The use of cloud-based electronic health records is spreading, especially among small physician practices, observers say. But the strength of this trend varies by region, and many doctors' distrust of cloud services still impedes their use of this technology.
In New Jersey, for example, most regional extension center members in practices of three or fewer doctors -- who form about 60% of the REC's nearly 8,000 enrollees -- have chosen cloud-based EHRs. But in Kentucky, only 17% of the physicians enrolled in the state's REC who have gone live on EHRs are using cloud-based solutions or traditional EHRs hosted remotely by hospitals.
Ninety percent of Kentucky REC members have access to high-speed Internet, according to Carol Steltenkamp, the organization's director. So, while some areas of the state remain off the grid, that's not what deters most physicians from going to the cloud.
Many practices have selected an onsite client/server EHR rather than a cloud-based solution because they want to connect to the system their hospital is using, she says. "They realize it would make their life easier to have a system that integrates more closely with their referring hospital organization," Steltenkamp -- who is also CMIO of University of Kentucky HealthCare and vice chair of the Healthcare Information and Management Systems Society -- said.
In addition, "there's a certain comfort level with seeing the machine and how it works" in one's own practice, she pointed out. So despite the technical challenges of running the system locally, she said, many physicians prefer that to the unknown risks of remote hosting and data storage.
In contrast, Ronald Manke -- North Jersey regional director for NJ-HITECH, the New Jersey REC -- said that most small practices lack the technical expertise to deal with the manifold challenges of operating an EHR system onsite. Cloud-based EHRs are as secure as online banking, he said. Therefore, the REC advises small practices to adopt remotely hosted EHRs rather than onsite systems.
Nationwide, an increasing number of practices are making that decision on their own. According to a recent survey by Black Box, 42% of physician practices plan to upgrade their billing software within six to 12 months, and most of those prefer an integrated EHR/practice management solution that includes outsourcing options. In effect, that means using cloud-based vendors that can take over some or all of the billing and collection work, said Doug Brown, managing partner of Black Book.
Revealingly, the five EHR/PM products ranked highest for user satisfaction in the survey were:
- Care360 Quest Diagnostics;
- athenahealth; and
The first four are cloud-based vendors, and eClinicalWorks has a cloud version that it combines with back-office outsourcing services.
Definitions Are Fluid
The onsite client/server system has not changed much over the years. It still consists of one or more computer servers that provide the EHR application to a network of computers (clients) and that store the data. While there are variations involving "thin" and "thick" clients, this is the basic model.
Remotely hosted products fall into one of two main categories:
- Hosted versions of client-server products, now offered by all the major vendors; and
- Cloud-based EHRs available only on the Web.
Most of these Web-native solutions come from newer companies such as athenahealth, Practice Fusion, CureMD, and Medplus/Quest.
Mark Anderson, a health IT consultant in Montgomery, Texas, said that the key difference between these two approaches is that the "Web-delivered" product runs off of a single database, while non-Web-native EHRs (sometimes called ASP model) have a separate database for each user. According to Manke, the application itself is stored on the client's hard drive, while the data are stored in the cloud.
Both types of remotely hosted EHRs are easier to update than onsite EHRs, but updates must be applied separately to each user's EHR in the ASP model, Anderson said. That is because the same EHR can have multiple versions, depending on how it is customized. In contrast, everyone uses the same version of a pure cloud-based EHR, which allows users to choose among only a few custom features.
The biggest advantage of a cloud-based solution is that a practice does not have to buy or maintain a server. That alone can save a small practice several thousand dollars. In addition, practices with onsite EHRs must set aside a secure area -- usually a separate locked room -- for the server and must adopt other security measures to safeguard personal health information. They also must have some kind of data redundancy and offsite backup to guarantee access to the EHR in case of a system crash or natural disaster. A cloud vendor will provide all of those services.
The challenge of onsite security, Steltenkamp said, is not a major deterrent for Kentucky REC members. But data backup can be a problem, she noted. So can server and network maintenance, especially in rural areas where technical expertise is limited and hard to find. According to Anderson, many small practices get over that hump by purchasing equipment from a firm like Dell that offers technical support services to its computer purchasers.
Usability Varies With EHR
Only a few years ago, some physicians complained that Web pages loaded too slowly in remotely hosted EHRs. That is no longer the case, according to Manke. Desktop, laptop and even mobile computers now have huge amounts of RAM, and Web pages are getting "lighter" because much of the data are cached. As a result, he said, "It is as easy to use a cloud-based EHR today as it to shop online at Amazon.com."
Moreover, he observes, Web-native EHRs enable practices to test changes in their EHR templates on their vendor's server before their clinicians start using them in their daily work. But, as noted earlier, these EHRs severely limit the amount of customization that an individual practice can perform.
Because of this cookie-cutter approach, Steltenkamp said, "small practices are more challenged to accomplish what they want to get accomplished" to make the EHR fit their workflow or to generate reports. "In terms of usability, it's about the software," she said. "It's not about whether it's cloud-hosted or not. It's about the application and how the application facilitates the workflow of the clinician."
Cost of Ownership
Because there is no upfront cost for the software, and a practice is not required to buy a server, the cloud-based EHR might seem on first glance to be less expensive than the onsite client/server setup. Manke also noted that "with a Web-based solution, you don't have to buy backup or redundancy. If you have a couple of laptops, Internet access, and a small network with a couple of printers, you're ready to go."
Over a five-year period, he said, the onsite client/server model is more costly than the cumulative fees for a cloud-based EHR, partly because a server has an expected life of only three to five years. "You're going to have to replace it, and that's a cost most practices don't recognize," he said.
But Anderson estimated that after 20 months, a remotely hosted solution will cost more than an onsite EHR does. Including the license fees for the EHR software, hosting and various extras, the total monthly cost ranges from $400 to $600 per provider, he said.
The biggest drawback of a pure cloud-based EHR, from his perspective, is that "nobody comes on site to do training, configuration or setup. It's all done remotely. These software products are not designed to work the way a doctor practices medicine, and it has to be modified based on the workflow. That's why you have so many doctors not using these products to generate clinical documentation."
Observers say remotely hosted and onsite EHRs have pros and cons. Vendors may be pushing their cloud-based products, Anderson suggested, because monthly fees increase the recurring revenue that investors like to see. But it is unclear at this time whether physicians are going to move to the cloud en masse.