Born in the Cloud – Born to Win

So you just signed up for a new Clinic Management Platform. Great, the sales team of the software vendor has managed another 99 clinics to sign up this month. Assuming 6 people per clinic that’s 600 additional users who are going to hit the login button in the peak hour traffic at the same time. What do you think is going to happen?

Let us consider another situation. You are an existing client of an Online Clinic Management Platform. Some days things work as expected but on other days the solution seems to be dragging its feet through basic tasks. What is causing these sporadic delays?

The demo looked good, and the features looked good, but no one told you – that performance, could be variable, that only uptime, is guaranteed, that everything else is variable. Could you have done something to avoid this from happening, what questions should you have asked? Before we get to that, let us understand the root cause.

In this article, we will go behind the scenes to understand the infrastructure on which your Clinic Management Solution runs. Understanding this is critical to understanding the potential issues with a wrong choice and its impact on the longevity of the solution you are going to be putting all your data in.

Any internet-based software that you use is actually running not on your computer, but on servers that are sitting far away on someone else’s office premises. This someone else is called a Hosting Company. Hosting companies rent out physical servers (computers) to software companies. Software companies load their software on it and then sell a subscription to that software to you. This infrastructure provided by the Hosting Company is the key to the performance that you get, security of your data, data integrity against corruption and most importantly, the ability of your software to handle your Clinic’s growth. In spite of that the infrastructure usually blind-sides Clinics, and is not considered as part of the equation influencing the purchasing decision.

Let’s begin with a 10,000-foot view of the different kinds of solutions available. There are 3 kinds:

  1. Web Solution
  2. Web Solutions that run on cloud infrastructure, are often marketed as a “Cloud-Ready Solution”
  3. Pure Cloud Solution.


Before we go further, I am going to eliminate Option 2 from this article, “Cloud-Ready Solution.” These are web-based solutions retrofitted on infrastructure that is a mix of physical servers and cloud servers, offered by Tier II (or lower) Hosting Companies. This is usually done as the solution was originally built in the past using web-based technologies, but since the cloud became the buzzword today, the technical team has had to employ a mix of architecture to make the solution run on the cloud. This endeavour by the Technical Team is usually driven by the Marketing arm of their company so that the marketing team can ‘somewhat truthfully’ use the word “Cloud” on their websites, brochures and demos. It is a complicated mess, and ‘somewhat truthfully’ is not the same as being simply truthful. Avoiding such a culture of technological deception as Cloud or not Cloud will be the least of your worries when dealing with such an outfit.


Let us focus on Web v. Pure Cloud

Web Solution Pure Cloud Solution
Large web-based systems can be built with significantly less effort by employing tools such as AJAX, and ORM, with the loss in performance being papered over by powerful databases and large physical servers. Quick to market, quick to get customers on board, quick to monetise, and quick to fail after the solution gains some ground in the market. There are many alleys to keep darting into – the most common being deploying a different database for each customer to keep the head just above the water. Works fine when you have only 50 customers. Try imagining the software company managing 100, 200, or 500 databases? As the user base grows, the support costs to maintain the application also grows, but exponentially, the frailty of the application increases, exponentially, and dependence on manual systems increases, exponentially. It is a ticking bomb, and your data is right in the middle of it. By default, performance is lower for Pure Cloud Solutions. Every button click from your end has to pass through an extra layer of computing, from the physical machine to the virtual machines sitting inside it. Developers of Pure Cloud solutions are therefore compelled to employ best practices in technology to extract every ounce of performance to compete with the web-based solutions in the short term. No quick fixes here, else the solution will be too slow to compete. You get a better architect-ed solution, that has been built with the best that technology has to offer. No shortcuts are possible.


No technical debt, no ticking bombs. As we say in IT, WYSISYG (What you see is what you get).


The software vendor has to request hardware from the Hosting Company. Hosting companies are supposed to respond within 48 hours (I have seen hosting companies take as long as 7 days to get this right). Once the hardware is available your software vendor will manually configure the new server with the necessary software, link it to the existing network of servers and test everything out manually. Response time is typically 2 weeks.


Automated software bots monitor application performance and provision (create) servers based on workload. Loading necessary software in it, linking new servers to the existing infrastructure and testing to ensure configuration accuracy and end-user availability are all automated, without any human intervention. Response time is usually 15-20 minutes.


Lightning-fast response time to changing business environment.


The high workload of some customers can start affecting the performance derived by others. The high workload of some customers cannot impact others as the infrastructure scales up or down based on the workload.


De-risked from the workload of other clinics.


Application Updates usually come about with server downtime. Application Updates in most instances can be done live, without the users even getting to know that an update is going on. The networking capabilities of cloud infrastructure are far, far superior to that of traditional web-based hosting.


Less downtime for you during software updates.


Your risk of an outage is directly linked to the servers the software is running on. There can of course be redundancies but if a server goes down, it stays out till an engineer in the Hosting company physically walks up to it and fixes the issue.


The software runs on multiple virtual machines. Virtual machines are hosted within computers. A Hosting company would be running multiple such computers, within each multiple virtual machines. If a virtual machine goes down, gets unhealthy, or lags behind in performance, automated bots fire up the next one on their own. There are no physical visits required by an engineer.


‘0’ risk of hardware failure.


Market fragmented by scores of bit players, comprising mainly of resellers and marketing fronts who own no infrastructure and are just a façade for a completely different hosting company in the backend. Pure Cloud Hosting companies are very few and far between. There are only 5 capable of offering an end-to-end pure cloud infrastructure: Microsoft Azure, Amazon Web Services, Google Cloud Computing, IBM and Rackspace. Each one of them is worth several billion $. No bit players here.


The best infrastructure money can buy, is guaranteed for your clinic.


Licensing and operating costs are usually 1.50 to 3x higher than Pure Cloud. Being significantly cheaper ensures your Total Cost of Ownership will be always much lower as compared to a web-based solution.


Lower cost month after month, year after year.




When does the difference between Web and Cloud not matter
If you are a hospital, or a Clinic which has poor internet connectivity, you will opt out of the Online Offering. You will want a local server to be installed on your premises that are to be accessed only by your users. In this situation, it does not matter whether it is Web or Cloud. Just focus on whether your workflows are being met.



When does the difference between Web and Cloud become CRITICAL
If you are Clinic Chain, you ideally want to invest in customization, workflow configuration, and staff training, only once. After that for each additional clinic in the chain, you want a replica to be available with ‘0 effort.’ Each time you open a new branch, you want the same to be provisioned in minutes rather than weeks, with no performance hits to your existing users. You want the lowest total cost of ownership and you need to project costs over at least 5 years. Even if you do not expand into more clinics, every year your data is going to grow by 20,000-50,000 patient records, associated bills, appointments, and more. You want to be sure you are on a scalable platform ie Pure Cloud.



Questions to ask your Software Vendor

  1. What database do you use?
    SQL Azure, Firebase, Amazon Dynamo DB, IDM dashDB, Heroku PostgreSQL, and NoSQL like Cassandra, Memcached, Mongo, and Redis are some of the most popular cloud databases around. Usually, the database is the giveaway. If your vendor is not using a cloud database, the solution is definitely not a pure cloud one.
  1. Who is your Hosting Company
    Remember the big 5 given above. If you hear of different hosting companies, do check them out online. Cloud Hosting Data Centers are extremely capital intensive to build and operate. It is beyond the means of most hosting companies in the world.
  1. Ask if the application is hosted on VMs (Virtual Machines) or Web Servers?
    The right answer is Virtual Machines.

Make sure you ask before you buy.