SAAS Versus Client Server in EHR

Posted on January 6, 2009 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I was invited to join in on a discussion that Ben over at tempdev started with the CEO of Practice Fusion, Dr. Robert Rowley. The guest post by Dr. Rowley essentially began to highlight some advantages of the Practice Fusion SAAS model versus the client server model which NextGen (and most other EHR companies) employs.

Much of Dr. Rowley’s guest post and the comments on it were about whether a hosted one database for multiple practice system facilitates sharing of patient information better than a bunch of disparate client server installs. I’ll leave most of that discussion for the comments on the post, but I will mention that the biggest challenges with sharing information between multiple EHR systems isn’t the technology. The 2 biggest problems I see with sharing patient information between doctors are:

  1. Doctors who aren’t using an EHR and won’t give up their paper charts
  2. Defining the rules for sharing

Think about what it takes to share information. You have to ensure that the patient has given you permission to share that information, manage how long and which parts of the information can be shared and then go to work to make that happen without sharing more than you should share. Much more could be said about sharing patient records, but my point is that the technology of sharing information isn’t the problem with client server installs. The technology is there, but the policies aren’t.

One final note about sharing using the Practice Fusion model of SAAS EMR is that it still strongly depends on everyone using Practice Fusion. The problem is that there are at least over 400 EHR vendors selling product. This means that ever EHR system will have to learn to talk with each other and can’t just learn to share with itself. At that point, I’d argue that it’s not that much easier for a one database hosted solution to share data with a different EHR software than it is for a client server based EHR to do the same.

Wait, I told you’d I wasn’t going to talk about sharing….so back to some of Dr. Rowley’s other points.

It is true that a client server based system does require a larger up front cost in server and IT support than a hosted solution like Practice Fusion. However, it’s really quite amazing how quickly those costs have dropped. Just today I got a quote for a server for a local doctor’s office that cost under $3k. Prices on servers have become so affordable that it’s not nearly the expense that it was 5-10 years ago.

What wasn’t pointed out by Dr. Rowley is the need to invest in a more reliable and faster internet pipe when using a SAAS EHR. A client server EHR works on your local network which will always be much faster than anything an ISP can provide. Not to mention significantly more reliable. Choosing to go with a hosted EHR can work, but you’ll just have to plan well for when your internet connection goes down.

Hosted EHR companies also love to tout how the software automatically updates as new releases are made. This really can save time compared to in house EHR systems that require you to update an application on each computer (we won’t talk about the in house EHR software that is web based). What they don’t tell you is that you may not want or be ready for the new features. In the client server world, you can test the update and prepare for the changes being made on your schedule. A one database hosted option doesn’t give you that flexibility. If the update breaks something you enjoy, then you’ll have to deal with it until the company can fix it (assuming they think fixing it is a priority).

It’s getting late or I’d keep going about the pros and cons of both the SAAS versus client server models. Don’t get me wrong, I think hosted EHR are certainly a viable option for those implementing an EHR. However, even hosted EHR come with their own list of challenges. Selecting an EHR is more about choosing which challenges you are willing to work around than it is choosing the perfect EHR that does everything exactly the way YOU want it.

I also wanted to talk about Dr. Rowley’s suggestion that “NextGen is an example of one approach, and PracticeFusion is an example of a fundamentally different approach. Rather than seeing them as “a spectrum” of approaches, it might be more appropriate to consider them as different generations of product: EMR 1.0 vs. EMR 2.0”

I think it’s unfair to call NextGen or any other similar EMR as EMR 1.0. Some of the features offered by the client server model blow away PracticeFusion and other web based EHR. The web has come along way (and is continuing to improve), but still can’t compare with some of the UIs client server can offer.

I do agree that they are fundamentally different approaches to solve the same problem. They each have their own benefits and challenges. Pick your poison.

Finally, I was a little surprised that Dr. Rowley didn’t mention the most unique part of his model until the end of his guest post. PracticeFusion’s “free EMR” model that is funded by advertising is what sets it apart from even the various hosted EMR options. This description of PracticeFusion’s business model is its most defining characteristic:

Practice Fusion’s free EMR is an emerging product built on this vision, and has a business model where in-product targeted ads pay for the service. The ads can be traditional vendor ads (pharmaceuticals, devices, billing and transcription services, etc), or can be “counter-detailing” ads, where insurers or local medical groups or IPAs can display their preferred treatment methods for the condition-at-hand.

You can read some of my past thoughts on free EMR by PracticeFusion. I’m still very curious to see how PracticeFusion fairs in the marketplace. One thing is certain, they’ve got a pitch and their selling it to everyone who will listen.