The cloud brings many flavors of EHR deployments: What you need to know


Today, every medical practice must consider moving in the direction of installing an electronic health record (EHR) system. Not only are there up to $63,750 in meaningful use incentives to claim, the entire industry – like it or not – is being pushed in the direction of EHR use by policymakers, payers and even the White House.

Historically, medical practices haven’t had many options for how they could deploy an EHR. In the early 2000s, practices were pretty much restricted to hosting their EHRs on premises, which involved purchasing and maintaining expensive hardware and networking gear. However, as cloud computing technology has exploded onto the scene in recent years, today's practices have a variety of options for deploying their EHR solutions, each with their own advantages and disadvantages.

Switching to a cloud-based EHR can be a compelling choice for practices, especially for independent physicians who are struggling with the costs and complexities of maintaining their own EHR software. That said, not all clouds are created equal and, in general, physicians face important considerations (such as security, usability and data ownership) to determine which type of EHR deployment works best for them. Here’s a look at prominent “flavors” of EHR deployments, as well what you need to think about before pursuing these various options.

Self-hosted EHRs
One method for bringing an EHR into your practice is to install it inside of your practice. This approach gives you the greatest level of control over how your software is set up, what security controls are put in place and more, which can be a good thing. That said, buying and hosting your own software comes with some significant challenges.

Costs to consider
Though estimates vary, there’s no question that buying and hosting your own EHR can be a significant investment. While meaningful use EHR incentives can defray these expenses, they usually do not cover the long-term costs of an EHR installation. Coping with the expense of installing and maintaining in-house EHR software can be very challenging. In fact, the total first-year cost of an EHR implementation for a five-physician practice is an estimated $233,297, with an average per-physician cost of $46,659, according to a recent study published in Health Affairs.

To run the software properly, you may also need to buy powerful server computers, which can cost thousands of dollars. What’s more, in some cases you might even need to upgrade the desktop or laptop computers your physicians use if you want to get optimal performance from your EHR.

Do you have the technical know-how?
Installing EHR software also requires a high degree of technical skill, and few small or medium-sized practices have an IT guru on staff.  Bringing on IT consultants is pricey and once they’ve gone, some vendors may leave you on your own when it comes to handling technical problems. This situation can get ugly fast if your EHR stops working and you don’t have someone available to fix it quickly.

Also, whether you pay a vendor to provide EHR training or train your staff in-house, most practices find that it takes weeks to get staffers and clinicians oriented. Worse, productivity can remain at lowered levels for months. Are you ready to take on the responsibility of training your staff while keeping your EHR running in optimal condition?

Securing your own practice
Once you have your EHR set up to run on premises, you will be solely responsible for making sure that patient data in your EHR isn’t compromised. This involves constant management and maintenance of security tools such as firewalls, which protect programs from intruders. There’s also the issue of backing up your data:  Where will you store backups, and how can you be sure that that location is safe from physical destruction and hacking? Not only that, it’s critical that your data protection methods meet HIPAA standards. You need to ask yourself: Do I know how to accomplish this?

Generally speaking, then, it’s clear that installing an EHR on-site may not be the best choice for all practices. While you get to retain full control over your EHR, there is also a tremendous amount of responsibility and cost that comes with this control. That’s why many practices are now looking to cloud-based EHRs as an option to defer many of these costs and responsibilities onto their EHR vendor. But, here too, there are important things to consider depending on the type of cloud model your vendor supports. 

Cloud-based EHRs
Cloud-based EHRs (an approach known to vendors as Software as a Service or SaaS) offer a few distinct advantages over deploying your own EHR on premises. Perhaps most significant is that cloud-based EHRs are usually much less expensive to buy or license compared to deploying and managing your own on-site software. That’s because many of the infrastructure and maintenance costs become the vendor’s responsibility as part of hosting your EHR in their cloud environment. However, cloud-based software does pose some challenges as well.

Are you sure that you’re secure?
With cloud-based EHRs, often you share a server with hundreds of other practices; each “instance” of the software runs side-by-side with the others. If that server is hacked, due to lax security practices by the vendor or the other practices, every practice may be affected. With a cloud-based EHR, your data may be less secure than you’d like. This is an important question to ask your vendor — as you may prefer to go with a cloud-based EHR that runs your EHR on what’s known as a “virtual server,” an isolated virtual database and computer completely dedicated to your practice, thereby eliminating the “cross-contamination” risk.  

Whose data is it anyway?
Not having data on-site can be convenient, as the vendor performs the necessary backups and protects the data from disasters. But what happens if you decide not to use the Web-based vendor anymore?  Who owns the data, and how will you get it back if there’s a dispute?  You may have this covered in a contract…but if a dispute arises, it could get nasty. Also, bear in mind that some vendors currently sell or have plans to sell aggregated patient data to pharmaceutical companies or advertisers. Is that something you’re prepared to accept? If not, you may want to consider an EHR vendor that does not mix all of its practice data into one big database to use for data mining. At Amazing Charts, for example, we do not engage in the practice of pooling data.

Usability
A common method for delivering cloud EHR software is through a Web browser. However, what many people forget is that accessing EHR software through a Web browser, while convenient in some ways, is at the mercy of your browser’s limitations. EHR software designed for a browser may be awkward to use, as it needs to comply with browser restrictions, requiring you to click extra times to get to what you need, which can be time-intensive enough when using an on-premise EHR. Also, if your browser is running slowly, be prepared for long waits for the next screen refresh. If this is an issue for your practice, you may want to seek out a cloud-based EHR solution that is not browser-based. 

All told, no EHR is going to be perfect for every practice. That’s why it’s important to really look under the hood and kick the tires before committing your practice to any EHR implementation model. While the cloud offers easier, more cost-effective and maintenance-free ways to implement your EHR, it’s also important to remember that not all clouds are created equal, and in some cases there are weaknesses that should give your medical practice pause.

Jonathan Bertman, MD, is CEO and Founder at Amazing Charts, a developer of EHRs.