Which electronic health record system should I select?

Among physicians and managers in small-group practices today, there is no more common question.

But lately, another vexing question has emerged: Whether to install EHR software on servers in your office, or subscribe to an Internet-based system maintained in “the cloud.”

What Is “the cloud”?

When EHR vendors began offering their products via the cloud, many physicians were puzzled. Some think that the cloud is simply techie parlance for the Internet.

In fact, it refers to a method of computing whereby the critical applications are housed in remote locations — “hosted remotely” in tech jargon — and accessed by end users via the Internet.

Physicians have long been accustomed to “hosting” critical software applications on servers in the office. That is how they’ve accessed practice management systems — the information technology (IT) backbone of medical practices — for 20 years or more.

Having all the practice’s data hosted remotely — on the cloud — raises questions about data access and security.

Some of those fears may be eased if you consider how much you are already doing in the cloud.

For instance, many people conduct much of their banking via secure websites that allow them to access all of their private financial information, transfer funds, check investment accounts, and pay bills. Millions have used Web-based email systems such as Gmail for all manner of personal and professional correspondence for many years.

These services live in the cloud.

You do not have any software loaded and running on your computer to use these tools.

So, the cloud is really just a giant client-server model: a distributed application structure that partitions tasks between the providers of a service (called servers) and the clients. A client (a user workstation or PC) initiates communication sessions with the server by requesting a service function.

In the cloud, the server providing the service — for example, an EHR service — is hosted remotely. Your Web browser is the client.

Why the cloud is gaining in popularity

Cloud computing represents a paradigm shift in IT management. The cloud makes it possible for you to grow and expand rapidly and generate efficiencies and cost savings by paying as you go for the services you use.

Cloud-based EHR services are typically offered as complete software packages provided over the Internet, eliminating the need to install and run an application on your own computers and simplifying maintenance and support.

Sometimes this is referred to as “software as a service,” or SaaS.

For many practices the cloud-based solution is a good choice for several reasons:

• Generally, there are no retained earnings in a medical practice, so any new investments must be financed externally or the physicians take a hit against their current earnings. Low up-front costs are more palatable and less complicated.
• IT expertise and resources may be nonexistent or retained on a project-by-project basis. The cloud model does not require sophisticated technology infrastructure that must be built and maintained by expert, costly IT staff.
• A cloud-based EHR does not require a special facility or environmental considerations because on-site servers are unnecessary. Backup and disaster recovery services are central and inclusive in the cloud model.

But fear of losing control over critical data is often a stumbling block in cloud adoption. Actually, though, cloud computing can give you more control over your data than you get with a client-server EHR.

Cloud providers offer many options for protecting the data entrusted to them — often more than your in-house IT staff or budget could make possible. In all situations, however, data sovereignty should belong to you.

Other benefits of cloud computing:

• An encrypted high-speed Internet connection provides your practice with access to data and applications without having to manage software changes or invest in server hardware
• Updates are automatic and managed by the vendor so you won’t need staff to work over a weekend to install software, migrate files, or test data conversions
• And you’ll always be on the most current version, without requiring additional infrastructure investment.

Although there are start-up costs with the SaaS cloud model, typically around $13,000, there is no up-front software license to purchase or lease. With a client-server setup, those usually run more than $60,000.

And although you won’t be paying a software maintenance or upgrade fee, you will be paying a monthly subscription or service fee, typically about $500.

For organizations that have the wherewithal and staff to maintain a data center (multiple servers, perform regular data backups, manage software upgrades, and attend to the details of technical troubleshooting) a client-server model is a viable choice, but may still be cost-prohibitive.

Practices that find startup investment in a data center daunting, or do not have adequate IT support, will find clarity in the cloud.

Rosemarie Nelson is a principal with the MGMA Health Care Consulting Group.