Time to touch on a few popular topics that I found being discussed on Twitter. First, I’ll put the tweets and then a little but of my own commentary on these hot button issues in healthcare IT.

@GovHIT
Does a nationwide #EHR lower healthcare costs? Social media reactions | #GovHIT Blog http://ow.ly/64DL1

I always love when people talk about a nationwide EHR. I actually think that it’s a bad title by Government Healthcare IT, but that it’s a very good question. To me a nationwide EHR implies that there is one EHR for the entire nation. I think a number of other countries which are much smaller and less complex than the US have proven quite well that a nationwide government run EHR is a bad idea. I think the Government HIT article actually refers more to widespread adoption of EHR. To that, I’m obviously amenable and can’t wait for that day. Although, we still have a very long way to go.

@ekivemark – Mark Scrimshire
Should Health Care Move to the Cloud – Absolutely (but carefully)! #EHR #HIT 2.healthca.mp/oMMtNA

Might as well cover the cloud in healthcare issue if we’re talking about hot topics in healthcare. Little by little, I’m really seeing the shift to “the cloud” when it comes to EMR and EHR software. There are certainly still instances where the cloud based EHR doesn’t make sense. We also can’t start counting the days to the death of the client server based EHR software. In fact, non-cloud based EHR software is going to be around for a LONG LONG time to come. There’s far too many millions of dollars invested in these systems. However, I still do sense a shift from in house servers to cloud based EHR solutions.

I do appreciate the comment in the tweet about moving to the cloud…”Carefully!”

I think the debate over a SaaS based EMR versus a Client Server EMR is never going to end. Maybe we should just have a peace treaty and decide that whoever has a SaaS EMR is going to love the SaaS model and the benefits and features of a hosted EMR solution. The client server EMR people are going to love their in house “doctor controlled” EMR software with its inherent features and benefits.

What inspired this post? A few old threads popped up on my stats page. First, is a SaaS EMR versus Client Server EMR poll I did back in June of 2009 about which type of EMR setup people prefer. Here’s the results (as of this posting):
Client Server EMR (Client Install) – 35 Votes
Client Server EMR (Web based) – 28 Votes
Hosted Web based EMR (SaaS/ASP) – 84 Votes
Huh? – 3 Votes
Doesn’t Really Matter – 7 votes

That’s good enough as a tie for me. Probably reflects the chasm we have in EHR and EMR companies. There’s plenty of each to go around.

The above poll also led me to this post about the myth that a SaaS EHR is required to show meaningful use. I forgot that some EMR companies (or likely their sales people) were spreading these crazy myths about meaningful use.

I knew that my previous post about the cost to update an EMR would bring out the people who like to back the SaaS EMR model versus those who like to back the Client Server EMR. As I’ve said before, it’s one of the most heated debates you can have in the EMR space.

I realized in the comments of that post why it’s such a heated topic. It’s because once an EMR software chooses to go down one path or the other, it’s nearly impossible to be able to switch paths. Why? Cause if you do choose to switch you basically have to just code a new application all over. Basically, the switching costs are enormous. So, only a few software companies (let alone EMR software companies) ever change from one to the other.

Considering the high switching costs, that basically means that an EMR vendor that is SaaS based has a strong vested interest in the benefits and upside of the SaaS model of software development. The same is true for Client Server EMR software and client server EMR companies looking at the benefits and upside of the client server model of software development.

This entrenching around a software development methodology (for which they can’t change) is what makes discussing each model so interesting. Each party dutifully makes the most of whichever software development methodology they’ve been given.

Of course, from the clinical perspective it’s sometimes hard to cut through all this discussion and get good information on the real pros and cons of each model.

In that vein, I’m looking for a couple EMR and HIPAA readers that would be interested in making the case for one or the other. All you’d need to do is create a guest blog post on the pros and cons of your preferred method. If needed, you’d also be welcome to do a response post to the other method’s post as well.

If this interests you, leave a comment or let me know on my Contact Us page. I think this could be really interesting.

On a different note, it looks like I’m going to be attending the AAFP conference in Denver next week. Is anyone else planning to be there? Anything I should know about the conference to get the most out of it?

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’ve come across a number of websites and people who’ve made the assertion that with the short time frames for meaningful use, a SaaS EHR is the only option to be able to meet the meaningful use requirements in a timely manner. Let’s see if I can do my part to clarify this idea which isn’t completely accurate.

First, there is still plenty of time for a clinic to implement an EMR of any type and get EMR stimulus money. At some point this might change, but at this point we are still far enough out that time is not an issue. Although, I’ll admit that it would be helpful if CMS and HHS would finally get some EHR software certified and provide some practical meaningful use details. Of course, these details shouldn’t be stopping doctors from evaluating and planning for their EMR implementation.

Second, it is worth acknowledging that in general a clinical practice can implement an EMR faster if it’s a SaaS EMR and not a client server EMR. The time for the server to be shipped to your office alone just takes time not to mention getting an IT person or your EMR vendor to install the server in your office. However, if you need more computers and a laptop to be able to use your SaaS EMR, you’re going to be waiting for computers to arrive anyway. Generally though, SaaS EMR is faster to implement than client server.

Of course, this doesn’t mean that you can’t quickly implement a client server based EMR. For example, I implemented a local doctors office in a week from when the server arrived. It was an incredibly fast implementation. Other than ordering time (which they had to order workstations also), it was as fast as any SaaS EMR implementation. So, it’s certainly possible. You just better make sure you have the right IT people supporting your implementation.

My point in this post is that it’s mistaken to say that SaaS EMR is the only option that’s fast enough to implement in time for meaningful use. Many of the client server EMR companies out there have really streamlined the process for installing a server in a clinic. Although, this is not true for all of them. So, it’s a question worthy of asking any EMR company if you’re looking at compacted time lines.

At least for now, it’s a mistake to rule out a great client server EMR just based on the meaningful use time line. We’ll leave the other arguments for ruling out a client server EMR in favor of a SaaS EMR for another post.

Many of you probably realize how much fun I have ragging on the SaaS (hosted) EMR model. I admit that I love playing devil’s advocate. I think that’s what makes me great when working with an EMR, but I digress. What people don’t realize is that I really love the SaaS EMR model and I think it’s just as viable an option as a client server EMR. I just haven’t drank the Kool-aid for either side yet.

With that background, I was excited for the chance to do an interview with one of the biggest fans of the SaaS EMR model, Practice Fusion. In fact, they’ve even taken it one step further in providing a free, ad-based EMR. The following is an email interview I did with Practice Fusion CEO, Ryan Howard.

Give us a summary of Practice Fusion for those who aren’t familiar with the company.

Practice Fusion provides a free, web-based EHR for physicians. We’re the fastest growing electronic health record community in the country, just passing the 20,000 user mark in September.  Our system includes charting, scheduling, integrations with lab networks and billing providers, eRx (in October) and unlimited support – all at no cost.

What guarantee do you provide to users that are concerned about their data being stored offsite?

Our guarantee to our physicians is that Practice Fusion provides a level of service that is dramatically higher than they could ever do on their own. From a practice’s perspective, they have access to world-class infrastructure that only a Fortune 500 company could afford. This includes data redundancy, automated back-ups, biometric security, Cisco firewalls and bank-level encryption. For a physician to build this independently would cost millions of dollars.

What about those who might be concerned that Practice Fusion might not be around forever (always a possibility) or will be acquired by another EMR vendor and they’ll be unable to get access to their EMR data to move if they wish?

A practitioner always retains ownership of their data. They can choose to export their data from our system at any time – just as we offer free uploads of data into the EMR, our team will also assist with free exports as requested. This would be true in the highly-unanticipated event of a merger or closure of our system as well.

Do you provide any mechanisms for doctors to take their data from your system and move to another EMR?

Practices using our EHR always retain ownership of their data and can export any time if needed. Just as we offer free imports of data into our system, our support team can also assist with extracting records to be transferred to a different EMR.

What do you tell doctors who are concerned about how they’ll continue seeing patients if their internet goes down?

There’s risk with both paper and electronic methods. Think about what a doctor does in his office with paper records: what happens if the offices burns down or records are stolen?

Internet connectivity is generally a concern for all internet-based models. Practice Fusion has a number of ways to circumvent this issue. While a doctor is using our EHR, data entered about the patient is constantly being saved. If the computer crashes or the internet fails, the visit is automatically saved. The physician can log back in, pick up where the session was lost and continue directly with patient.

Specific to the operations of a practice facing long-term downtime issues with their broadband company:  Practice Fusion has partnerships with various hardware providers who offer network redundancy utilities for physicians. For example, these systems can seamlessly transition to a cellular network if there is a broadband issue in the office.

How will Practice Fusion be approaching EHR certification and the billions of dollars in EHR stimulus money?

Practice Fusion is pushing toward HHS certification aggressively. Our physician team – Dr. Laffel and Dr. Rowley – has been working closely with the HIT committee and other thought-leaders throughout the past year to ensure that the final criterion for “meaningful use” reflects what is best for physicians and patients. The criteria for EHR certification are still in development but we’re certain that Practice Fusion’s system will meet the requirements. And, if something emerges that we weren’t expecting in that process, Practice Fusion’s SaaS-based platform allows us a degree of flexibility that other systems can’t match. We’re very comfortable with the certification road ahead.

What effect do you think the EHR stimulus money will have on adoption of EHR software?

It’s the silver bullet. The EHR stimulus incentives are helping to push widespread EHR adoption in a sector that has traditional been hesitant to make the switch away from paper. And, honestly, physicians were hesitant for good reason considering the expensive, bulky, IT-intensive solutions that dominated the market in the past.

Now, things are changing quickly and the market is in a frenzy. Vendor bottlenecks are already becoming an issue with the surge in demand. Traditional EHR systems with 12+ week integration schedules can’t keep up with requests. I see Practice Fusion’s five minute online set-up process, Live in Five, as a big advantage in the market as this tidal wave approaches.

Which standards are Practice Fusion adopting to provide for portability of data between Practice Fusion and other EHR vendors?

Practice Fusion’s open platform accommodates HL7, CCR and XML portability. And as one of the only true SaaS based EHR’s, we can quickly adapt our system as new portability standards emerge.

Practice Fusion will also be launching an innovative new feature called Chart Share at Health 2.0 this fall. This system allows physicians to securely share crucial patient data with other providers at no cost with no integration. It’s a major step toward collaborative care and will allow doctors who don’t have interconnected EHR technology or haven’t made the switch to an EHR to still receive and use digital records in their practice.

Describe 3 specific features which make Practice Fusion special (not including your pricing plan).

• Practice Fusion is the only EHR with a true SaaS-based model. Other vendors – such as eClinicalWorks and Allscripts – claim to be SaaS but in fact use old-school ASP technology.
• Our ‘Live in Five’ set-up process is unique in the market.  Physicians who are interested in Practice Fusion’s EHR can sign up online and start charting in five minutes. An entire practice can be set up in a single afternoon.  No risks, no consultants, no downtime – fast and simple integration is key.
• I am also proud of Practice Fusion’s advances in connectivity. Physician using our free EHR can access integrated Surescripts along with real-time Quest Diagnostics and BioReference labs within the system. And we’re constantly working on adding new integrations to this list based on our community requests. With Practice Fusion, doctors are set-up with these sophisticated integrations with no cost and no development time.

What technologies and devices do you think will be the future of EMR software?

I fundamentally believe that the only way to solve the problem of national adoption of EMRs is to accommodate physicians through a web or cloud-based platform. Once this is implemented, the benefit will be unprecedented. Central reporting and trending of patients’ chronic conditions will enable providers and caretakers to identify emerging trends and truly perform evidence-based medicine.

What is needed is a unified platform to be a conduit between patients and their doctors. There are a lot of devices – such as Continua and smart phone applications – that monitor patients’ chronic conditions. The challenge is to integrate this data in EMR’s in a meaningful way to improve the quality of care.

I thought it would be interesting to see which type of EMR setup readers of EMR and HIPAA preferred. If you’re not sure what I mean by the various options, I put a short description of each EMR setup below. Also, feel free to leave a comment about why you made the choice you did.

Hosted Web Based EMR (SaaS/ASP) – This is where the EMR company (or some outside entity) hosts the EMR and provides you access to the EMR usually through your web browser. Data is stored in their location and requires an internet connection to access the EMR.
Client Server EMR (Web Based) – This is where you host the server for your EMR in your office, but you can access your EMR server using a standard web browser. Data is stored on the server in your office, but access to the server using a standard web browser can be available anywhere.
Client Server EMR (Client Install) – This is the traditional model of EMR where you have a server in your office and you install a client which you use to access your EMR. Data is stored on the server in your office and is only accessible from outside the office using some sort of remote desktop connection.