing costs, performance and security comes down to finding a balance between scalability and the level of customization. The cost can be seen as a tradeoff between the public cloud’s economies of scale and the private cloud’s higher capacity to match specific needs.

Figure 2. An assessment of how different cloud models compare with each other in respect to various evaluation criteria.


The role of the hybrid cloud in medical imaging

No one cloud model is better than another in all dimensions. To leverage the benefits of both public and private clouds, the hybrid cloud model might be a suitable alternative. By combining models, you can take advantage of the private cloud’s higher degree of customization, ensure high-performance applications and a suitable business model, while leveraging the public cloud’s superior elasticity and redundancy.

In combination, a hybrid model can outperform the best private and public cloud. For example, the public cloud could work as a database for research and training data for AI, while applications and patient data are kept within a private cloud. In this case, the public cloud’s pay-for-use model becomes especially beneficial as the data might only be needed temporarily. However, we are seeing a trend of more and more functionality being shifted to public clouds because of the advantages they offer in terms of security, scalability and economies of scale.

What it all comes down to

Healthcare providers are adopting the cloud for their IT systems to a much greater degree now than just a few years ago. No one cloud model is better than another in all dimensions. This article has hopefully given you some guidance on which cloud model—private, hybrid or public—and vendor to choose for your organization.

But whatever model you choose, it is important to know its strengths and limitations, and select the model that fits your organization’s needs. Because of the major benefits of using a public cloud where the enterprise imaging vendor takes full responsibility, known as enterprise imaging as a service, this seems to be the dominating setup and we will likely see more of it in 2022.



  3. Quote: “Being geographically diverse protects you from weather events, construction and other single location incidents”
Author: Simon Häger, Market Strategist at Sectra

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