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.

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.

Lately the comments have been hopping with interesting conversations. Oh wait, I said that just a few posts ago. Well, it’s the truth! Turns out, a really interesting idea came out of a discussion about EMR vendor’s ability to export the data out of their system.

The basic concept is to create what I’m calling a “Provider EMR Bill of Rights”

The idea is to together create a list of criteria that would ensure that the EMR vendor isn’t just trying to make a sale, but has the best interest of the provider at heart as well. Here’s just a few examples of things that a Provider EMR Bill of Rights could include:

• Providers Always Own the Data in the EMR
• An EMR will provide a way to easily export all of the EMR data into a usable format

It might be wise to also make specific sections of the EMR Provider Bill of Rights for things like SaaS EMR. For example, we could include the following: “SaaS EMR vendors will provide a way for clinics to have a daily download of their SaaS EMR data which they can store locally.” As you can see, I’ll need your help and suggestions to make the list useful, effective and reasonable.

I think once the list of “EMR rights” is developed, EMR vendors could choose to adopt and implement these options or not. By choosing to adopt these criteria, EMR vendors would get the benefit of saying they have the providers best interest in mind. Providers will get the benefit of EMR vendors taking a stronger interest in them. Plus, providers that come upon the Provider EMR Bill of Rights will also be more informed on some of the issues they will want to discuss with EMR vendors.

I’m currently working on a redesign of this partial list of EMR and EHR vendors which I started years ago. Part of that redesign could be having a list of those EMR vendors that have chosen to adopt the Provider EMR Bill of Rights. Who knows, maybe even an icon that indicates this status and some badges to put on their website as well.

What do you think of the idea? Do you think it would be valuable? If you’re an EMR vendor, would you consider adopting this? Are there other ideas which could make this idea better?

If you like the idea, let’s start listing out items that you think should be included in the Provider EMR Bill of Rights.

One of the unforeseen and planned for challenges of having an EMR is the fact that software wants to be updated regularly. This is especially true for EMR software in its current state. EMR vendors are constantly making changes to the EMR software and for good reason. EMR software is rather immature as far as the features, usability, etc that it needs. Of course, an update to your EMR software is a great thing if it gives you even a half dozen new features that will make your life easier, your clinic more efficient and make your EMR more usable.

One of the challenges of updating your EMR software is managing the list of changes (most people call them updates since change is bad) that were made to your EMR software. The goal of course is to be able to update your EMR software and still keep on running your clinic as efficiently as possible. You want to know of changes to the software beforehand so that you’re not blindsided by a change that will cripple your workflow. You also want to make sure that you’re utilizing the new features that were added to the EMR in the best possible way.

I’d love to hear people’s experience with software updates to their EMR. How does your EMR company notify you of updates? How does your EMR vendor inform you of the changes that were made? How often do you update? Do you test the update before you actually do the update? How do you notify your end users of the changes in the next EMR software update?

Of course, the other wrinkle in this is whether you have a client server EMR or a SaaS EMR. In a true SaaS EMR, the updates just happen. In fact, they often happen whether you like it or not. So, I’d love to hear from some SaaS EMR vendors talk about what they do to communicate the updates to their EMR.

After I hear some comments, I’ll summarize the comments in another post and share my experience doing updates to an EMR software. I’m doing the same with my ePrescribing Challenges post and you’ll see that summary post about ePrescribing coming soon.

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.

When I was writing my last post about updating your EMR software, I knew that I had to also write a post talking about the update process for an SaaS (often called hosted) EMR solution.

Basically, updating your SaaS EMR is a two edge sword. Hosted EMR vendors will often talk about how great a hosted solution is because you never have to go in and update your server’s software. The updates just happen and are all managed by the EMR vendor itself. Kind of like if you use any of the free email services like Gmail. It’s updated all the time and you don’t have to worry about it. Essentially updates to an SaaS EMR work similar. The updates are applied on the server that’s managed by the EMR vendor and you automatically get the latest updates.

It’s worth noting at this point that this really is a huge time saver. I hate dealing with updates of client server based EMR software. I even push out the updates to my over 100 computers using an automated solution, but I still hate doing it. There’s always some sort of issue with some computer not updating properly. In an SaaS EMR solution you just have to make sure that your web browser’s updating doesn’t screw things up. Otherwise, no need to worry about updating every computer in your clinic when your EMR decides to update.

However, the second edge of the sword is that you EMR software will just automatically update. When all goes well this is great. When there is a problem with the update then you didn’t have a chance to test it first. You don’t get to choose when the updates happen (usually) and that includes delaying an update while you wait for another enhancement to fix what the update breaks. I will say that most SaaS EMR software are much quicker to fix if something really bad does happen with an update. The point is that you’re much more at the mercy of your hosted EMR vendor when an update is done. It’s nice to have it hassle free, but sometimes the hassle is worth it.

Let’s hear your stories. I know you all have them. That includes challenges with updating both in the hosted (SaaS) or client server world. Share it with us in the comments.

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.

Note: This post starts a bit technical, but even those less technical should benefit from the second half of the post.

Today I had the very exciting event of a hard drive dieing on one of my servers. Luckily, I had the drives mirrored and nobody noticed. The server just kept running off of the good drive. I’ve had this happen a couple times and it always makes me happy to say that we lost a hard drive and nobody noticed the difference. Nice to know that things work the way they should be working.

However, the thought of losing the other hard drive before I could restore the second drive is always a little bit tense. Luckily for me, I was able to just connect to the raid controller (yes I just lost half my readers) and rebuild the failed hard drive and we’re back in business (at least for now).

I admit that when this happened I went straight to my backups to make sure that they were working correctly and I immediately made a backup of all the databases on that server. Of course, the thought being that if I lose both hard drives I’d at least have my backups (which I’d saved to another machine).

Enough technical already. My point of this post was that this event really made me think about what a doctor’s office would do if they lost a hard drive. They better hope they have good IT staff to be able to fix it. It’s far from rocket science, but you do have to be careful in these situations. The other important lesson is who do you have monitoring that the drive failed? Most servers have the ability to notify you when a drive fails. However, how many doctors or IT people that support doctors have set up these notifications?

I wish I could say this was an isolated incident that’s rare. Over the past 4+ years in my current job, I’ve had 3 or 4 hard drives fail. Not a huge number, but also enough to require a good plan for when this happens. I’ve often heard that the first thing to die on a server is the hard drive. Why? Because the hard drive is a moving part (the disk spins) and moving parts break. So, you just have to expect for these things to happen and plan for it.

At the end of the day, nothing was lost and there was no down time for our EMR server. That’s the good news about a well designed EMR server. The problem comes when no one’s watching for these events or when the EMR server isn’t installed in order to plan for these types of events.

I’m pretty sure my SaaS EMR friends are going to love this post. There’s no doubt this is a huge plus for SaaS (hosted) EMR companies, but there are other challenges associated with SaaS that should be considered as well. I’ll let the SaaS enjoy this benefit for now and leave those comments for another post.

I finally had a few moments to watch the Matthew Holt interview of Glen Tullman, Allscripts CEO at HIMSS. Allscripts is no doubt a large player in the EHR industry (like it or not). This is especially true after Allscripts acquisition of Misys. So, Glen Tullman will have a large effect on the EHR industry so it’s worth listening to hear what he has to say. I’ll include a few quick comments of my own below the video.

Overall a pretty low key video. There were a few things that are worth commenting on.

The first thing that hit me was that Glen Tullman thought that the controversy over CCHIT was that CCHIT certified over 300 EHR vendors. Glen makes the argument that government wants a smaller footprint of EHR vendors and that 300 was too many. I guess I can kind of see why government might not want to certify 300 EHR providers since doctors just don’t have time to look through that many. However, it was the first I’d heard of that CCHIT controversy.

What does make a lot of sense is why the CEO of one of the largest EHR vendors would want the certified EHR vendor list to be a really small list that includes them. So, it would make sense for him to lobby the government to keep the list small.

I’m glad that Matthew Holt brought up at least another reason that CCHIT as the EHR certification is a problem. How about you just start with the controversy that CCHIT certification doesn’t provide benefit to doctors. Solve that one and we can find a way to deal with any other CCHIT controversies.

Of course, at the end Glen Tullman also said “CCHIT has done it [EHR certification] very effectively.” Effectively? Seriously? Can he provide me some data on how effective it is? It might be effective for his organization’s interests. So, maybe that’s what he meant.

Glen Tullman did make a great comment about SAAS EHR versus client server EHR. He basically said that most users don’t know the technology behind SAAS EHR and client server EHR. Glen suggested that most users just know the financing model of the two EHR options. A very fine point. I’d just add that they know the financing part AND the IT support part of the equation (ie. SAAS EHR means you [the EHR vendor] do the IT. Great!) Glen does seem to understand how to sell an EHR product to his customers.

There you go, there’s my quick comments. What can I say? I type fast.

I recently posted my belief that the EMR and EHR industry is about to shrink. This can happen in a number of ways, but will most often happen through either a merger or a company just closing its doors.

There are definite challenges associated when your EMR or EHR company gets merged into another company. I’ll save those discussions for a future post (or would welcome a guest blogger to write about their experience with it), but in this post I just wanted to raise awareness about what could happen if the company hosting your SAAS EHR goes belly up.

When selecting an SAAS EHR, it is important to learn how the EHR company is funded. Depending on how your company is funded will give you a good idea of how long they’ll be around. A company that is running off of venture capital funding or new sales could run into real troubles in this current economic crisis. Once an EHR company runs out of money they’ll generally have the choices listed above: sale/merge the company and assets or shut down the company. Of course, an EHR company that is structured to survive on reoccurring revenue is in a much stronger position financially and will weather the economic crisis better.  In a future post I’ll discuss some warning flags that might indicate that your EHR company is in trouble.

Imagine what effect it would have on your clinic if your hosted SAAS EHR were to close their doors.  An EHR becomes as integral to a practice as breathing.  You can only hold your breathe so long before you start experiencing some major consequences.  Have you thought about a plan in case this happens to your EHR company?  Do you even have the rights to the data in your SAAS EHR company?  What would you do with that data if God forbid, the company was going to shut down?

The good news is that I believe most SAAS EHR companies will try to give you at least some notice before shutting down the company.  However, you shouldn’t expect more than a month’s notice.  If a company is shutting its doors, then every month their in business their losing more and more money.  So, you better be prepared with a plan of what you’ll do in the event this happens.

Unfortunately, mergers or sales aren’t that much better than a company shutting down.  Depends on the merger or sale, but often the software from the company being purchased goes from being highly developed to mostly maintained.  Help requests will often go unanswered or at least a delayed response while the companies figure out the best way to merge the two companies.

Planning for this even is even more serious when using a SAAS EHR software.  In a hosted EHR situation, even if the company goes under you can still use the EHR for as long as you want.  You just won’t get support if something goes wrong with the software.  This gives you a longer runway to be able to plan the move to another EHR system.  An SAAS EHR software has a much shorter runway to make a change.

I wish these things weren’t a reality.  It would be nice to think that every EHR company is going to do great and be around forever.  However, it’s just not the case.  EHR companies of any sort are still a software company.  In fact, many are startup software companies and the statistics don’t lie that the majority of software startup companies fail.  Are you prepared in case your EHR company fails?