Preprints (earlier versions) of this paper are available at http://preprints.jmir.org/preprint/10041, first published Feb 05, 2018.
Background: Cloud computing is an innovative paradigm that provides users with on-demand access to a shared pool of configurable computing resources such as servers, storage, and applications. Researchers claim that information technology (IT) services delivered via the cloud computing paradigm (ie, cloud computing services) provide major benefits for health care. However, due to a mismatch between our conceptual understanding of cloud computing for health care and the actual phenomenon in practice, the meaningful use of it for the health care industry cannot always be ensured. Although some studies have tried to conceptualize cloud computing or interpret this phenomenon for health care settings, they have mainly relied on its interpretation in a common context or have been heavily based on a general understanding of traditional health IT artifacts, leading to an insufficient or unspecific conceptual understanding of cloud computing for health care.
Objective: We aim to generate insights into the concept of cloud computing for health IT research. We propose a taxonomy that can serve as a fundamental mechanism for organizing knowledge about cloud computing services in health care organizations to gain a deepened, specific understanding of cloud computing in health care. With the taxonomy, we focus on conceptualizing the relevant properties of cloud computing for service delivery to health care organizations and highlighting their specific meanings for health care.
Methods: We employed a 2-stage approach in developing a taxonomy of cloud computing services for health care organizations. We conducted a structured literature review and 24 semistructured expert interviews in stage 1, drawing on data from theory and practice. In stage 2, we applied a systematic approach and relied on data from stage 1 to develop and evaluate the taxonomy using 14 iterations.
Results: Our taxonomy is composed of 8 dimensions and 28 characteristics that are relevant for cloud computing services in health care organizations. By applying the taxonomy to classify existing cloud computing services identified from the literature and expert interviews, which also serves as a part of the taxonomy, we identified 7 specificities of cloud computing in health care. These specificities challenge what we have learned about cloud computing in general contexts or in traditional health IT from the previous literature. The summarized specificities suggest research opportunities and exemplary research questions for future health IT research on cloud computing.
Conclusions: By relying on perspectives from a taxonomy for cloud computing services for health care organizations, this study provides a solid conceptual cornerstone for cloud computing in health care. Moreover, the identified specificities of cloud computing and the related future research opportunities will serve as a valuable roadmap to facilitate more research into cloud computing in health care.
Cloud computing (CC) is an innovative paradigm that provides users with on-demand access to a shared pool of configurable computing resources such as servers, storage, and applications . CC possesses unique features (ie, on-demand self-service, broad network access, resource pooling, rapid elasticity, and measured services) that are argued to enhance traditional in-house health information technology (IT) approaches in health care organizations (eg, hospitals and clinics). Researchers claim that IT services delivered via the CC paradigm provide major benefits for health care, including improved flexibility in the use of IT resources , high availability of IT infrastructure to address ever-changing health IT demands , and low upfront investments and IT maintenance costs for the use of health IT . Surprisingly, the benefits promised by using CC often do not hold in practice: it has, for example, been reported that the use of cloud computing services (CCSs) is tied to implementation and preparation activities that impede the flexibility of CC , the promised high availability of cloud-based IT infrastructures also cannot always be ensured (eg, sometimes the maximal attainable IT resources are strictly predefined) , and the use of CCSs is not guaranteed to yield the expected economic advantages for users in health care (eg, due to unexpected high upfront costs) [7,8]. There is therefore a mismatch between our conceptual understanding and the accepted meaning of CC for health care (ie, the value and/or consequences of using CC) in practice. Such a mismatch not only hampers the meaningful use of CC in the health care industry (ie, CC should provide constructive support)  but also could lead to countereffects for health care. As reported in a recent case, performance of an electronic health record system enabled by CC in a United Kingdom hospital diverged from initial expectations and led to countereffects, resulting in a £200 million (US $262 million) project failure and the hospital's inability to deliver key services on a large scale [10,11].
Although the topic of CC in health care has been widely discussed in the literature, existing publications mainly focus on development of single CC applications or platforms in health care [12-16] and development of security mechanisms for the use of CC [17-21]. Although some studies have tried to conceptualize CC or interpret this phenomenon for health care settings [4,22,23], they are heavily based on a general understanding of traditional health IT artifacts or mainly rely on the interpretation of CC in a common context, which leads to an insufficient or unspecific conceptual understanding of CC for health care. CC is an IT innovation for the health care industry that differs from traditional health IT approaches; in addition, when conceptualizing the topic of CC in health care, it is essential to seriously consider the health care context. The health care industry is markedly different from the commonly understood context and interpretation of CC . Thus, this more general CC context is not necessarily adequate for health care. To this end, past research suggests that a nonspecific grasp of the CC concept in research and practice, irrespective of the intricacies of the health care sector, might be a major reason for why few successful implementations of CCSs in health care exist .
RQ1: What are the relevant properties of CC for service delivery to health care?
RQ2: What are the specific meanings of these properties for health care?
To address the research questions, we drew on data from a structured literature review and 24 expert interviews to develop a taxonomy of CCSs for health care organizations. Taxonomies are a form of classification  that are widely used to understand IT concepts in health care [27,28]. We expect to use this taxonomy to organize existing knowledge about CC in health care to fulfill our research purpose. In particular, we relied on the taxonomy to understand CC's key service delivery properties for health care organizations (RQ1) and thereby conceptualized CC for health care settings. By classifying 50 CCSs for health care organizations that we identified from both the literature and interviews using the taxonomy, we derived specificities of CC for health care (RQ2) that subverted and, therefore, challenged our understanding of CC in a common context or from a traditional health IT perspective. Our study conceptualizes CC specifically for health care. More importantly, we derived concrete research directions based on our conceptualization of CC to facilitate research on CC in health care.
CC is an innovation for health care organizations. In the health care industry, 3 types of innovations can be observed: (1) innovation focusing on the manner in which consumers access health care and fund the related services; (2) innovation applying technology to improve products, services, or care; and (3) innovation generating new business models . CC is an innovation of applying (information) technology in health care organizations (type 2) that is in sharp contrast to traditional health IT approaches. CC provides 3 different service models—software as a service (SaaS), platform as a service (PaaS), and infrastructure as a service (IaaS)—all of which are Web-based . CC can therefore deliver fundamental IT resources such as processing, storage (IaaS), and platforms together with programming languages, tools, and/or libraries that support users to develop and/or deploy software (PaaS). CC can also provide ready-to-use software applications (SaaS), which run on the cloud infrastructure, to health care organizations.
CC relies on different deployment models to provide IT services. First, in a public cloud, the infrastructure of CCSs is provided for open use by the general public. Second, the infrastructure of a private or community cloud is provisioned for the exclusive use by a single organization or a specific group of organizations, respectively. Third, a hybrid cloud is a combination of 2 or more of the aforementioned deployment models. Whereas public clouds exist off the premises of cloud users, private and community clouds may exist on or off premises.
Our research aimed at organizing knowledge about CC and conceptualizing CC in health care. We employed the concept of knowledge about innovations by Rogers  as a means to interpret the knowledge about CC in health care and guide the taxonomy development. We chose it because Rogers' concept of knowledge is one of the few established concepts in research that can specify an IT artifact by observing it as an innovation, which is appropriate for CC as an innovation in health care. Moreover, Rogers' knowledge about innovations serves as a basic concept in his diffusion of innovations theory. Although we did not specifically address issues regarding CC's diffusion, we aimed for a specific understanding of an innovation (in health care), which is consistent with Rogers' ultimate purpose for this concept in the diffusion of innovations theory.
According to Rogers, 3 different types of knowledge are relevant for an insightful understanding of an innovation: (1) awareness knowledge comprises information about the existence of an innovation, (2) how-to knowledge describes how the innovation can be applied, and (3) principle knowledge explains the approach in which an innovation works. In this research, we targeted how-to and principle knowledge to understand the term knowledge. This is because most are aware of the term "cloud computing" . Our research focused on the properties of CCSs that describe how CC can be used in health care organizations (how-to knowledge) and the ways in which CCSs support health care organizations (principle knowledge).
We employed a 2-stage approach to develop a taxonomy of CCSs for health care organizations. As illustrated in Figure 1, we conducted a structured literature review and 24 semistructured expert interviews in stage 1, drawing on data from theory and practice. In stage 2, we employed the views of how-to and principle knowledge, applied the method used by Nickerson et al , and developed a taxonomy of CCSs for health care organizations. The taxonomy development method integrates the evaluation of the taxonomy into its development process such that no further a posteriori evaluation of the taxonomy was required.
To obtain data for the development of our taxonomy, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework  and performed a review of the literature on CC in health care organizations. We searched literature databases to identify research articles addressing the topic of CC in health care organizations. Figure 2 presents a schematic of our approach, which includes the literature databases and the search string employed. It must be emphasized that we iteratively developed our search string. We tested broader keywords (eg, "eHealth," "health IT") but decided to employ more specific keywords that target health care organizations for the final search string because our taxonomy specifically focused on health care organizations. Moreover, we found that the broader keywords did not result in many additional relevant articles but increased noise, which diminished the quality of the literature review. We performed keyword, title, and abstract searches and ultimately full-text reviews. Next, 2 researchers independently screened the identified articles. The articles were first screened using keywords, titles, and abstracts and then using the full texts. We excluded articles that were not published within the last 10 years (not up to date: the term CC was not readily used until 2007), not in English, not peer-reviewed, or did not address the topic of CC in health care organizations (off-topic). A total of 66 articles remained after the screening.
Figure 1. Research methods overview. Asterisk refers to taxonomy evaluation by means of the ending conditions. CC: cloud computing, CCS: cloud computing service.
Figure 2. Flow diagram of inclusion/exclusion and literature analysis.
Once the screening was complete, we analyzed the remaining articles and identified 17 additional articles that were off-topic but could not have been excluded without an in-depth full-text assessment. This process resulted in a final sample of 49 eligible articles that were assessed in detail. With the assessment, we aimed to understand the concept of CC in health care organization contexts from a research perspective. Moreover, we attempted to identify concrete CCSs for health care organizations in addition to their characteristics from the literature. Accordingly, we classified the literature into 2 categories: conceptual and empirical. The conceptual category covered articles providing general conceptual statements about CC in health care and articles proposing CCSs that have not been deployed in practice. The empirical category contained articles describing concrete CCSs for health care organizations. This occurred because the applied taxonomy development method employed both a deductive approach (development based on data from the conceptual category) and an inductive approach (development by observing objects that need to be classified, namely, data from the empirical category) . Of the 49 eligible articles, 24 were classified as conceptual and 25 as empirical. Articles that describe general features of CC and apply them to concrete CCSs were classified as special cases of the empirical category. Two researchers separately analyzed the articles. Each relevant statement was extracted and converted into 1 or more pieces of code representing a property of CCSs for health care organizations. Codes created by both researchers were compared and aggregated resulting in a master list containing codes encapsulating the properties of CCSs. The master list covers codes from both the conceptual (ie, general conceptual understanding of CC) and empirical categories (ie, concrete CCSs and their properties). It must be emphasized that 25 concrete CCSs for health care organizations were identified from the literature. A description of these CCSs can be found in Multimedia Appendix 1.
To gather knowledge that could inform the development of the taxonomy from practice, we conducted 24 semistructured expert interviews, as listed in Table 1. We applied a purposeful sampling strategy that focused on selecting individuals who are especially knowledgeable about a phenomenon of interest to recruit interviewees . We included only experts who were engaged in IT activities in health care organizations and who had used, provided, or knew about concrete CCSs for health care organizations. After 24 interviews, we reached data saturation and stopped recruiting additional interviewees. The first 12 interviewees listed in Table 1 focus on the Chinese health care cloud market, and the rest focus on the German market. We selected these countries because they are the main cloud players in Asia and Western Europe, which are among the regions with the highest market share in the overall  and the health care cloud markets . Moreover, the cloud markets in China and Germany are complementary to each other: whereas CCSs for health care organizations in Germany are restricted to European cloud providers due to data protection regulations by the European Union, CCSs in China rely on large health IT players (eg, IBM, Cisco, and Microsoft) mainly from the United States supplemented by Chinese domestic providers . Thus, we were able to gain insights into knowledge about CC in health care from a wide spectrum of practices. The interviewees came from 18 different organizations and had an average of 15 years of work experience.
Table 1. Overview of interviewees.
Our interview guide was structured into 3 topics, as shown in Multimedia Appendix 2. Topic 1 addressed the interviewee's organization, work activities, and professional experience. Topic 2 focused on the interviewee's (conceptual) understanding of CC in health care. In topic 3, interviewees were asked to enumerate and describe all concrete CCSs in health care organizations with which they were familiar. The interviews lasted between 30 and 90 minutes, with an average of 51.33 minutes. All interviews were audio recorded and transcribed afterwards.
Two researchers separately analyzed the transcripts. For the same reasons as in the literature analysis, the interview analysis focused on not only the conceptual understanding of CC in health care but also concrete examples of CCSs, including their properties. Thus, we classified the interview data obtained from topic 2 of the interview guide in the conceptual category, whereas the interview data obtained from topic 3 fell into the empirical category. Both researchers employed the same coding technique used in the literature analysis to analyze the interview data. Consequently, we obtained a list of codes representing a conceptual view of CC in health care for the conceptual category and a list of codes representing properties of concrete CCSs in health care organizations for the empirical category. In total, 25 CCSs for health care organizations were identified from the interviews, which are presented together with the 25 CCSs identified from the literature in Multimedia Appendix 1.
For the taxonomy development, we chose the method proposed by Nickerson et al , which provides a systematic taxonomy development approach for IT objects and is well acknowledged in the domain of health IT [38,39]. According to Nickerson et al , a taxonomy is a set of dimensions in which each dimension consists of more than 1 characteristic. In taxonomy development, several iterations are used to determine dimensions and characteristics. After each iteration, predefined ending conditions are employed to evaluate the taxonomy: if not all ending conditions can be fulfilled, the taxonomy development continues with the next iteration. In each iteration, researchers can choose between an inductive and deductive approach. A deductive approach is based on theoretical knowledge about the objects that need to be classified; an inductive approach is based on observing and analyzing a sample of the objects. For the deductive approach, we applied all data about CC from the conceptual category (see Figure 1). For the inductive approach, we employed data from the empirical category for all 50 identified CCSs in health care organizations.
Before developing a taxonomy, researchers must define a meta-characteristic and ending conditions. The meta-characteristic guides the choice of dimensions and characteristics in the taxonomy. As a result, each dimension or characteristic of the taxonomy is a logical consequence of the meta-characteristic. Our taxonomy builds on 2 relevant knowledge types of CCSs to define the meta-characteristic: how-to and principle knowledge. We defined "service delivery properties of CCSs for health care organizations" as our meta-characteristic that covers how CCSs can be used by health care organizations (how-to knowledge) and describes the approaches in which CCSs support them (principle knowledge). Both knowledge types serve as the conceptual orientation of the taxonomy as a whole. For the ending conditions, we adopted all of the objective and subjective ending conditions from Nickerson et al . The subjective ending conditions also serve as criteria to evaluate the sufficiency of the taxonomy.
For each iteration, we randomly chose a developmental approach (ie, inductive or deductive). Based on the chosen approach, we randomly selected data from our data pool accordingly (ie, understanding of CC from the conceptual category for a deductive approach and concrete CCSs and their properties from the empirical category for an inductive approach). The amount of data was adjusted such that each iteration could be performed in a reasonable time frame (45 to 60 minutes).
For an iteration using the deductive approach, we first examined codes about CC to identify and summarize new characteristics and/or dimensions. We determined whether each potential new characteristic or dimension derived from a code could be considered a logical consequence of the meta-characteristic and whether there was a concrete CCS in our empirical category that could be classified into this characteristic/dimension. If both criteria were fulfilled, the new characteristic/dimension was added to the existing taxonomy. For an iteration using the inductive approach, we first examined and compared the properties of the selected CCSs from the empirical category. We attempted to derive common characteristics of the chosen CCSs by comparing their codes. If the identified characteristics were new, we attempted to assign them to existing dimensions (as characteristics) if possible. Otherwise, we grouped the characteristics, inspected their conformity with the meta-characteristic, and defined them as new dimensions for the taxonomy, if necessary. After each iteration, we applied the predefined ending conditions to evaluate our taxonomy. For an inductive approach, we additionally classified all CCSs that were analyzed using the (preliminary) taxonomy, as required by Nickerson et al . After 14 iterations, we met all ending conditions and thus stopped the taxonomy development. Multimedia Appendix 3 summarizes these iterations and the data we applied to each. Because all identified CCSs for health care organizations (n=50) were analyzed in our research (ie, an objective ending condition), these CCSs were classified by the taxonomy. The final classification result serves as a part of the taxonomy.
Our taxonomy of CCSs for health care organizations is composed of 8 dimensions and 28 characteristics (see Table 2 for overview). The first 4 dimensions (service form, deployment model, targeted cloud advantage, and timeliness) represent principle knowledge, which is related to the inherent mechanisms and principles of a CCS and describes the approaches in which CC supports health care organizations. The remaining 4 dimensions address concrete methods to implement (ie, how to use) CCSs for health care and represent how-to knowledge.
The service form and deployment model dimensions are consistent with the service and deployment models of CC, respectively . They clarify the most basic operational principles of CCSs for health care organizations, which relate to principle knowledge. The dimension service form contains 3 characteristics: infrastructure, platform, and software, which refer to IaaS, PaaS, and SaaS of CC, respectively. The deployment model dimension indicates whether CCSs are deployed using a public, community, or private cloud. Because a hybrid cloud is, by definition, composed of 2 or more of the aforementioned deployment models, we do not define hybrid as an independent characteristic of the deployment model. Instead, our taxonomy represents a CCS with a hybrid deployment model by using 2 or more of the characteristics defined above.
The targeted cloud advantage dimension describes the concrete cloud properties from which a health care organization can benefit. This dimension highlights the effects of using CCSs and is also considered a type of principle knowledge. Scalability refers to the advantage of a CCS that extends its IT resources (eg, storage, processing, and memory) to overcome a health care organization's IT resource scarcity or support resource-intensive tasks. Elasticity represents a CCS's capability to dynamically allocate available resources based on users' demands and thus optimize resource use for all users. Ubiquity indicates that users can access the CCS from any location. Cost efficiency emphasizes the cost advantage brought by CCSs. Shareability refers to the ability of CCSs to enable the efficient exchange and sharing of data between different users, whereas interoperability denotes the ability of a CCS to smoothly integrate and operate with disparate systems and machines. Security allows health care organizations to take advantage of cloud providers' advanced data security mechanisms or technologies.
Timeliness assesses how quickly CC is able to deliver services and related data to health care organizations (real time vs not real time) and thus relates to principle knowledge. We define a CCS as real time if it is ready to process or transfer data at any time, such that the computational results and requested data are immediately available.
Table 2. Taxonomy of cloud computing services for health care organizations.
The supported task dimension specifies the areas in which health care organizations use CCSs. This dimension highlights the manner in which CC supports health care and is deemed a type of how-to knowledge. Supported task includes 4 characteristics: clinical, administrative, strategic, and research. Clinical refers to medical activities in health care organizations that are directly associated with patient diagnosis and treatment. Administrative denotes management or support tasks in health care organizations, such as patient registration, admission, and discharge. Strategic represents tasks performed by management teams in health care organizations, such as strategic planning decisions, human resources management, and performance evaluations. Research represents all activities that are related to medical research.
The user dimension relates to how-to knowledge and aggregates the possible user types of CCSs. This dimension differentiates between a patient who receives medical treatment at a health care organization, the medical staff (health care professionals as well as administrators), and the family members of the patient.
Service delivery device refers to how-to knowledge because this dimension represents the types of client devices used to access the CCS. A CCS with an independent characteristic allows users to access services using any computer or mobile device. Adapted specifies that a CCS is compatible with different types of devices but operates more efficiently on a certain group of devices (eg, mobile phones or tablets) via technical adaptation to those devices (eg, developing specialized applications for tablets or compressing data to accelerate data transfer for mobile phones). Specialized represents those CCSs that can be accessed by only 1 or several designated groups of devices, such as authorized tablet computers, workstations in health care organizations, or specific medical devices.
Finally, the patient data involvement dimension, which also relates to how-to knowledge, explains how patient-related data are used to deliver services. Internal indicates that a CCS uses patient data that are internally available to the health care organization for IT service delivery. External refers to a situation in which a CCS uses patient data collected from external sources, such as outside medical professionals or the patients themselves. No involvement indicates that a CCS does not have access to patient data and thus does not use such data in IT service delivery.
After completing all taxonomy development iterations, we classified all 50 CCSs that we identified during stage 1. Multimedia Appendix 4 presents the final classification results. In this section, we provide an example of how our taxonomy can be used to classify CCSs for health care organizations. This example examines a hospital decision support system for bed-patient assignments (see C22, Multimedia Appendix 1). Because this CCS addresses patient administration and assists hospital leadership in measuring and benchmarking hospital operations, it supports both administrative and strategic tasks. The CCS is delivered in the form of a software application and is hosted in a public cloud environment. The targeted cloud advantage is scalability because the hospital benefits from CC's computing resources to analyze large quantities of data based on complex mathematical models. The CCS does not operate in real time (not real time). It is used by medical staff and is not device-specific (independent). Finally, the patient data processed by the CCS are internal.
Our taxonomy fulfills all predefined ending conditions after 14 development iterations. In particular, the fulfillment of 5 subjective ending conditions indicates high sufficiency of the taxonomy. We summarized these subjective ending conditions and provide a justification for the fulfillment of each condition in Multimedia Appendix 5. Notably, the subjective ending conditions describe the essential features of the derived taxonomy.
By observing the taxonomy, which includes the classification results of CCSs for health care organizations, we obtained specific implications of CCSs for health care.
bSaaS: software as a service.
cPaaS: platofrm as a service.
dIaaS: infrastructure as a service.
eThe specificity challenges what we have learned about CC in a general context.
gThe specificity challenges what we have learned about traditional health IT.
Table 3. Specificities of cloud computing for health care.
As demonstrated in Table 3, these implications offer 2 types of challenges to our previous understanding of CC in health care: they challenge what we have learned about CC in a general context (type 1) and in published traditional health IT studies (type 2). We employed the term "specificities" to summarize these implications, thereby highlighting the specific meanings of CC for health care. More importantly, as shown in Figure 3, the summarized specificities suggest research opportunities with exemplary research questions, facilitating future research about this relevant phenomenon in health IT.
Previous studies show that in a common context, PaaS and IaaS are as relevant as SaaS in the cloud market ; however, this result is challenged by CC in the context of health care (type 1). We found that 92% (46/50) of the CSSs deliver services in the form of SaaS (dimension service form). The identified research articles and the interviewees even applied the term "X as a service," such as "hospital information system as a service"  or "documentation as a service" (i17), to emphasize the importance of such CCSs, although by their nature they belong to SaaS. This is possibly because health care organizations expect to exploit the advantages of SaaS to the greatest extent and in a timely manner.
For hospitals, cloud almost only means software as a service because many hospitals want to use (them as) off-the-shelf products. ...SaaS products that support medical areas are especially welcome because hospitals always expect to get immediate improvement from the cloud in their core business.
The lack of PaaS and IaaS in health care organizations indicates an insufficient state of CC in health care, which was confirmed by several interviewees (i07-i08, i10, i17-i19). For PaaS, our taxonomy shows only one CCS (C06), although several interviewees noted the urgent need for industry-specific PaaS.
We want to develop our own SaaS, but there is just no specific PaaS for health care organizations. General PaaS are not enough.
The need for PaaS in health care is not only because PaaS in general provides ready-to-use technical support for programmers but also because it has the potential to provide solutions to effectively fulfill industry-specific IT requirements. This is, for example, explained by an interviewee who was involved in developing a CCS for a hospital.
There were so many complex things we had to consider for hospitals. We kept wasting time on unnecessary meetings to find technical solutions. I dreamt of having a PaaS that could support us. ...Of course, there is more. ...Compliance is also a main topic. Hospitals ask over and over again whether our software is compliant with this or that. ...Example HIPAA: If the PaaS we use is compliant with HIPAA, then we can tell them: Yes, our software is HIPAA-compliant.
Further industry-specific IT requirements that can potentially be supported by a health care PaaS—constant demand on cutting-edge technologies, high health IT agility (to meet changing medical requirements), the need for different domain-specific medical data structures, and support for industrial joint implementation activities (eg, between government and hospital)—were also mentioned by the interviewees.
For IaaS, previous research studies  and our interviewees both emphasized the strategic meaning (i08) of IT infrastructure (ie, critical information infrastructure) for the health care industry and consequently the extremely high importance of IaaS (i20) for health care organizations. We identified only a limited number of IaaS (n=3) used for general administration of health care organizations (C28, C37) or data storage (C38), which hardly fulfills all health care organization IT infrastructure requirements.
Figure 3. Research opportunities for cloud computing in health care. CC: cloud computing, CCS: cloud computing service, IaaS: infrastructure as a service, IT: information technology, PaaS: platform as a service.
Future research could focus on exploring the lack of PaaS and IaaS for health care. As revealed by our interview data, there is a particular need for research studies that systematically investigate specific requirements for health care that cannot be covered by PaaS and IaaS in a common context and thus a need to design and develop industry-specific PaaS and IaaS.
Previous studies have raised concerns about security and privacy as the Achilles heel of CC , which are main barriers for the adoption of health IT artifacts [44,45]. These concerns might be more severe for public clouds, whose infrastructures are accessible by many different users . However, the dimension deployment model indicates that more than half of the investigated CCSs are based on public clouds, especially given that almost all of these CCSs involved patient data (dimension: patient data involvement) that were sensitive and entailed security or privacy issues. To this end, providing a high level of data security was regarded as a targeted cloud advantage in 10 of the identified CCSs, of which 6 were deployed on public clouds. This challenges our understanding of CC in a general context (type 1). Additionally, interoperability may also impede the adoption of CC in a general context . For health care, however, our taxonomy demonstrates that increased interoperability is a benefit of CC. Security and interoperability are traditionally the most intractable challenges in health IT, and industry standards concerning IT security and interoperability in health care are evolving . Cloud providers can devote resources to the implementation of industry standards or best practices that many hospitals cannot afford . CC can thereby address security and interoperability issues in a more effective manner, which was confirmed by the interviewed experts (i03-i04, i06-i07, i10, i13-i14, i16-i18, i21).
CC is safe. The problem is how to make people believe that.
Data security, interoperability...these are pluses. Speaking of data security, using paper is also not safe, if you insist on saying a cloud is not safe.
As highlighted in Figure 3, future research could investigate the role of security and interoperability in cloud adoption studies and focus on the adopter's awareness or perception of increased data security and interoperability from CC in health care settings. Moreover, researchers could focus on exploring the factors (such as security and interoperability) that have industry-specific impacts on cloud adoption in health care, in contrast to a general context.
It is surprising that CC offered economic advantages (cost efficiency) for only 11 of the 50 CCSs. In a general context, the use of CC is heavily motivated by short-term economic interests . Research relying on this general understanding of CC claimed the low costs were the principle advantage of CC in health care . Our research challenges the understanding of CC in a general context (type 1) by revealing that when using CCSs, many health care organizations frequently must transfer large volumes of data to and from the cloud (eg, medical images ). This can cause data transfer bottlenecks due to the obsolete (network) infrastructures currently in place at many health care organizations—a typical industry-specific IT issue (i02, i08, i15). Thus, CC might still require significant short-term investments in health care organizations' network resources, internet bandwidth, or other relevant infrastructures. It is therefore not surprising that the interviewees were not convinced of the potential financial advantages of using CC in health care (i01-i05, i07, i10, i17). They (i01-i02, i10) even noted that additional expenses for CC, such as consulting fees, could increase health care organizations' expenses. However, our interviewees reported that in the long term, CC will reduce their general IT maintenance work (i02, i24) and help them avoid possible IT reinvestments (i22). Future research could therefore focus on (re)examining and explaining the economic results of using CCSs in health care organizations. Moreover, researchers could focus on CC business processes or investment strategies in health care settings that enhance the short-term benefits for health care organizations.
We recognize that most of the identified CCSs (36 of 50) support clinical tasks in health care organizations (dimension: supported task). This observation challenges previous studies about traditional health IT (type 2), which have concluded that health care organizations primarily focus on the use of IT applications for administrative, strategic, or financial functions rather than clinical activities . These findings reflect an urgent need to use CC to remedy the deficiencies of traditional health IT in the context of health care organizations' clinical activities, as revealed by our literature review .
In clinical practice, even ordinary data analysis occasionally overwhelms traditional health IT with large volumes of data and complex analytical algorithms.
CC can address this problem with highly scalable IT resources and is therefore considered a "powerful weapon for IT tasks in the clinical area" (Interviewee i03).
This viewpoint is supported by our taxonomy, as more than 70% (23/32) of the CCSs possessed high scalability as one of their advantages (dimension: targeted cloud advantage), with a focus on clinical areas. For research opportunities, we suggest researchers concentrate on CC that supports research tasks in health care because both the literature  and our interviewees (eg, i18) reveal that research activities in health care depend even more on highly scalable IT resources to address large amounts of data, which is currently managed only in a small number of identified CCSs (n=6).
Seniors, the disabled, or someone who doesn't like technologies also needs to use appointment services, so we decided to involve their relatives. ...Although we have to have more users and processes now, I believe CC can offer the necessary computer resources. It's a good thing, and I think this might be a reason to have more CCSs.
We even have some patients who don't use the Internet at all. Their children could help them...only in this way can we ensure that each patient truly benefits from our services.
Despite the potential of CC to support patient-centeredness, only a limited number of patient-centered CCSs were identified in this study. Future research could therefore focus on examining how CC supports patient-centeredness and on designing further CCSs that support it.
We found that 42% (21/50) of the identified CCSs adapt themselves to or are specialized for certain devices for service delivery (dimension: service delivery device). For CCSs that support clinical tasks, this rate is even higher (16/36, 45%). In general, a barrier impeding the use of health IT is the alteration of users' traditional workflow paradigm . For health IT that supports clinical functions, physicians who are forced to adapt health care delivery processes to technologies are often unwilling to use it. Our taxonomy reveals that almost 80% (16/21) of the CCSs that were adapted to user devices, such as mobile phones and tablet PCs or other specialized medical devices, targeted service ubiquity (dimension: targeted cloud advantage) and thus the mobility and flexibility of IT service delivery (type 2). Existing health IT research concluded that these devices are inherently subjected to limited computing capacity and are criticized as unsuitable for complex tasks, such as clinical work . However, our research shows that more than one-third (8/21) of the CCSs that were adapted to user devices enjoyed the benefit of resource scalability (dimension: targeted cloud advantage). Thus, as emphasized by our interviewees, CC can effectively "offset the [traditional] limitations of mobile devices or other small devices. It can increase the use of innovative devices in health care" (Interviewee i07). Future research could explore how CC overcomes the limitations of mobile or small devices in health care, which is a relevant but underinvestigated topic in health IT .
Specificity 7: Cloud Computing Facilitates Collaboration in Clinical Settings.
Our taxonomy demonstrates that most of the CCSs (46/50) involved the use of patient data (dimension: patient data involvement). One major expected purpose of involving patient data in health IT is to employ the data as a means to link users or systems in different clinical areas and thereby facilitate their collaboration . However, research generally highlights a lack of sufficient health IT applications that support collaboration . Our taxonomy challenges this (type 2) and reveals that CC has the potential to address this issue, as 21 of the 46 CCSs (that involve patient data and support clinical areas) possessed shareability or interoperability as an advantage (dimension: targeted cloud advantage) and had improved collaboration between users or systems as one of their main purposes. However, these CCSs are not without limitations. Only a small fraction of these CCSs (6/21) involved patient data from external sources (dimension: patient data involved). Including patient data from different sources is the basis of collaboration in clinical activities . Our interviewees (i02, i05, i08, i11, i15) noted that including patient data from external sources (eg, external medical professionals or patients themselves) is relevant for improving collaboration in clinical processes because "no hospitals can depend only on themselves. They need continual cooperation with, at least, patients" (Interviewee i02).
The interviewees remarked that CCSs in health care organizations that have a collaboration purpose mostly focus on internal data exchanges (which was also revealed by our taxonomy), although they believed that CC has the potential to also facilitate collaboration with external parties. The timeliness dimension is another indicator for collaboration because it addresses how intensively data exchanges occur. However, for the 21 CCSs that supported clinical areas and possessed the shareability or interoperability characteristics, we found that only 8 enabled real-time data exchanges. Real time is crucial for effective data exchanges and the resulting collaboration in clinical processes (i05-i06, i08, i11, i18).
Collaboration [based on data exchanges] should not only take place but also in a real-time manner. A delay of important data for even a few minutes could be fatal for clinical activities.
Future research should therefore strive to improve CCSs for collaboration in clinical activities due to the currently (still) insufficient state of CCSs (as well as general health IT [51,60]) for supporting collaboration. Moreover, researchers could also investigate how CC supports collaboration in areas other than clinical settings in health care.
For health IT research, our contributions are threefold. First, we suggest a taxonomy that structures the knowledge of CCSs (ie, CCS properties) for health care organizations. In particular, our taxonomy targets principle and how-to knowledge to systematically conceptualize the concept of CC for health care settings. Unlike previous research that heavily relied on CC literature from common contexts or on traditional understandings of health IT, our study analyzed CC's industry-specific properties not only from the health IT literature but also from practice. Thus, the derived dimensions and characteristics of the taxonomy highlight the aspects of CC that are most relevant to health care. We thereby contribute to closing the gap between an insufficient conceptual understanding of CC and the actual phenomenon in practice for health care. Second, our taxonomy suggests 7 specificities that subvert and thus challenge our previous understanding of CC in a general context or of traditional health IT. These specificities advance the understanding of CC in health care. Third, we derived concrete research opportunities for health IT (see Multimedia Appendix 6 for a summary). As presented at the beginning, health IT researchers have been interested in the development of single CC applications or data security topics. For both topics, we provide suggestions that guide future research (eg, to focus on developing CCSs that enable collaboration in health care) or even create new opportunities and directions (eg, to focus on inherently increased, instead of decreased, IT security in health care by using CC). In addition, we noticed that research topics on CC are by nature broad and diverse, which should not be limited to the development of CC applications and IT security, as in current health care settings, but can include more areas such as its business perspective [61,62], its adoption (by organizations) [63,64], user awareness and acceptance [65,66], and its certification [67-69]. The proposed research directions in this study are a step toward facilitating research on CC in health care settings.
For health IT practice, the derived taxonomy can be applied to investigate CCSs for health care organizations on 2 different levels. On a macro level, the classification of available CCSs in a certain health IT market using the taxonomy can serve as an indicator of the current state of these CCSs. Cloud providers or policy makers could, for example, suggest new CCSs that address possible market gaps (eg, PaaS for hospitals). On a micro level, health care organizations could apply the taxonomy to understand an individual CCS. In particular, by combining the characteristics from the dimensions that a CCS possesses, health care organizations could specify each CCS's profile as demonstrated, for example, by the hospital decision support system for bed-patient assignments, as referred to in the Results section. By finding matches as well as mismatches between the CCS's profile and their own organizational needs, health care organizations could screen and identify CCSs that would be useful to them and thereby increase the meaningful use of CC.
A main limitation of this research is that our data focused on health care organizations that are hospitals and clinics, as implied by the literature review search string and by the interview questions. This is because hospitals and clinics are not only the backbone of the health care industry  but also representative IT consumers in health care . We therefore expected that a taxonomy derived from hospitals and clinics would provide more generally valid insights into CC for health care settings. Research that focuses on CC in more specific health care settings (eg, nursing homes) could employ our taxonomy as a starting point. We suggest that such research use the proposed dimensions and characteristics as a checklist to investigate CC. If required, adjustments along the taxonomy's dimensions and/or characteristics can be easily carried out , resulting in more specific taxonomies that are useful for certain health care settings. Future research should also broaden the perspective on the topic of CC to cover further health care settings by using, for example, more general search strings for literature reviews (eg, including terms such as "health IT" and "eHealth") or by designing interview topics that cover CCSs in other health care areas.
Our work relied on data from 24 expert interviews, which does not necessarily guarantee that all CCSs for health care organizations from practice were discovered. However, the selection of our interviewees ensured a wide spectrum of knowledge about CC in health care in Asia, Western Europe, and the United States, which represent the main CC health care markets. Future research could also include niche CC markets to further verify and improve our taxonomy.
Although the term "cloud computing" has existed since 2007, the phenomenon of CC in health care remains in its infancy and calls for research on this phenomenon have emerged [4,25]. By relying on perspectives from a taxonomy for CCSs for health care organizations, we provide a solid conceptual cornerstone for research about CC in health care; moreover, the suggested specificities of CC for health care and the related future research opportunities will serve as a valuable roadmap.
We acknowledge support by Deutsche Forschungsgemeinschaft and the Open Access Publishing Fund of Karlsruhe Institute of Technology. We acknowledge support by the Multi-Disciplinary Identification of Lineage-Specific Signaling Dependencies in Cancer research project (FKZ 01ZX1406/01ZX1615), funded by the German Federal Ministry of Education and Research.
Overview of identified cloud computing services.
Taxonomy of cloud computing services for health care organizations.
Taxonomy's fulfillment of the subjective ending conditions.
Paul M, Das A. Provisioning of healthcare service in cloud. In: Mishra DK, Azar AT, Joshi A, editors. Information and Communication Technology. Singapore: Springer; 2018:259-268.
Nelson R, Staggers N. Health Informatics: An Interprofessional Approach. 2nd Edition. Philadelphia: Evolve Elsevier; 2018.
Tawalbeh L, Bakheder W, Song H. A mobile cloud computing model using the Cloudlet scheme for big data applications. 2016 Presented at: 2016 IEEE First International Conference on Connected Health Applications; Washington.
Patton M. Qualitative Research & Evaluation Methods: Integrating Theory and Practice: the Definitive Text of Qualitative Inquiry Frameworks and Options. 4th Edition. Thousand Oaks: Sage Publlications; 2015.
Sahni N, Huckman R, Chigurupati A, Cutler D. The IT transformation health care needs. Harvard Bus Rev 2017(Nov–Dec 2017):128-138.
Nepal S, Pathan M. Security, Privacy and Trust in Cloud Systems. Berlin: Springer; 2017.
Gao F, Thiebes S, Sunyaev A. Exploring cloudy collaboration in healthcare: an evaluation framework of cloud computing services for hospitals. 2016 Presented at: 49th Hawaii International Conference on System Sciences (HICSS); 2016; Koloa.
Wilson E. Patient-Centered e-Health. Hershey: Medical Information Science Reference; 2009.
Eltayeb M, Dawson M. Understanding user's acceptance of personal cloud computing: using the technology acceptance model. In: Latifi S, editor. Information Technology: New Generations. Volume 448. Berlin: Springer; 2016:3-12.
Schneider S, Lansing J, Gao F, Sunyaev A. Development of a taxonomy for cloud service certification criteria: a taxonomic perspective on certification schemes. 2014 Presented at: 47th Hawaii International Conference on System Sciences (HICSS); 2014; Waikoloa p. 6-9.
©Fangjian Gao, Scott Thiebes, Ali Sunyaev. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 11.07.2018.


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Chilifest organizers announce spring festival lineup
By Lexi Ellis @lexiellis10
In between bouts of Friday night dancing, the organizers behind the 2020 Chilifest Music Festival took over Shiner Park on Jan. 17 to announce this spring's country-fried lineup.
The past, present and future: A look back on the changes of the decade and forward to the future.
By Rebecca Morris @RebeccaSheWrote
This month marked the beginning of a new decade. As with the start of every year, people are reminiscing and creating resolutions, but due to this important time marker, they are also looking further back over the past 10 years as a whole and turning toward the next decade with hopeful eyes.
Randy Rogers Band, William Beckmann welcome back Aggies with Hurricane Harry's performance
By Shelby McVey @xshelbymcveyx
Friday night, the Randy Rogers Band will be rolling into College Station with special guest William Beckmann to play a full band show at Hurricane Harry's.
Student wins big and gives back over holiday season
By Stanley Clark @Stanleyjclark2
While most people string light-up icicles along their rooftops, Jordan Maywald spent the winter break creating a 2.5 acre light display at his family home in Austin and raising money for charity along the way.
Say cheese: Macaroni-based restaurant oozes way into town
By Hollis Mills @sillohsllim
Following a minor delay involving infrastructure, I Heart Mac & Cheese at Jones Crossing will host its grand opening on Jan. 29 at 11 a.m.
Generation Z: A Latinx Center at Texas A&M
By Daniela Flores
National Media highlight Generation Z, the generation after millennial, as the most progressive and diverse generation. National media also mentioned that Gen Z has the ability to choose what is going to happen in the future; that is one of the factors that helped create the student-led peti…
Navigating difficult discussion in college classrooms
By Lauren Devenzio
Sleepy-eyed college students of varying ages sat nestled behind their glowing laptops in an early morning lecture class, including sophomore Gracia Luo. As the political science professor at the front of the room flipped back and forth through her PowerPoint slides on immigration policy, one…
More than classes, Texas A&M is a major job provider for students
By M'kenna Norman
They are seen all over College Station, transporting students to and from the Texas A&M campus. Those who haven't seen them, have heard them. At every turn, an Aggie Spirit Bus grinds and squeals its way around campus and the surrounding city.
Coffee culture at Texas A&M University
By Nicole Shair
Ever since Jane Turchi could remember, every morning her mother would make herself a cup of coffee, complete with tons of creamer and whipped cream on top. Being a curious child, Jane would scoop the whipped cream from the top of her mother's mug and get a hint of coffee along with it. Thoug…
A very jazzy Christmas: brass ensembles present an energetic twist on holiday classics
Classic jazz beats causally blended with jingle bells to create the peppy and nostalgic musical arrangements to fill the air in Rudder Theatre Thursday night.
MSC OPAS to ring in the spirit with holiday classic 'A Christmas Carol'
By Cynthia Duarte Julian @cynthiakarid
The Aggie spirit will be joined by the likes of Christmas Past, Present and Yet to Come this upcoming weekend.
Folk duo Ordinary Elephant to perform at Village Café
Ordinary Elephant has toured the world and are set to bring their live, folk sound to Bryan.
History professor David Vaught named Distinguished Lecturer
History professor David Vaught's name was added to the list of nearly 600 Distinguished Lecturers within the Organization of American Historians on Nov. 21.
Sip-and-shop event promotes Christmas spirit in Downtown Bryan businesses
The Downtown Bryan Association will host the Wine and Wassail event in Downtown Bryan on Saturday from 4 to 8 p.m., where patrons can walk store-to-store, sipping wine and homemade wassail while browsing the unique offerings of local businesses.
Some Texas A&M students away from home during the holidays
The holidays are a time to celebrate with family and friends, and for Texas A&M students, that often means going back home.
New majorette dance team Maroon Prestige hits stage for first time
Texas A&M's new majorette dance team Maroon Prestige made their debut at this year's Fusion Fiesta. Afterward, the team's performance was posted on social media, gaining hundreds of likes and shares from supporters.
A&M Club Golf Team places eighth in National Championship
For the first time since its inception in 2012, the Texas A&M Club Golf Team has qualified for the NCCGA National Championship at the WinStar World Casino and Resort in Thackerville, Oklahoma.
University Band gives final performance of the semester
Several hundred people gathered in Rudder Theatre to attend the final University Band Concert of the semester at 5:30 p.m. on Nov. 24.
Thanksgiving events around Aggieland
By Oscar Fuentes @osfuentes
With Thanksgiving just around the corner, there will be many holiday celebrations and activities taking place throughout the upcoming week. For anyone spending their Thanksgiving break around Bryan-College Station, here are four events to keep your eyes peeled and stomach empty for.
Department of Multicultural Services celebrates 30 years on campus
In recognition of diverse voices and inclusivity on campus, the Texas A&M Department of Multicultural Services (DMS) celebrated its 30th Anniversary on Nov. 23.
Local restaurant celebrates 20 years
Twenty years ago, Christopher's World Grille opened its doors in Bryan with owner and chef Christopher Lampo in the kitchen, serving cultural cuisine from around the world.
A&M steel pan ensemble Maroon Steel performs around B-CS
Maroon Steel is a steel pan ensemble club that started at Texas A&M in 2013 with the purpose of getting together to play and spread the drum music associated with the Caribbean islands.
TEDxTAMU organizes third fall conference
By Amishi Sachdeva @amishisachdeva
MSC Aggie Leaders of Tomorrow (ALOT) will host the third and final session of TEDxTAMUSalons for this semester on Nov. 19 from 6 to 9:30 p.m. in Rudder Forum.
Forsyth Galleries celebrates anniversary with immersive opera experience
Texas A&M's Forsyth Galleries celebrated their 30th Anniversary on Nov. 15 with an interactive opera performance curated by Austin based musician Nathan Felix.
Dance Arts Society's fall show brings passion for dance to the stage
With stories of love and loss told through the medium of movement,the theme of "Rise," the Texas A&M Dance Arts Society (DAS) took to the Rudder Auditorium stage Sunday afternoon at 2 p.m. to perform their student-choreographed fall show.
"A Pop-Up Shop to End Slavery" raises funds for rescue mission
In an effort to raise on-campus awareness of modern day slavery, The International Justice Mission hosted "A Pop-Up Shop to End Slavery" on Nov. 14 and 15 from 1 to 4 p.m.
Fusion Fiesta celebrates diverse cultures and heritage at A&M
Across the MSC Bethancourt Ballroom, a group of students clothed in bright orange and blue áo dàis pose for a picture, and as the throng of people continues to mill about, the first trills of a mariachi band fill the room with rich, vibrant sound.
Employees at A.P. Beutel Health Center celebrate namesake's 127th birthday
By Meagan Sheffield @mshef350
Student Health Services employees are celebrating A.P. Beutel's life, as well as the Texas A&M health center's history and future, in preparation of the namesake's 127th birthday.
Mechanical circus comes to Aggieland
The classic circus routine will be reimagined with a modern twist, as Cirque Mechanics takes over Rudder Auditorium at 7 p.m. on Tuesday to perform 42ft - A Menagerie of Mechanical Marvels.
World War II veteran reflects on his time in Aggieland
At 98 years old, William "Bill" Jones, Class of 1942, still reflects on his time at Texas A&M in the Corps of Cadets and the role he possessed while serving in three wars after graduation.
Cultures come together for Brazos Valley Worldfest
More than 8,000 people are expected to walk throughout the cultural displays at this year's Brazos Valley Worldfest on Saturday.
Reynolds Gallery presents stories from sexual assault survivors
Along the walls hang everyday clothes, including T-shirts, jeans, shorts, and even a child's dress, its flowery pattern standing out against the white interior of the gallery. While the articles of clothing look innocent, there is a painful story behind each outfit: the story of someone who …
BUILD converts shipping containers into medical clinics through student-unifying work project
In order to bring healthcare services to third-world countries and communities in need, the student organization BUILD has worked for the past eight weeks to turn metal shipping containers into mobile medical clinics. Until Nov. 22, groups of student volunteers will work from 9 a.m. to 6 p.m…
From daytime Aggie to nighttime DJ
By day, Ethan Swindull walks around campus as just another Aggie rushing to class. By night, he is a DJ who is making a splash in the electronic dance music scene.
MSC Town Hall Coffeehouse Series showcases student artists
By Alyssa Gafford-Gaby @AGaffordGaby
MSC Town Hall hosts its Coffeehouse Series every other Wednesday in the MSC Barnes & Noble Starbucks to showcase student and local talent.
A&M sororities expect over 1,000 visitors at Halloween celebration
The Texas A&M Panhellenic Council will host Trick or Treat on Greek Street this Halloween from 5 p.m. to 7:30 p.m. on Athens Drive in College Station.
Spirits of Aggieland
Believe them or not, ghost stories and spooky tales are woven into the fabric of Texas A&M's long history.
"Bandstand" performance opens at Rudder Auditorium
With every note, the auditorium fills with energy. The men onstage increase the beat, passionately channeling raw emotion through the instruments at their fingertips. As the lights begin to glow brighter, the woman at the microphone and the rest of the cast pour their hearts into the final r…
Local haunted house to dish out Halloween frights
By Hollis Mills @sillohsllilm
From the depths of Downtown Bryan, Fright Nights Haunted House is set to scare unsuspecting guests from 7:30 to 11:30 p.m. on Halloween night.
Broadway musical "Bandstand" premieres first national tour at A&M
Texas A&M is the opening stop on the first national tour of the Broadway production "Bandstand" in Rudder Auditorium Tuesday and Wednesday at 7:30 p.m.
Card company puts a new spin on personalized mail
The greeting card company Tellinga was created with a goal to help people stay connected on a tangible, personal level. Tellinga allows people to send individualized story cards through snail mail with their loved ones as the characters.
Youtubers Cody Ko and Noel Miller to perform Thursday night
Youtubers Cody Ko and Noel Miller will perform their sold-out comedy show "Tiny Meat Gang" today at 8 p.m. in Rudder Theatre.
A&M's Model UN reflects on program achievements in recognition of United Nations Day
On United Nations Day, members of Texas A&M Model UN (TAMUN) reflect on the program's short but successful history and how the program has shaped their interests within the topic of international diplomacy.
Students recognized for their sustainability efforts
To promote the sustainability program on campus, Dinner with a Prof partnered with Residence Life Sustainability to host the 6th Annual Fall Sustainability Dinner and Awards on Wednesday at 6 p.m. in Commons 109.
Annual race promotes fitness with a hoppy twist
Bright and early Sunday morning, community members and Aggies from all across Texas piled into Kyle Field to earn their racing stripes and throw back some cold ones.
Wynn Williams to join Kyle Park on Hurricane Harry's stage
For most of the week, the old wooden dance floor of Hurricane Harry's sits empty. But as the weekend approaches, the bar and dancehall will be filled with country music lovers from all across Aggieland.
Sounds of Italy brought to America in OPAS show
As a part of their first U.S. tour, Italian opera group The Four Italian Tenors will bring listeners on a vocal journey through Italy on Thursday at 7:30 p.m. in Rudder Auditorium.
National park comes alive in experimental orchestra performance
In its latest showcase, experimental orchestral group Montopolis visited the Queen theatre on Oct. 13 to perform songs enlivened with the spirit of one of Texas' most popular parks.
Forsyth Galleries to host first silent disco among the artwork
For many students, going to parties is not a fun prospect, getting dragged along by their friends to listen to music they don't like at high volumes. However, there is another way to go clubbing where everyone has control over their own music selection and volume — the silent disco. And ther…
KAGS Chief Meteorologist Bob French retires
After about 40 years of forecasting the weather throughout southeast Texas and the Brazos Valley, KAGS Chief Meteorologist Bob French is retiring.
Former student learns to walk again following year long paralysis
In Hawaii, "Ala a'e" means to rise. One year ago this fall, Jon Price lost the ability to move any segment of his body from the neck down. Today, he is standing tall.
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We can't win our battles when we're our own worst enemy.
We'll never stand in victory if our thoughts constantly condemn us.
We were made for more.
Our confidence comes from Christ.
His power surges through our veins.
His heart beats in our chest.
His Word opens doors, parts the waters, and heals the broken.
Your life is hidden in Christ.
He already won the victory.
Refuse thoughts that weaken you.
Think, stand, and fight like the heir you are!


graduate students to fulfill the University's mission in the state of Texas.
additional funding for increasing the total faculty.
increase diversity in units under their supervision.
I'm not clear on the context for the four names.
process the produced those names?
committees in the university. The faculty senate appoints one or more to them when there are vacancies.
who are elected by their college senate caucuses.
list was updated on Oct. 8.
Q: Would it be fair to report that the list was "finalized" on Oct. 8?
A: I believe that this is the composition of the current committee.
that admissions criteria changes can be adopted) is not the best strategy.
IT HAS NOT OCCURRED IN PREVIOUS YEARS (caps intentional)!
rights movement since the Sixties, and was even an Affirmative Action Officer in an earlier life.
is right for this university, even if he has to take a lot of heat over it.
approved by the President within four days.
A: Usually a letter comes from him to me.


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Wearable Artificial Kidney: A portable dialysis machine for patients on the go
By: Nidhi Goyal | October 24th, 2014
People with kidney failure regularly need to check into a hospital to purify their blood through dialysis. The whole process is fairly time consuming.
But things are about to change. A new wearable dialysis system is going to be tested in a clinical trial in the U.S.
Dubbed the Wearable Artificial Kidney (WAK), this device is light enough to wear as a belt. It works just like a conventional dialysis machine. Blood is purified through a series of molecular filters to sieve out the waste and purified blood is then pumped back.
WAK is battery powered and it doesn't require an external source of pure water. Typically, a conventional dialysis machine requires around 120 liters of fresh water for a single dialysis treatment; this device uses only 375 cubic centimeters of water. It continuously filters the water that was used and reintroduces it back into the device.
Weighing just about ten pounds, WAK has been developed by researchers at Cedars-Sinai Medical Center, Los Angeles, and the David Geffen School of Medicine at UCLA.
Nidhi Goyal
Nidhi is a gold medalist Post Graduate in Atmospheric and Oceanic Sciences. You can also find Nidhi on Google+.
Stroke Survivors Walk Again After Researchers Inject Stem Cells Into Their Brain
Daisy Is Apple's New Recycling Robot Tasked With Taking Apart iPhones and Recovering Materials
Watch Exuberant POV Skydive Into Packed NASCAR Racetrack
Amazon Prime Air Faces Many Pre-Flight Challenges
Tomatoes, Rye and 8 More Food Crops Grown Successfully in Mars-Equivalent Soil Ahead of Mars One Mission
Drone Sets World Record For Heaviest Payload Lifted By a Remote-Controlled Multicopter


The DUPLO program is an opportunity to join a structured group within a safe and non-judgemental environment. Its aims are to support and mentor carers whilst increasing children's social skills and fostering an inclusive, creative culture. Children play whilst focusing on their abilities to talk, feel, play and communicate with other children. Parents and or Carers have the opportunity to receive resources & advice on strategies relating to issues that may be of concern as well as appreciate the occasional visiting guests. As there is a regular group of children attending each session, both parents and children build a supportive network through meeting with others in a similar situation.


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Q: How to un-pretty print XML I would like my XML to be not-pretty printed, i.e. all on one line, no spaces between elements. e.g.
<element>value</element><element><nested>value</nested></element>

(Exception handling removed)
public String transform(Document doc) {

    javax.xml.transform.Transformer transformer = TransformerFactory.newInstance().newTransformer();
    transformer.setOutputProperty(OutputKeys.ENCODING, "UTF-8");
    transformer.setOutputProperty(OutputKeys.INDENT, "no");
    transformer.setOutputProperty(OutputKeys.OMIT_XML_DECLARATION, "yes");

    DOMSource source = new DOMSource(doc);
    transformer.transform(source, new StreamResult(stringWriter));
    String result = stringWriter.toString();

    return result;
}

Even with OutputKeys.INDENT as no, I am still getting pretty-printed XML when my input is created from pretty-printed XML.
I looked at How to unformat xml file, but I cannot just strip newlines and whitespaces from my XML, as my data may contain them. I don't really want to parse the string and format it myself, but I can't think of any other solution.
I am being passed the Document object, so I cannot modify the DocumentBuilder (as seen here https://stackoverflow.com/a/15462951/3887715). I could use the StringBuilder solution (https://stackoverflow.com/a/13163891/3887715), but I am concerned that any comments will be merged if they span multiple lines.
However, this is mostly used for logging purposes, so lacking any other solution, I think the StringBuilder one is the cleanest.

redpajama_set_name: RedPajamaStackExchange


Not much is known about Cheung Bo. He was very private, and prefered students "Go practise" than concern themselves about "Who learned from who". There are several differant traditions, on who he learned his Wing Chun from.
The usual story preserves that Au Shi, a friend of Yuen Kay Shan, that learned along side Yuen, from famed Bounty Hunter Fung Siu Ching, passed his system to a Nationalist doctor named Wai Yuk Sang. For a brief period of time Wai taught Wing chun and passed some of what he knew to Cheung Bo. Later in life, Wai Yuk Sang regretted teaching fighting skills and became a devoit Taoist. It was he who taught Sum Num the Sun Hei Gwun Hei Gung form, telling Sum to start and end his training with this special healing set.
Cheung Bo was a cook at Tien Hoi restraunt, and passed down Wing Chun to some of the employees. He was fairly large and strong, and had a fierce fighting reputation. Cheung Bo's Wing chun, was taught in mini sets refered to as San Sik. In the Cheung Bo family, Its not known if the Wing chun system they practise, was always San Sik based, or if it had at some point been a form, that was broken down into segments for ease of teaching. Its also possible that Cheung Bo may have worked or at least known famed Cho Gar Wing Chun Kuen Master Cho On who was also a cook by trade and had worked at Tien Hoi during the same time period, Cheung Bo did.
As Cheung Bo was a larger guy, he didnt have the body structure to keep his elbows in, as many of the Wing Chun masters of the day did. So he compensated with fast body shifting and wide sweeping "Sickling hand" motions.
He passed his art to Sum Num prior to Sum being accepted by Yuen Kay Shan, as his only disciple. Sum used some of Cheung Bo's San Sik method, as well as San sik he learned from Yuen, as early training to his students and has become a valuable part of the Sum Num lineages curiculum. It is also said that the Cheung Bo method, was refined by Yuen's expresion of Wing Chun Kuen.
Cheung Bo, just prior to his death, asked Sum Num, to help train both of his sons, in the Wing chun System. Sum Num, vowed to do so, and to this day, Cheung Bo's lineage preserves the hand forms of Yuen Kay Shan, just as the Yuen Kay Shan/Sum Num lineage presereves some of the Cheung Bo's San Sik method. Cheung Hon (Cheung Bo's 3rd Son), Cheung Mo Kun (Cheung Bo's 7th Son) as well has their classmate Wong Gut Chuen, incorporated the hand forms into there training system. Cheung Mo Kun accepted Fok King On to pass his skills down to.
Wong Gut Chuen, known as one of Cheung Bo's top students, lived in a house in a "4 in 1 building" owned by a landlord named Mak Gee Wan. Mak Gee found out Wong Gut was a Wing Chun Sifu, and asked to be taught. Wong Gut Chuen accepted him as a student, due to his serious nature in learning Wing Chun.
Mak Gee's son Mak Yiu Ming, developed a love for the Wing Chun system from all the time watching his father train. When Mak Yiu Ming was 16 years old, he asked his father if he could learn from Wong Gut Sifu. His father agreed and took him to see Wong Sifu. Mak Yiu was immediatly accepted as a student and learned from Wong Gut Chuen Sifu up until 1988, when he was given permision to start teaching himself. Mak Yiu Ming also learned from his Sisook Cheung Mo Kun. Mak Yiu Ming started teaching at the Culture Club of the Workers, and has had many champions from various Chi Sau and Jing Wu Athletic Association competitions. Wong Gut Chuen is still alive to this day being ruffly 92 years old.
According to information passed down by Mak Yiu Ming, Wai Yuk Sang learned from his elder brother, not Au Tzu.
Oral tradition from Sum Num varies dependent upon who asked him. It has been said he clearly stated Cheung Bo learned from Wai Yuk Sang -student of Au Tzu. Others he stated, "no one knows for sure, as Cheung would never confirm". An interesting fact surfaces, when one considers Fung Siu Ching was teaching Yuen and Au in 1933–1936. Sum started learning from Cheung Bo in 1938. So that means that Au Tzu would have had to have taught Wai Yuk Sang, who than taught Cheung Bo within a two year period, which seems highly unprobable.
Some Oral tradition suggests Cheung Bo didnt pass down a Look Dim Boon Gwun Form, or Knives, but did pass down a double ended pole/ Chan Mei Gwun, San Sik, San Sau and a Muk Yan Jong form.


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Bugasong
Tagudtud North
Bugasong § Barangays
Tagudtud North, Municipality of Bugasong, Province of Antique
Tagudtud North is a barangay in the municipality of Bugasong, in the province of Antique. Its population as determined by the 2020 Census was 1,145. This represented 3.30% of the total population of Bugasong.
The household population of Tagudtud North in the 2015 Census was 1,102 broken down into 246 households or an average of 4.48 members per household.
Number of households in Tagudtud North (1990‑2015)
According to the 2015 Census, the age group with the highest population in Tagudtud North is 5 to 9, with 135 individuals. Conversely, the age group with the lowest population is 80 and over, with 14 individuals.
Population of Tagudtud North by age group (2015 census)
The population of Tagudtud North grew from 843 in 1990 to 1,145 in 2020, an increase of 302 people over the course of 30 years. The latest census figures in 2020 denote a positive growth rate of 0.81%, or an increase of 43 people, from the previous population of 1,102 in 2015.
Population of Tagudtud North (1990‑2020)
Tagudtud North is situated at approximately 11.0684, 122.0832, in the island of Panay. Elevation at these coordinates is estimated at 30.0 meters or 98.4 feet above mean sea level.
Tagudtud North shares a common border with the following barangay(s):
Tica, Bugasong, Antique
Talisay, Bugasong, Antique
Cubay South, Bugasong, Antique
Anilawan, Bugasong, Antique
Tagudtud South, Bugasong, Antique


She could either cause a scene or go along with him. Didn't he understand if she protested, he'd be a dead man?
He turned and pulled her into his arms.
The bittersweet moment her body met his stole her breath away, while memories of passion and love assailed her. For the briefest of times, she'd belonged in the safe circle of his arms. The only time in her life she'd been truly happy and not alone. Ah, the dreams she'd spun, even though she'd known better.
Happily ever after didn't exist for her. Hell, it didn't exist for anybody.
The music wound around them, through them, proclaiming a romance that couldn't really exist. His heated palm settled at the small of her waist.
Every instinct she had tempted her to slide against him, to burrow into his warmth. Her mind fought to keep her body calm, but her brain had never triumphed when dealing with Nathan. Her heart had ruled, and in the end had been completely broken.
She tried to step back and didn't move. Yeah, she knew she'd hurt him when she'd ended their relationship, but after nearly five years, he shouldn't still be so mad. He'd had freedom for five years, which was a hell of a lot better than she'd had. She'd had pain and fear and uncertainty. She blinked.
"No" He spun her, easily controlling their movements.
His gaze narrowed, and he spun her again. She tripped again. Her damn leg didn't move that way.
She glanced toward the doorway and the two soldiers watching her. They'd straightened to alert stances. Damn it.
She threw his words back at him, gratified when his nostrils flared in irritation.


text:
DHQ denies granting amnesty to Boko Haram
Nigeria Defence Headquarters (DHQ), have denied granting amnesty to Boko Haram members, contrary to an online report that 800 repentant members of the sect, are currently undergoing skill acquisition training.
A statement credited to the Director of Defence Brig Gen Rabe Abubakar, quoted him as saying "the story is false and has no iota of truth in it, as the DHQ has never mentioned amnesty in all its statements."
This is even as the military issued a warning to Niger Delta militants to desist from acts of economic terrorism.
Abubakar in the statement said, the DHQ was aware of the emergence of a group in the Niger Delta region, which has vowed to cripple the economic activities of the country.
This they planned by vandalising pipeline, stealing and kidnapping expatriate workers and reaffirmed the "deployment of available resources to deal decisively with any threat to economic lifeline of the nation."
AmnestyBoko HaramBrig Gen Rabe AbubakarNigeria Defence Headquarters


text:
« Press Releases
Hon. Barry R. Poretz (Ret.) Joins The McCammon Group
Rich Huffman
Direct Dial: (804) 421-5530
The Honorable Barry R. Poretz, retired Magistrate Judge of the United States District Court of the Eastern District of Virginia, has joined The McCammon Group, a leading dispute resolution firm in the mid-Atlantic.
Judge Poretz served the United States District Court in Alexandria starting in 1992 until his retirement in August 2008. His distinguished judicial service was preceded by a civil litigation career representing both plaintiffs and defendants in Northern Virginia and Washington, DC. Judge Poretz is a former Partner at the DC office of Jordan, Coyne, Savits and Lopata. Judge Poretz is a former Assistant Commonwealth's Attonery in Alexandria, VA.
In addition to his notable legal credentials, Judge Poretz has served the community as a former Member on the Board of Directors for the Alexandria Hospital, a former Master at the George Mason Inn of Court, and a Judicial Member of the Federal Bar Assocation's Northern Virginia Chapter. He is a past Director and Executive Board Member of the Alexandria Bar Association.
An accomplished neutral with more than 200 settlement comferences to his credit, he is now available to serve your private mediation and arbitration needs throughout the mid-Atlantic and beyond.
Judge Poretz joins the other professionals of The McCammon Group located in Northern Virginia and Washington, DC:
Hon. F. Bruch Bach (Ret.) – Fairfax
Geoff A. Drucker, Esq. – Arlington
Frances Fite, Esq. – Vienna
Hon. Johanna L. Fitzpatrick (Ret.) – Alexandria
Robert J. Grey, Esq. – DC
Robert T. Hall, Esq. – Reston
Grayson P. Hanes, Esq. – Falls Church
Susan Massie Hicks – Fairfax
John A.C. Keith, Esq. – Fairfax
Hon. Donald H. Kent (Ret.) – Alexandria
Warren R. King, Esq. – DC
Stanton T. Lawrence, III, Esq. – DC
Hon. William H. Ledbetter, Jr. (Ret.) – Fredericksburg
Willie L. Leftwich, Esq. – DC
Glenn C. Lewis, Esq. – DC
Robert T. Mitchell, Esq. – Winchester
Alexia Morrison, Esq. – DC
Hon. William C. Pryor (Ret.) – DC
Russell H. Roberts, Esq. – Fredericksburg
Hon. Paul F. Sheridan (Ret.) – Arlington
Hon. Alfred D. Swersky (Ret.) – Alexandria
Bruce E. Titus, Esq. – Vienna
Hon. Arthur B. Viereff (Ret.) – Fairfax
Robert P. Watkins, Esq. – DC
Hon. Robert W. Wooldridge, Jr. (Ret.) – Fairfax
Hon. Wiley R. Wright, Jr. (Ret.) – Alexandria
The McCammon Group consists of sixty-five professionals including retired judges and practicing attorneys located throughout Virginia, DC, and Maryland. Since its founding in 1995, The McCammon Group has conducted more than 11,000 dispute resolution proceedings resulting in a mediation settlement rate exceeding 85%. It also provides arbitration and other dispute resolution services. The Facilitation, Training & Consulting division provides services to local, state, and federal agencies as well as public and private entities. For more information, please visit www.mccammongroup.com.


That brings us to the dreaded Fiscal Cliff, where tax rates and tax "reform" dominate the public discourse. By all media reports, increased tax rates for the "top 2%" are all but inevitable, while reform is also in the wind, now or shortly later. Reform seems likely to include at least some limitations (read, reductions) of itemized deductions such as home interest, local taxes paid and employer provided health care.
Yet, with all the talk of cutting tax preferences, we have not heard a word about any threat to the alimony deduction. Could this be because alimony payers are a formidable interest group? Is it that too many Congressmen pay alimony? Is it that alimony dollars are taxable to someone – the recipient? Maybe, the cost to the treasury is not great enough to garner attention. Whatever the reason, the alimony deduction, like the near-sacred charitable deduction, seems safe.
In fact, it looks like the value of the alimony tax deduction will increase in 2013 since, as the tax rates of alimony payers increase, so too will their alimony subsidy. If the top bracket resumes its Clinton Era 39.6% level, the value of the deduction for the high income earner will increase commensurately: a 13.1% increase! Where else do we find a tax shelter of increasing value in Fiscal Cliff America?
The November 28th Patriot Ledger reported that Judge James Menno, of the Plymouth Probate and Family Court, had entered the first court order of protection for a pet, permitted under a recent statutory enactment signed by Governor Patrick. LDRC's Chouteau Levine recalls from her years on the bench that serious abuse cases routinely included threats of and/or acts of abuse towards human victim's pets. Abuse is abuse, whatever its manifestation. That Judge Menno made the first order of this kind in Massachusetts is both random and fitting. No judge has a bigger heart or inclination to use his bench authority to protect and benefit his litigants and their dependents.
Dogs have long been recognized for their forensic and security usefulness to police and military institutions, as guides for the blind and most commonly, as beloved family members. In an era in which offices, hospitals, therapists and even courts are using or experimenting with pets as aides to reducing stress their own uniquely stressful environs, the role and importance of pets continues to grow. We have seen this principle at work in our own practice at LDRC.
For restructuring families, the disposition of pets is a growing demand. Some states have dipped their toes into "pet custody". We have not, which is probably appropriate. Pets remain "property" under our divorce framework. But, under Massachusetts law, people may now fund testamentary trusts to provide for care of a pet; and now Judges like Menno may enhance the security of these important members of our society.
Good for Judge Menno, and good for all of us.
As our practice develops, more of it seems devoted to lawyer-attended mediations, arbitrations and hybrids. When clients come to us with their counsel it is most often after the parties have experienced some litigation, and its attendant costs, delays and confrontations. They are either in the phase where the case has been pre-tried by the court and sits in the long queue for trial; or before the pre-trial conference itself. Occasionally, the case is in an earlier stage.
Why would litigation attorneys encourage or participate in mediation at any of these stages of litigation? It might seem to run counter to their own economic interest, and it involves relaxing some measure of control, something lawyers are loath to do. One reason is that some clients insist upon it, having heard from others that it may be an effective way of shortening what feels like an interminable process. Another is the wear and tear that increasing costs and the lack of any assured containment within the public court process imposes on lawyers and clients alike.
But, we find that the most common reason is that every week, more lawyers are realizing that it works! The lawyers themselves realize that they do retain a good measure of influence in this process. They see and experience that the mediation is fairly run; that everyone has their "say"; and, that in the end, no one is forced to do anything. Counsel also realizes that it is better to be paid fully for a process that bring early closure, than to run up an often uncollectible bill from a client after a long trial. Clients in the end are happier, and thus, more inclined to refer new clients to the mediation-friendly lawyer.
Mediators who do not welcome litigation counsel are cutting off a valuable source of business. Lawyers who refuse to mediate are short-selling their clients. The meeting of the two is good for all, especially the clients.
What's Good About Mediating Without Lawyers Present?
For many people, mediation with lawyers present is a contradiction in terms, as in "if we have a mediator, why do we need lawyers?" In fact, mediation without lawyers present is the dominant form in Massachusetts family law practice, though not in commercial mediation generally here, or even in family law elsewhere. While clients who choose to mediate without lawyers in "the room" (in quotes, because much mediation with lawyers "present" involves "caucus-style" mediation, wherein the mediator shuttles between the parties, who are in separate spaces), many do, and all should, have lawyers with whom to consult between sessions.
Two additional advantages for clients to enter into mediation without their lawyers on site are pacing and understanding. Agreements that are the product of direct party-to-party negotiation tend to evolve at a slower and more deliberative pace, often resulting from periodic (1- 2 hours) sessions, paced out over the course of other life events. As any divorce lawyer would confirm, coming to grips with family law issues is usually part of a larger emotional process. People who are immersed in the shock/anger/grief/confusion of the early days of separation (and for some, not so early) need time to process the most intense personal crisis of their lives to date, and making prompt decisions at the expense of deliberative ones can result either in buyer's remorse (making a "bad" deal to get out of the discomfort of an unsettled situation) or being blinded/hindered by the emotional moment so as to be unable to recognized a "good" deal because of the confounding influence of negative emotions.
Mediated agreements that do not involve the "crutch" of having a lawyer present to formulate and articulate "positions" and demands, may be made with greater understanding for the people who must live the deal. Especially if these clients are consulting with their lawyers between sessions, they have the ability to discuss their own interests in their own way, while still gaining clarifications, nuances and strategic guidance that help shape the ongoing process. Yet, they have the time to question, to ponder, to re-think and to re-shape a settlement at a pace that may increase understanding and appreciation of the stakes, the concepts and the solutions.
But,there also advantages to mediating with lawyers present. I will consider this in another blog post.


http://www.duas.org/regularsd.htm is updated on Duas.org and can be very useful to all Momineen.
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text:
Infographic: Here's a look at the digital habits of sports fans
Omar Akhtar
Sports fans are emotional, vocal, and huge consumers of all types of media. Brands that can directly connect with them have an opportunity to create massive digital engagement and crucially, get them to act on calls to action.
The results from the Fan Engagement Study conducted by Catalyst, an IMG consulting firm showed almost 70 percent of sports fans
who "like" or follow brands on social media are willing to take additional
action during sports events, including purchasing, commenting or sharing brand content.
"Content strategy is a major component for any brand, and this study reinforces that sports fans frequently consume and engage with social content that takes them well beyond the box score," said Bret Werner, senior vice president and managing director at Catalyst. "Avid sports fans are more likely to interact and identify with brands that act like fans."
The study, conducted annually since 2010, collected information from over 2,100 avid sports fans aged 16 – 64, measuring the digital media
attitudes and usage habits of NFL, NBA, MLB, college football and basketball. This was the first year soccer fans were included, with international data gathered from fans in Brazil and the UK.
Here are some of the key findings from the study, and an infographic:
While Facebook remains the
most widely used channel, fans are increasingly using Google+ and YouTube to
disseminate and acquire sports information
Google+ (+94%) and YouTube (+35%) witnessed the largest
year-over-year growth
Fans frequently engage with
content that advances story lines or provides a point of view
Pre-game excitement (72%), historic video (68%), bloopers
(66%), Q&A with coaches and players (66%) and game debate/banter (63%) are
among the most popular
Game day social
network interaction is on the rise
Fans engage on social channels before, during and
after sporting events at a higher rate than ever before. In some cases,
engagement is more than 30% higher than compared to 2012.
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