Miguel sent me the following email about local server EHR and Web Based (SaaS) EHR:

A lot of vendors in Puerto Rico are selling their local server application over the web application. In fact, to my view, they have very weak arguments when selling Local Server vs Web based application.

Can you direct me where to get additional information regarding the comparison of the two? Do you have an estimate, from the 100% physicians that are using EMR in US, what is the proportion of physicians using local server? What would you recommend?

This is a tricky question and the question that really divides many EMR vendors into their various camps. The tricky part is that both camps are right in their assertions. So, there is no clear winner. From my perspective you can make the case for either solution.

However, in certain situations one type of EMR might win over another. For example, if you’re in a place where your internet connectivity is not reliable, then you probably should go with an in house EMR instead of a web based EMR. Many doctors who don’t have formal IT support avoid an in house server and go with a web based hosted EMR to avoid the lack of IT support of the in house server.

I’ve written quite a few times about SaaS EMR and so a scroll through my previous posts will provide insight on a number of other topics including this post discussing the SaaS vs Client Server EHR. I should take the info and add it to this EMR and EHR wiki page. Maybe someone else can help with that too.

I don’t think anyone has an idea of the percentage of user who use a local server vs a web based EMR. I did do this EMR poll back in June, 2009 that showed a split decision between SaaS EMR and the 2 different style of client server EMR.

Finally, here’s the section from my EMR selection e-Book (which everyone should buy) that talks about the SaaS (web based) EMR vs. the Client Server (local server) EMR:

SaaS (hosted/web based) EMR versus Client Server (in house) EMR

This is one of the most heated questions you can ask EMR vendors when considering an EMR.  For an EMR vendor, choosing one or the other becomes like a religion.  My personal belief is that either model is reasonable.  Certainly the SaaS EMR people are correct that web based systems are the major trend in technology and that EVERYTHING is going web based.  However, it is also true that there are some things you can do with a client server EMR that still aren’t as effective with a web based system (ie. complex document workflow).  Some EMR vendors are combining the two models by having an in house server that is web based.  Others are putting their client server EMR in a data center also so they get the advantages of a SaaS EMR while still having some of the client server benefits.  For those that do not know the differences in SaaS versus client server, here’s a high level summary of the advantages and challenges of each model.

SaaS (hosted/web based) EMR

A SaaS EMR is one that is hosted by the EMR company (or partner of the EMR company).  Access to the EMR is done through a standard web browser. (Note: Client Server EMR can be hosted by the company and accessed using terminal server software as well, but that isn’t usually considered a SaaS EMR for purposes of this description.)  The biggest advantage to a SaaS EMR is a clinic doesn’t have to pay for the server and associated IT help to support a server in the office (ie. server room, tech support, redundant network, UPS, backups, etc).  SaaS EMR vendors reasonably argue that most clinics in house IT support cannot provide reliable and redundant server support the way a SaaS EMR can provide.  Part of this is due to the lack of expertise of in house IT support (or lack of in house IT support altogether) and the other part is due to lack of funds to build a reliable and redundant server environment.  Another advantage of SaaS EMR is that since they are web based they are available anywhere you have an internet connection.  When a SaaS EMR updates its software, you will automatically get the latest and greatest features of the software.  This can be a good and a bad thing depending on whether the latest updates were well tested and if they included features that would help your office.  Since a SaaS EMR uses a standard internet web browser, you will not need to spend time installing special software on each computer in your office.  This is even more beneficial when your SaaS EMR does an upgrade to the software.

The major disadvantages of a SaaS EMR are: internet connection dependence, EMR data not stored on site, and reliance on your EMR vendor.  Access to a SaaS EMR is completely dependent on a clinic’s internet connection.  Since the SaaS EMR is stored offsite in the vendor’s data center, any loss of internet connectivity means the clinic is without an EMR.  The solution to this is to have redundant internet connections (where possible), but also often means an increased cost for your internet connection.  Cellular broadband cards have helped to lower the cost of clinics having a redundant internet connection in many places.  Many rural locations with poor internet connectivity should probably avoid using a SaaS EMR.  Many clinics are also leery of SaaS EMR because the patient data in their EMR is stored in the vendor’s data center instead of on site.  Some SaaS EMR vendors will provide a backup copy of your data which you can store locally, but this is not very common and cannot usually be done at regular intervals.  SaaS EMR vendors argue that there’s no need to store a copy of your data locally since the server where your data is stored uses enterprise level backup to avoid any loss of data.  Ensuring these backups are completed appropriately and your SaaS EMR server is always available means you as a clinic are relying on your EMR vendor’s expertise in setting up those processes and configurations.

Client Server (in house) EMR

As would be expected, the advantages and disadvantages of an in house EMR mirror those of a SaaS EMR.  In house EMR software is traditionally done through a client install on a computer which accesses a server stored in the clinic.  Since the server is stored on site, you are no longer dependent on your outside internet connection.  Access to the EMR is done through your more reliable local network.  This also means that all the data from your EMR is stored in your office.  Many people would argue that client server EMR software is faster and can do more than web based software.  Web based software is making major strides in this regard, but there are still some features of an EMR that are better implemented by a client server EMR.

The biggest challenge associated with an in house client server EMR is that it requires a certain amount of local IT expertise to support your local server.  Many EMR vendors will assist your local IT support, but they still usually require some local IT support.  The quality of your local IT support matters regardless of which EMR you choose, but is more important with a client server EMR.

Another challenge with an in house EMR is that you are the one required to make the backups.  Some people consider this a pro since then you can be sure that the backups are done regularly and properly.  However, most people would argue that this is a problem with an in house server.  The reason for this is that too often making sure the backups are done and done correctly is forgotten or not done at all.  This is very common since backups aren’t appreciated until some major disaster happens and it’s too late.  Some local IT companies will partner with you in this effort and this can help solve this problem.

One of the most irritating parts of a client server EMR is the need to install the client software on each computer.  Certainly this is less of an issue the smaller your clinic, but it still can be a pain to manage.  Remember that this is not just a onetime event.  When your EMR software gets upgraded (usually 2-3 times a year), you will need to make the rounds to upgrade the software.  Certainly many EMR vendors have automated the upgrade process to some degree.  You can also often automate this process using active directory.  However, this upgrade process does create just one more area for something to go wrong with your EMR or require special IT support.  The good part is that this means that you can do the upgrades on your own timetable.

Hybrid Model

Some EMR vendors do a mix of the two options above.  They might have a server stored on site, but still have an EMR that uses web based technologies.  This still means you need the in house IT server support, but means that you don’t have to rely on your external internet connection to access the server.  It does however, usually mean that you can access your EMR from anywhere with an internet connection.  It also means that you can use a standard web browser to access your EMR instead of having to install a client on each computer to access your EMR.

This is not meant to be a comprehensive list comparing SaaS EMR with client server EMR.  Instead it’s meant as an overview of the major differences between the two types of EMR setup, but should give you enough information to choose which option will work best for your office.

I guess kind of like they just had Shark Week on TV, this week on EMR and HIPAA has been ICD-10 week. So far I’ve covered EMR vendors ICD-10 planning, moving to ICD-10 and bridging from ICD-9 to ICD-10.

In response to my previous ICD-10 posts, Gordon Fenton provided this interesting insight about the UK’s experience with ICD-10.

Over in the UK we already use the ICD10 along side the OPCS code to generate our HRG’s which is the currenvy that commissioners and providers use in the billing process.

While I am based on the commissioner side I know that our providers employ coders whose specific job is to translate Doctors notes into ICD and OPCS codes.

The main challenge will be in varifying and validating the codes being applied by providers, the IT is just a small issue. It will be very easy for providers to inadvertantly apply the wrong code simply by the fact that there are so many.

You could do a lot worse than look at the UK model for guidance on how we deal with it

I’m always interested to learn from what other countries are doing with technology and EMR. I’d love to learn more about UK provider’s experience with ICD-10 and how we can improve the eventual ICD-10 implementations in the US.

In this Sunday’s HUH? news we have a report by Healthcare IT news that Google may be considering using their Google Wave technology for EHR. Of course, I think the writer at Healthcare IT news must have had a deadline or something since the paper written by Google engineers Shirley Gaw and Umesh Shankar about representing “Individual Health Records” that are aggregating from “multiple sources” which sounds a lot more like a PHR to me than an EHR

That minor verbiage aside, it’s hard for me to imagine Google Wave used as a PHR or an EHR. Ok, I get the idea that it would be interesting to see all the clinical data elements added to a patients history in real time (basically what Google Wave does). This is an innovation that is needed. I just think that re-architecting the very consumer focused Google Wave product isn’t going to get us there.

Not to mention, Google has chosen to stop supporting Google Wave. I think Google probably has enough to do with health with Google Health. I’ll be very surprised if we really see the Google Wave technology used in healthcare.

Many of you might remember that one of the most interesting things I saw at HIMSS this year was the natural language processing that was being done by MModal. In case you don’t know what I’m talking about, check out this video interview of MModal that I did at HIMSS. I still think there really could be something to the idea of retaining the narrative that dictation provides while also pulling out the granular data elements in that narrative.

With that background, I found it really interesting when I was on LinkedIn the other day and saw Dr. Nick van Terheyden,the same guy I interviewed in the video linked above had switched companies. Nick’s profile on LinkedIn had him listed as working for Nuance instead of MModal. I guess this shouldn’t have been a surprise. Nuance has a lot of skin in the natural language processing game and it seemed to me that MModal had the technology that would make it a reality. So, now Dr. Nick van Terheyden is the Chief of Medical Information Officer for Nuance.

I’d say this is a really good move by Nuance and I’m sure Nick is being richly rewarded as well. Nick was one of the most interesting people that I met at HIMSS this year. I’ll be certain to search him out at next year’s event to hear the whole story. Luckily, I also found out that Nick is blogging about voice recognition in healthcare on his blog Voice of the Doctor. I always love it when smart people like Nick start blogging.

Trent Peters from Umbrella Medical Systems added an interesting comment on my previous post about Domain Controlled Networks and HIPAA that I thought really added to my original post. Plus, Trent goes into a nice list of other benefits of having a “Management” server in an office. It gets a little technical for some of my readers I’m sure, but is valuable if you’re office is embarking on this adventure.

Here’s Trent’s comment:

This is an interesting question and can be argued either way, but again it comes down to what’s “reasonable and appropriate”. A little background, my company is a IT Consultant group that works specifically in the healthcare arena offering services to medium-sized and small healthcare organizations, we have plenty of EMR implementation experience. Over 95% of our clients are in a domain environment and we always push for an Active Directory environment if one is not present. However, in the small offices (1 – 2 providers) this can be difficult because of the initial cost and the fact it’s “server” based. Many small offices will choose a “hosted” emr solution for the low up front cost and adding on the extra 5 -7K is not a valid option as the cost outweighs the benefits (from their perspective). The other 5% simply do not have the same security and manageability as the domain environments.

Any networks Security solution is only as strong as the weakest link. While not having a domain controller doesn’t necessarily equate to not being HIPAA compliant, it sure helps secure the environment to IT best practices. We call the Domain / Active Directory server the “Management” server because it provides more functions than just AD. For instance, WSUS patch management to make sure all computers have the latest security patches and don’t have the updates that may conflict with the EMR (some EMR software are not compatible with IE8 or SQL 2005 SP3, etc), centralized backup and client folder redirection for non-EMR critical data, centralized monitoring platform for servers (hardware + software), workstations, UPS, networks, VPN, etc, centralized AntiVirus protection is also important to notify the support team of malicious software and vulnerabilities. Group Policies is a big part of the overall security that can manage (if properly configured) all aspects of the network including password policies, computer and user permission rights, power setting, audit controls, etc. There are many benefits to a DC / Management and is the choice to achieve IT best practices (I believe MS recommend 3+ computers to be on a domain environment, although this is aggressive).

It’s nice to be able to bundle server roles (such as SQL or FAX) in order to justify the management server, but generally it comes down to cost. We hold our HIT practices to the highest standard, so our rule is that if the organization has +5 computers, you must have a Domain Controller / Management Server in order to qualify for our full support program. We can’t justify the extra effort required to properly manage the environment without it. In those rare cases where a small organization choses to not invest in a Domain Controller when we feel it’s required, then unfortunately we wish them the best of luck and turn down their business.

In a post on EMR and EHR about Transcriptionists Partnering with an EMR Vendor, I got an interesting comment by George Catuogno from StenTel about the various technologies that the Medical Transcription (MT) industry are using alongside EMR software. George called the use of transcription with an EHR “practical use” while still showing “meaningful use.” I think it’s a mistake for any EMR company to ignore the transcription industry.

Here’s George’s description of the medical transcription technologies which I think people will find interesting:

The Medical Transcription (MT) industry actually has done a lot to advance itself amidst HIT, particularly EHR technologies, while supporting narrative dictation, which for many physicians is still the preferred method of information capture because it’s fast and easy (efficient) and it tends to more comprehensively captures the patient “story”. DRT, BESR and NLP are three examples of this. I’ll save the best for last.

1. Discrete Reportable Transcription (DRT) is the process of converting narrative dictation into text documents with discrete data elements than can be easily imported into the appropriate placeholders inside an EMR.

2. Backend Speech Recognition (BESR) has been in play for years which allows physicans to dictate without engaging the computer for realtime correction. The correction is instead done retrospectively by a medical transcriptionist. Some speech rec technologies (like M*Modal) support data structuring. The gap remains, however, in getting applications written that readily move that strucutred infomration into EHRs like DRT can.

3. Natural Language Processing (NLP) trumps both of these solutions because it takes a narrative report, regardless of how it was created, and codifies it (SNOMED) for a number of extraction, analytics and reporting applications: Patient Summary, DRT feed into an EMR, Core Measures and PQRI, coding automation, interoperability, and support for the majority of Meaningful Use requirements. Secondary use opens up to clinical trials and other applications as well.

Overall, if the transcription industry can market itself and get its messaging out through the right channels regaridng these innovations that augment transcription and keep physicians dictating, then transcription is a terrific EHR adoption facilitator, enables “practical use” along with Meaningful Use, and will remain relevant for the foreseeable future.

Many of you will remember my post making the case for in house EMR backups versus SaaS EMR backups. It was my first swing at my favorite part of blogging. I personally call it blog sparring. Basically, two (or more) bloggers discussing various viewpoints about a certain issue (I welcome other bloggers to join in).

Well, Lyndsey from Nuesoft brought the President and CEO, Massoud Aibakhsh, in on the fun in a post they called, “Continuing the Discussion…Data Backups: Leave it to the Experts.”

I appreciate Massoud’s response and he does make some interesting points about what is possible when a SaaS EMR vendor does the backups correctly. There’s no doubt that a SaaS EMR provider has more resources available to do a more robust backup, disaster recovery and business continuity plan than a small doctors office with a single server. His points about possible HIPAA breaches are also worthy of serious consideration. However, that kind of avoids a discussion of the points I made about relying on your SaaS EMR vendor to do the backup.

Nuesoft, why don’t you offer your end users a nice single click download of all their patient data which a doctors office could store in a nice HIPAA secured place in their office weekly/monthly or some other reasonable amount of time? Then, you’ll have the best of both worlds for a doctor’s office. They have your enterprise level backup, availability and load balancing and they’ll have a local copy of their data which helps them sleep better at night knowing it’s safely stored away in their office.

Of course, I’m not really trying to single out Nuesoft. I don’t know ANY SaaS EMR vendor that provides this service and that’s really unfortunate. Who’s going to be the first EMR software company to step up and provide this kind of support to the doctors?

If you’re really brave, you’ll even provide it in a format that they can extract the data themselves should they so desire (say if your company gets bought by someone else). I actually believe I heard of one EMR vendor that does this (client server though). They provide all of the data from their EMR in a nice exportable XML file which could easily be maninipulated.

I’m sure many in the room reading this will say, but what about vendor lock in? Why would I as an EMR vendor make it easy for my users to export their data out of my system? If I do that, they might *gasp* leave for another EMR vendor.

I of course asked the above mentioned EMR vendor about this problem. Their answer was a confident, “there are some that might leave because it’s easy to leave, but so far people have no reason to leave our EMR because they like it so much.” Kind of an interesting concept. Make an EMR that people love so much that they have no reason to change even though the door is open.

Granted, I’m not naive enough to think that some won’t leave. I’ve heard many a horror story of doctors leaving an EMR (for good reason or not) and then realizing that the grass wasn’t greener on the other EMR vendor side. Many of these doctors end up heading right back to their old EMR vendor.

One day a SaaS EMR vendor is going to revolutionize the backup process for their end users and start providing this level of data backup to their users. I know I’d be impressed with a SaaS EMR vendor that had that much faith in their product that they’ll give you a regular export (backup) of all the clinic’s data.

Now, back to some other comments from the Nuesoft post. In it, you asked me, “Do you seriously think banks use some of the services you mentioned to back up financial data?”

Well of course banks don’t use the services I mention to back up their financial data. Although, find me a bank that has 1 banker and 6 employees and I’ll show you a bank that uses the services I mention to backup their data.

At the end of the day. Let me liberally use a quote from the movie Shrek:

Shrek: Backups are like onions.
Donkey: They stink?
Shrek: Yes. no.
Donkey: Oh, they make you cry.
Shrek: No.
Donkey: Oh, you leave them out in the sun, they get all brown, start sproutin little white hairs.
Shrek: NO. Layers. Onions have layers.

Yep, backups are all about layers. The more layers of backup you have, the happier you’ll be. I know there’s been a number of times in my IT career that I’ve had to go to my 2nd, 3rd and 4th options to recover all the data from various backups I’d done. The more well designed layers of backup you have, the happier you’ll be if (when?) disaster hits.

EMR and EHR has been getting a ton of traffic related to my posts on the iPad EMR. It’s a really interesting discussion that I think people that love technology and EMR will enjoy. I have no doubt that the interface that the iPad is helping to promote and develop is going to have a major impact on healthcare. Not that everyone will have an iPad in healthcare, but that the technology behind it will be copied and we’ll see lots of interesting documentation methods for EMR software.

Dr. Larry Nathanson, MD from BIDMC seems to disagree with me in his writeup about his experience using the iPad in an Emergency Room. However, what I found most interesting about his writeup is his comments about the challenges of the iPad.

The first was how well it will hold up in a clinical environment. The iPad doesn’t seem to be the most rugged device and clinics like to abuse devices (from my experience). The second was the challenge that plagues all tablets: difficulty entering strong passwords. between the numbers, symbols and mixed case, it’s harder to enter these passwords on a device like the iPad. Is biometrics the solution to that?

What do you all think about the iPad and EMR? Will we see an iPad only EMR develop into a real power player in the industry?

My favorite part of HIMSS is meeting all sorts of interesting people. One of those people I met was Lyndsey Coates from Nuesoft. I have a soft spot in my heart for Nuesoft since they were the company that trained me on my first EMR. I still remember the 3 day intense training in their office. Lyndsey and I had interacted a few times before the conference and so it was nice to meet her in person. It was just too bad that we didn’t get to spend more time together.

What does this have to do with EMR backups?

Well, Lyndsey and I didn’t have much time together at the conference, but she sent me a nice bloggers “love note” in the form of a blog post about offsite EMR backup systems after meeting me at the conference. She even sent me a friendly tweet to let me know about the post.

I was a little busy with HIMSS and all, but I’m always happy to share in a little blog sparring. So, Lyndsey, here we go.

I’m really glad to hear you respect my opinion, but I’m a little surprised that you didn’t like my post about offsite EMR backup services. I guess I could have imagined that a SaaS EMR vendor might have a different view. In fact, you make a nice case in your blog post about the challenges of backup with the client server model. Definitely a number of good points for doctors to consider when selecting their EMR.

However, somehow your post left out some of the problems related to backups with a SaaS EMR. No worries though, I’ll be happy to share;-)

First and foremost, I can’t believe you think that doctors will trust an EMR vendor to back up their EMR appropriately. I mean seriously, we’re talking about my whole clinical practice stored on your servers and trusting that your IT staff are doing my backups? I don’t think so. I barely trust my own staff to do backups, so why would I trust my EMR vendor’s staff to do something as important as the backups of my EMR?

No, I’m definitely not trusting you and your IT staff to backup my EMR. Maybe there are a lot of doctors that don’t do backups properly, but there are a lot of large vendors that don’t do backups properly either. Yes, even the all powerful Google lost some data because they didn’t have the right backups.

Plus, if you’re doing my backups that means that you establish the policy and time frame that the backups are done. If I do them in house, I get to schedule the backups, verify the backups and see the reports and logs about when backups are done. I get to choose when and how often those backups are done. With you, I just have to hope that you’re doing them.

Plus, there’s just something that doesn’t feel right about you having the backup of all my data. Maybe you don’t remember that the data stored in the EMR is my life. Not my literal life, but the life of my practice. Maybe you feel comfortable with my life being stored in your redundant data centers across redundant servers who mirror the data and all sorts of other cool backup processes. Personally, I feel comfortable knowing I have a backup of my life in my office with me. I can see it, touch it, pet it and know that it’s safe in my loving arms.

Finally, let’s not call out my previous post about Offsite Backup Service for EMR for “missing the mark a bit.” While SaaS EMR are doing very well, there’s still a VERY large number of people who will select a client server EMR. Better to help them get their client server backup services right than to just tell them that they should have bought a SaaS EMR.

Plus, maybe Nuesoft and other SaaS based EHR should consider partnering with one of these offsite backup solutions. I imagine a lot of doctors would love to have their SaaS EHR backed up to an offsite backup provider like the ones I mentioned in that post. Basically, a location that the doctor can access and control. Could be an interesting service to offer your clients.

Your turn Lyndsey!

P.S. I personally don’t care either way. I think that the client server or SaaS model are legitimate EMR solutions. Long term SaaS EMR are likely to win the day, but that’s still a long ways away. I do enjoy playing devil’s advocate though.

On more than one occasion I’ve talked with people about the work the people at MModal are doing in the healthcare IT space. I think they’re a really interesting technology that could save all those doctors that want to still dictate their notes. MModal offers an interesting solution for preserving the valuable story that a narrative tells while also pulling out the key data elements into granular, reportable pieces.

I don’t think I need to say much more about MModal. Just watch this video interview I did with them at HIMSS 10:

This video coverage of HIMSS 10 sponsored by Practice Fusion and their Free EMR.