By: James O’Neill, MD

Iltifat Husain, MD contributed to this piece

This is another part in an ongoing series of how the Wake Forest University School of Medicine’s Emergency Medicine Department is using cloud computing to improve the workflow of the Emergency Room and Residency learning. In Part 1 and Part 2 of this series, we discussed the advantage of going to the cloud and the typical workflow of an Emergency Room in an academic center.

In this article, we focus on the difficult task of deciding on a Cloud based solution with the various options available on the market.

As the Assistant Residency Director and in charge of the Information Technology, I was asked to take over our education Sharepoint website. We began a discussion about how to make the most of newer technology. In the prior article we discussed the limitations that Sharepoint presents from a departmental and educational perspective. We needed to engage both our resident’s interest in new technology and their desire to use mobile devices.

Previously, our residency programs’s first move to include mobility was to give our 2011-2012 intern class iPads and then develop mobility around the device. But, this was ended by budgetary issues and the fact that most of the residents had already purchased mobile devices of their own choosing.

Furthermore, we realized that simply giving mobile hardware was not enough. Software that engages Residents is just as essential.

In the face of that disappointment, we moved to focus more on the content, and not the actual platform in determining our new direction. We were open to platform, but felt the ease of information sharing and ability to have conversations about topics, articles, and lectures being paramount.

We looked into a number of platforms including Dropbox,, Google Drive, Microsoft Skydrive, as well as a few smaller players. Whatever platform we chose would have to interact and work well with our institutional Sharepoint 2007 and later 2010 software.
This article is not meant to be an extensive review of these platforms, but we will touch on Dropbox, as this cloud solution is arguably the most used by those in medicine.

Dropbox is great for organizing your medical literature and sharing it amongst your close peers, but has one critical problem. Dropbox lacks the ability to easily secure files. If an attending Physician creates a folder and shares it amongst a large group of residents, all those files could accidentally be deleted by one of the residents. In Dropbox it’s difficult to create permissions for various users — an ability that is crucial if you want to use a Cloud based solution in a meaningful way amongst a large group of individuals.

After many conversations, research, and testing alternatives, our end decision decision was to go with — mainly because we found it the easiest to use and seamless for the functionality we were striving for. A final decision to begin an enterprise account with Box came after a 5 month trial with multiple residents and faculty with a business account.

We have tech savvy residents, but also folks who are not (and don’t have a strong desire to learn how to be). We needed a platform that was simple to use and we wanted to maintain our current workflow — anything complicated would take away from the task at hand for our residents: learning how to become a great Emergency Medicine Physician.

The main benefits of Box were the following:

Price: The price for Box is not inexpensive, but when spread across a large Emergency Department with satellite affiliates, Box is reasonable. The large amount of space we required made the final cost comparable to managing our own server without the headaches of recurring costs, the downtime, and the expertise to manage it. Also, all apps for the end users being free is very helpful.

Sharing: the ability for all members of the residency program to share pdf, word, excel, powerpoint documents, and videos. This could be done from a mobile device, or a computer in the emergency department or at home. There were multiple ways to forward attachments and files into the cloud on our mobile devices. A favorite was setting up an email address to a folder in Box that would automatically accept an attachment (i.e. an article authored by a faculty member). If we linked that folder to our Sharepoint site, the entire website was updated in a few clicks of our iPhone.

Organizing clinical documents: we needed an easy platform to share and update documents related to clinical care. There are protocols and patient handouts that are difficult to find and they pull the resident’s attention away from the patient’s bedside in order to find them. In our last article we gave specific examples of how Box improves this work flow.

Security: We have to know where and how information was shared. We have decided against any and all patient information on the cloud to make HIPPA violations impossible. Privacy and security were paramount as we did not want to introduce any weakness that our security people would take issue with. A stand alone file system that interacted with our sharepoint website, but did not leave it open was essential.

Copyright protection: We have taken very seriously the need to protect the journal articles, book chapters and intellectual property that we are sharing. We want open, easy access, but cannot have this information shared outside of our residency program.
Discussions: We loved the ability to have a discussion between residents and faculty about an article, a lecture, or a video. We have not even touched the surface of what this ability can add to the learning environment.

Massive Storage: Our Enterprise account gives unlimited storage space that is meticulously backed-up. (It is actually listed as 909 terabytes–so not truly unlimited, but more then we can use). Our current lecture and Grand Rounds videos take 500-700 mb of space each–which adds up approximately 100 gigabytes per year of video.

Streaming: all videos are streamed from the site and this enables residents and faculty to watch the video rapidly on their mobile devices and computers without downloading the entire file first. In addition, all videos, images, articles and powerpoints are able to be previewed in a web browser–this avoids the need for external players or programs and is a time-saving feature. Microsoft word, excel, powerpoint are supported as well as google docs (with many of them being able to be edited within Box).

In the next article we’ll discuss how our experiences have been with Box from a Resident Physician perspective.

No faculty member or resident of Wake Forest University Emergency Medicine Residency, including the authors, have any financial relationship or have received any type of payment with any of the companies that are mentioned in this article. In addition, the authors have no financial disclosures to make and do not own stock or any interest in any of the companies mentioned in this article.