Many of us claim to have cloud based solutions just by leveraging AWS/Azure infrastructure.  In order to reap all the benefits of cloud, we should move to PaaS. In our latest product development, we are taking this path. I just wanted to share some of my experiences in this blog.


I have built two products and both of them were hosted in Azure. Essentially, we had VMs on which WE managed SQL Server, IIS, OS etc. Of course we had separate VM for application servers and database servers. Things worked out nice as we had the availability/security of any world class data center.

However, people had to login to these VMs using remote desktop to manage lot of activities such as installing our web apps, web API apps, patch OS etc. As you can imagine, even though this helped a great deal, you still had to perform lot of manual work. For example, if the traffic increased and if you wanted to scale horizontally, it involves lot of manual work.

Now Azure offers a service called “Azure App Service”. I am not sure what is the equivalent service called in AWS. This is where things get very interesting.




All our products are built using Microsoft Stack, so will take this concrete example and describe the scenario. Like most of the modern web applications, our solutions are built using ASP.NET MVC. So in order to move from IaaS to PaaS, you do not have to make even a single change to your MVC application. I hope you understand huge benefit of this. Just like any normal MVC application you develop in your favorite Visual Studio 2015, debug on local IIS or IIS Express. Only when you are ready to deploy this application, there is an additional option to deploy to Azure App Service (You have to have installed Azure SDK 2.9.5 to see all the tooling in Visual Studio 2015). All the magic starts to happen from here onwards. When you choose this option and deploy this to Azure app service, you get an url. You will have option to map your domain and SSL certificates through azure portal.

What is different? Why Should I use Azure App Service?

Once the app is deployed, unlike you IaaS scenario, you cannot login to VM using Remote desktop. That is how it should be. Now let us assume a following scenario, traffic to your web site is heavy during certain times of the day. You can login to azure portal and configure how many instances of your web apps needs to be available during different times. When you do this, you do not have to worry about load balancing etc. Out side of those specified periods, azure will bring the number of instances automatically.

Besides, you tell Azure to dynamically scale the number of instances. For example, if the CPU goes above 80%, increase the instances.

Azure App Services has another cool thing called deployment slots.


In a given environment (For example, Dev, QA prod Prod), you can deploy your app to different slots. After deployment, you can test them and perform a hot swap once everything is working fine. I hope you understand the advantages it brings to your deployment process. Imagine a scenario where you cannot afford to have any downtime for your web application. Assuming your application very well tested, you can deploy to “Staging” slot of “Production” machine. You can perform a through testing on production instance to make sure everything works as planned. Once the “staging” slot on production instance is working as planned, you can perform a hot swap to production slot.


Few Minor changes we made to our existing MVC application

All our MVC applications use Enterprise Library for logging purpose. We used both database and file listener for logging. Once you move to Azure App Services, you won’t be able to login to VM, hence no access to file system. We started using Azure diagnostic listener.


Moving from IaaS to PaaS could not have been any easier than this. Happy moving !


You can empower  patient to do certain things. This helps us to keep information accurate and lesson the burden on medical practices. One such piece of information which can be tracked by patient is their pharmacy. We provide a user friendly way to pick their pharmacy.


In our patient portal, patients can search for pharmacies based on city,state and zip. They just click on the markers on the map to select a given pharmacy.


pharmacies on map

More information about cancer platform is available at


Agent (drug) billing is reasonably complex. When you administer drugs to patient, your have to submit a claim. This claim should have appropriate HCPCS code information.

If you have a system which provides all this information, you can have a more efficient billing process. Our oncology content management system covers both clinical and financial aspects.


The following screen shot shows how you manage agent information in our oncology content management system.

agent list


Every drug has different billing unit formation and determines what HCPCS code should be reported in your claim. If you have this information easily accessible. The following screen shot shows how you can capture detailed billing information and used in your billing process. Note that, Aloxi billing information is taken from internet for demonstration purposes only.

In addition to this description information, our system helps to manage the mapping of appropriate HCPCS code to help creating a very powerful super bills. This super bill will cover drugs and associated CPT codes used for chemotherapy administration.

aloxi agent billing information


With a powerful content management systems like ours, you can accomplish many things more efficiently.



Cancer patients under chemotherapy and radiotherapy experience many side effects. How does your software (EMR and Patient Portal) helps the providers and patients to capture side effect and its grade.

There are many ways by which you can enhance the UX (user experience). What I like about our side effect capturing piece is how we show grade information. Severity of all the side effects is graded using a number 1 through 5. If you just show a number, it means very little to the end user. Also, these grades mean different things based on what kind of side effect we are talking about.



Why did we go to this extent?

Patient engagement and patient navigation is very important in the cancer world. If you let patients record this information (via oncology specific patient portal), you can take appropriate actions based on the grade. It is important to guide the patient to select an appropriate grade. This helps the navigation team to act accordingly.

Every bit of extra attention you pay while building software helps. In this particular case, just by helping patients to select an appropriate grade, you can take timely action (if needed) so that patient does not end up going to ER.




The topic of patient scheduling in EMR is anything but new. However, patient scheduling in oncology specific EMR software needs some special considerations. When patient cannot make it for a given CxDx, should we consider shifting rest of the CnDn?


The following imaginary patient “Jane Doe” is on ACT regimen and her chemotherapy treatments are scheduled as follows.


If she cannot make it for C1D2 on scheduled date, there must be a easy option to shift rest of the treatment schedule accordingly. I was not sure what needs to be done. Finally decided to provide the option of automatic shifting of treatment days in our EMR software.

From what I understand, it is important to keep track of planned chemo admin date and actual administered date. Adherence to the planned dates has an impact on the efficacy of the chemotherapy treatment.

Cancer treatment workflow differs from other specialties in many ways. It needs a oncology specific solution. Scheduling is just one of those special cases.


All this clinical information has been there forever. But, very few tools have made it available to the clinician at the point of care in a easy and friendly fashion.

Process and evidence based approach helps in providing best and consistent care.


As we all know, every cancer has different stages. Treatment options differ based on the stage of cancer. One of the decisions by the clinicians at the point of care involves what kind of workups are needed. Some clinicians may remember all these things in their head. But, having a process and evidence based approach helps in providing  best and consistent care. As you can see from the following screen shots, a given practice can easily establish their process of what workups are recommended for a given cancer/stage. Our platform (content management and decision support tools) has a wonderful way of accomplishing these goals.

Every cancer type has its own definitions for TNM. It is hard for clinicians to remember all that. Our tools provide that information in a most user friendly manner.

stage-group TNM at point of care


When a clinician has to make a decision on workups, just by a click of button you can access this information.

stage-group workups at point of care


Our goal is to produce one of the best oncology platform to help everyone involved.

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When oncologists have to pick a suitable regimen at the point of care, it is important to have access to as much information as possible. There are three major solutions (including our ‘Pandith’ in Piiker platform) in the oncology industry. Eviti and Clear Value Plus (McKesson) are the other two solutions.


Clear Value Plus

This is a product offered by McKesson. You can find more information about this product at McKesson’s Clear Value Plus


Eviti is now part of NantHealth. This tool helps physicians to pick a suitable regimen at the point of care. More information about this product can be found here.

Pandith (Piiker Cancer Platform)

This is a new kid in the block. This is part of our Piiker platform. This software aims to provide unprecedented information while making the regimen selection at the point of care. You can search for regimens based on various clinical criteria.


Just by expanding a row (by clicking the gray arrow), provider will have access to very useful clinical information which will aid in the decision making process. In this screen shot, you can see that all the side effects caused by this regimen are easily available to the provider. Beauty of the solution is how information is made available in a most user friendly manner.


You can search for regimens based on various clinical aspects. The following screen shot shows a scenario where you can drill down to ICD codes of a given cancer type (in this case, user has selected breast cancer)



Comparing regimens side by side. The following screen shot will demonstrate the kind of user experience we are providing while working with such a complex set of information. In this screen shot you can see that, provider has selected two regimens and wants to compare various details of the regimen.

pandith-checkbox selection


pandith - compare

Our solution has many advantages. It is nicely integrated with pieces of the puzzle to provide a complete solution while not compromising the UX (user experience).

Our goal is to provide the best possible tools help providers and patients in the cancer treatment process. As you can tell from these screen shots, we pay attention to every small details to make that difference.

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Telemedicine value proposition in undeniable. We wanted to take advantage of this technology to help everyone involved in the cancer care. Our Piiker cancer platform supports telemedicine from ground up. While making appointments, there is an option to specify weather you want a face-to-face or telemedicine session.

There are many reasons why sometimes cancer patients cannot make it to physician’s office. Even if they do, there is lot of pain, inconvenience and cost involved. I thought, telemedicine in this scenario is very useful for everyone involved. In this blog I will briefly describe how our platform supports telemedicine from ground up.

Patient has to communicate with various treatment team members.


In our oncology specific EMR, we have option to start the telemedicine session (if that appointment was setup to be a remote session). The following screen shot shows how that interface looks in our EMR. Appropriate resource from the provider’s office will start the telemedicine session.

start teleconference

Patient can login into our oncology specific patient portal from their location and join this telemedicine session. The following screen shot shows how it is done in our patient portal. In this particular scenario, patient ‘Jane Doe’ is signed into her patient portal. She can look at list of her appointments and has an option to join the telemedicine session.

Join teleconference

As I mentioned in my earlier blogs, we have the concept of creating virtual office for counselors and nutritionists in our platform. Even counselors and nutritionists can interact with patients remotely using our telemedicine support in our platform.

The following screen shot shows scheduling feature with in counselor’s virtual office. You can see that, there is an option to setup either a face-to-face or telemedicine sessions.

counselling appt 01


Piiker platform offers everything you need in the cancer treatment process in one place. Every piece of the puzzle is nicely integrated to provide best experience and value. We want to make a very positive impact in the world of cancer treatment.

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premature optimization IS BAD

Product development is very challenging for various reasons. I personally feel that premature optimization is bad. This directly contradicts the tenets of MVP. When we are developing a product, we should aim to skip couple of generations and think beyond (dream big) .

I decided to write this blog after a recent incident that happened in our product design/development team.

I knew that we have a very good design which is built for accommodating changes. So I got the idea of virtual offices so that I can easily include the counseling and nutritionist aspects in the cancer patient care process. People started screaming at me and accused me (in a friendly way of course) of expanding the scope. In my mind, I was focused on the business value and had abandoned all other constraints.

After few design sessions, we all found out that, with very little refactoring, we could accommodate the ‘virtual office’ concept. The point of I am trying to make is, don’t unnecessarily constraint your self if you don’t have to. IMO, this is single most important virtue that differentiates startups (small companies) from big corporations. If you search for ‘corporate innovation’ on Google, you find many articles on why that has become such a hot topic.

Our product Piiker has taken a very different approach at solving the needs of cancer providers and patients. It has put together all the required pieces of puzzle in an innovative manner. This would not have been possible if I had focused more on constraints. Innovation thrives when you abandon the constraints!.

Cancer, Patient portal & Counseling

Counseling plays an important role in cancer patient’s treatment process. We wanted to provide an option for patients to look for counselors through their patient portal. Also, providers can refer to patients to counselors through our oncology specific EMR.

When bundled payments become the norm, the integrated solutions (like our Piiker) will bring a distinct advantage.


When I mention, ‘comprehensive’ cancer solution, I really mean it. My vision is to include everything that is important for cancer patients and providers (counselors and nutritionists are also part of this) in this platform. It is easier said than done. As you can see from my blogs here and at Piiker, we have tackled this in a most elegant fashion. Even though we could have created a cockpit like interface (with lot of buttons, dials and what not), we have kept user experience clean and simple.

Counselors can setup their virtual office in our platform. They can manage their employees,calendars and other related information in this virtual office.  Their notes will directly gets captured in this system and available to all the providers who are in charge of managing this patient. Patient-counselor scheduling activities takes place with in our platform. Same list of counselors is available in our EMR. Providers can easily refer patients to one of them using a friendly interface within the EMR.  I will write more on this virtual office later. It deserves its own blog post.

When patients login to this oncology specific patient portal, there is an option for them to search for counselors in couple of different ways. The following screen shots shows our interface in patient portal. In this case, patient wants to look at their location on a map.




Patient can zoom in to look at the street level information like this


When users click on those markers on the map, they can see more details about this particular counseling organization. The displayed information includes their contact information, what kind of services they offer etc..

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