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.
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.