What is the best EHR for your practice? As usual, the answer is, “it depends.” Choosing the right Electronic Health Record (EHR) system for your practice involves answering many questions. These include:
– Which specific EHR features and functions do we need?
– Which EHR vendor has experience in my practice type or specialty?
– Which vendor has the best reputation and a stable business?
– What’s the need for access to data for reporting and research?
– Does the EHR system have the necessary certification and functionality to qualify for “Meaningful Use” ARRA stimulus funds?
– Should we use a Web-based or Client Server EHR technology?
While this last question may sound overly technical, how you answer it can have a profound influence on the effectiveness of, and satisfaction with, your EHR.
Web-based systems, also called Software as a Service (SaaS), are usually Internet based (think of on-line banking). You access the application through a computer in your practice or exam room, via a web browser, but the data (information about each patient) and processing power actually resides off site at the EHR vendor’s facility. With a Client Server (C/S) system, on the other hand, the data and processing power resides on a server right in your office.
Both of these technologies have advantages and disadvantages. This article will explore the attributes of these different technologies, and why your practice might choose one over the other. For each technology we will look at the payment model, flexibility and ease of use, data security and ownership, and connectivity and performance. In addition, we will look briefly at a hybrid model that has some of the strengths of both SaaS and C/S.
With SaaS, you pay a monthly subscription fee (usually per provider) for as long as you use the EHR. There are no servers to buy or on which to load software. The EHR vendor will install new software versions, new features, upgrades, fixes or patches as necessary. You are only responsible for purchasing the individual computers, printers, and scanners, for your exam rooms and offices. The start up costs for the SaaS model are lower than with C/S systems, as you will not need to purchase the software license or purchase hardware servers and backup systems. Like a car lease, however, there is a break-even point where the monthly fee will start to cost more than outright ownership. Unlike with a car, though, you will not be trading in your EHR every three years.
With the Client Server systems, you pay for a software license (usually per provider) as soon as you install the system, and typically pay an additional 18% of the license cost as yearly maintenance to cover upgrades, patches, fixes, and customer support. You also purchase the servers that the software resides on, as well as the individual computers, printers, and scanners in the exam rooms and offices. You are responsible for maintaining the servers and individual computers, including upgrades, operating system patches (e.g., MS Windows), security patches, backups, and data security. The startup costs of C/S systems will be higher, but over time could actually be lower.
Flexibility and Ease of Use
By its nature, an EHR built on the SaaS model is less flexible because many different practices and customers are using the exact same software. There will be some individual or practice configuration choices to make, but, in general, SaaS software is not as configurable as C/S systems are. You may find that you will need to conform to the suggested workflow of the vendor, even if it’s different from the workflow of your practice. However, many practices, with straightforward needs, find the SaaS model easier to set up, train on, and adopt than with the more traditional C/S approach.
Typically, C/S systems are more flexible, allowing you to configure and customize the EHR to more precisely fit the way your practice actually works. If your practice has spent years refining specific clinical and business workflows this kind of flexibility might be important. Of course, a high degree of configuration and customization requires additional time and effort from your clinical and administrative staff, as well as from the vendor or consultants you may have partnered with for the implementation.
Data Ownership and Security
With the SaaS model the vendor takes care of backing up and securing patient data. Some SaaS vendors maintain redundant datacenters, meaning that they have replicated the data to multiple locations. If something happens to the hardware, software, or physical facility (i.e. natural disaster) at one location, the replicated hardware, software, and data at another location takes over so your service will not be disrupted, and you have access to all your patient data. The down side is that you must rely on another party for the security and reliability of your data. Another concern is getting access to your patients’ data if the vendor goes out of business. It is advisable to spell out in the vendor agreement who has ownership of your data, and how, and in what format, they must return it to you.
Many practices are reluctant to lose “control” of their patients’ data. With C/S systems, your practice has direct possession and control over that data. It is not comingled with other practices and there is less worry over the fate of the vendor. With that peace of mind, however, comes responsibility. Because you own the server the data resides on, it is your responsibility to backup the data on a regular basis, including storing duplicate sets off site (e.g.,. on CDs or tapes). You will need to consider the physical security of the server, as well as its vulnerability to water damage (flooding, pipes bursting, etc.) and heat (proper air-conditioned environment). You also need to schedule monthly maintenance of the server’s operating system, and often more frequent patches and updated anti-virus profiles.
Connectivity and Performance
A natural advantage of the SaaS model, for those practices that have multiple locations or where there is a need to review patient files at home, is that the EHR can be accessed anywhere there is an Internet connection and a Web browser. The drawback is that your access is only as good as your Internet connection. There are various Internet connectivity options, depending on your practice location(s), but it is essential to purchase reliable Internet connections at speeds recommended by the EHR vendor. In addition, several surveys have indicated that the performance of SaaS systems can be slower than client/server systems, often because of the lack of reliability and variability of the Internet service.
C/S systems typically have faster response times to bring up patient information and generally feel more responsive than SaaS. You are also able to more readily make changes to fine tune performance. For those practices with multiple locations, the C/S system takes additional work. You will need to engage a telecommunications company for a dedicated high-speed data link between your locations (if you don’t already have one) or use encryption technology (to secure your patients’ data) to connect offices over your high speed Internet connection.
The hybrid model combines the flexibility, performance, and cost advantage of the C/S system and the maintenance advantage of the SaaS system. The hybrid model is essentially a C/S system, but instead of the server residing in your practice (i.e. under someone’s desk), the server is located in a secure, professionally managed datacenter. All of your server maintenance, backup, and disaster recovery needs are taken care of by the datacenter. Another advantage is that you only need to purchase the data storage and processing power you need now. As your data needs grow, the datacenter can dynamically allocate more space. Obviously, your connection to the datacenter becomes a factor, as it does with SaaS. The Hybrid model is a relatively new service for EHRs, but has been around in other industries for several years.
Which technology or model is right for your practice? If you need to minimize start up costs, don’t have a complex environment, don’t mind conforming to a narrow scope of workflows, and don’t have the capacity for the “care and feeding” of servers, then the SaaS model could be right for you. Like many smaller practices, you may fit into this category. Make sure you negotiate clear ownership of the patient data, how you get access to it, and find the most reliable Internet access possible. In addition, you should add specific performance and software availability criteria in your vendor agreement, with financial penalties for violations.
If you need to configure the EHR for a more customized fit, can afford the upfront costs (to save money over the long run), and want to more closely monitor and control your patients’ data, then the C/S model could be the right choice. If you want the advantages of a C/S model but find the maintenance, back-up, security, and disaster recovery tasks daunting, than you could be a candidate for the hybrid approach. You retain the advantages of the C/S model, but outsource the IT headaches to those whose expertise is running a data center and protecting data.
As you go through the EHR selection process, the technology choice is just one of several factors you will need to consider, but understanding the trade-offs each of these systems has to offer will help ensure you make the right choice for your practice.
Mark Newman is a partner at EHR Associates; a consulting firm dedicated to helping physician practices adopt information technology. He can be reached at 215.690.4133 or firstname.lastname@example.org