SPECIAL SECTION: EHR CONVERSION

Cloud Based EHRs — Hope or Hype?

What you must know about this newer option.

BY David E. Silverstone, MD

The introduction of electronic health records into the medical community has been difficult for many practices. Not only do EHRs disrupt office systems and workflow, they are often both difficult and expensive to install and maintain. This is draining office finances and creating the need to employ highly paid information technology professionals.

EHRs have been a significant aspect of my own clinical practice for over a quarter century. During that time, I have seen our office computing infrastructure become increasingly complex and difficult to manage. As my own practice grew, I saw my IT staff grow to three and my IT budget expand exponentially.

The explosion of interest in EHRs has been fueled by the ARRA stimulus act, which includes HITECH. Practices are now being given bonuses for implementing electronic records. Eventually, if they do not implement EHRs, physicians will be penalized.

With decreased reimbursements looming, even the inflow of HITECH stimulus funds is not sufficient to stem the outflow of cash that most EHR systems will create. Stress levels are high among physicians and office staff as problems heretofore rarely known in medical practices become everyday crises. Suddenly, focus is centered on IT issues rather than medical care issues.

Cloud-based computing options are being proposed as an easier alternative and a solution to the problems being created by the introduction of EHRs. But what is cloud-based computing and is it a good solution to the problem?

To understand how a cloud-based option works, we need to know how it differs from our current, more traditional options.

Traditional EHR Systems

Since more than one computer or terminal is necessary for most medical office computing, especially medical records, there needs to be a computer network and the computers need to communicate with each other. The traditional arrangement is referred to as Peer-To-Peer or Client-Server computing. Each of the computers on the network maintains a copy of the software and executes it locally. All the data is housed on one computer or data server. Occasionally, simple terminals, referred to as thin clients, will connect to and operate off of one of the computers on the network. The software and the data are always operated locally and maintained locally.

The typical EHR system is a Peer-To-Peer or Client-Server system. The software is maintained on powerful and expensive hardware servers sitting at the site of the practice. The data is then stored on additional hardware at the site. The hardware requires rooms with special cooling systems. All maintenance is performed on site. All security and privacy control is managed on site. Software is updated on site. Software and data are backed up on site. Software upgrades are limited by the power of the hardware and expensive hardware replacements are often necessary when the software is upgraded.

Personnel on site need to keep the hardware and software working properly and to repair it when necessary. The various workstations at the site are interconnected with a network on site. If there are multiple offices in the practice, the offices need to be connected. Gateway switches need to be installed, which are then connected to each other by expensive communication lines. These elements of the system also need to be maintained and often repaired. When the system goes down, the practice cannot function. On-site IT personnel need to be employed or shared with other practices; they must be available instantly to keep the practice up and running.

Enter the Cloud

This arrangement is expensive to implement, difficult to maintain and vulnerable to physical and electronic hazards. Cloud computing options are touted as solutions to the problems introduced by Client-Server computing systems. With cloud computing, the main powerful computing hardware and software are housed at a remote location. The data are also housed at a remote location. The name cloud computing comes from the traditional computer network diagrams that traditionally showed the Internet as a cloud.

The simplest form of cloud-based computing is the Application Service Provider (ASP) model. Instead of the powerful hardware servers and data servers being physically located at the site of the practice, they are housed at a remote location and connected to the office network by the same type of communication lines that connect the practice’s different physical sites to one another.

The advantage to this system is that the server and the software and the data are all managed off site by a professional IT company. Usually, the practice still has to purchase the software, however. The hardware is usually rented to the practice by the IT company. HIPAA compliance, virus protection, intrusion protection, software maintenance and upgrades are all managed at the off-site location.

Public and Private Clouds

The type of off-site location can be either based on a system that is called a “public” cloud or a “private” cloud. The largest players in the public cloud services are Amazon, Google and Salesforce. They support millions of businesses on their computers. They each have a few data centers and they duplicate the data at multiple centers so if one goes down, the computing is shifted to another and the end-user has no interruption in service. Sharing of resources on a large scale like this can lead to lower costs.

When the users or the cloud are only using a particular set of software or are in a select group, the cloud model is referred to as private. This can be an insurance company or hospital system that is offering computing services to physicians. It can also be a particular software company that is using its cloud for its proprietary software only. As opposed to a public cloud, the computing characteristics can be optimized to the specific needs of the organization. Security can be better and performance can be optimized.

Advantages of the Cloud

Cloud-computing alternatives are becoming more of an option for physicians. With cloud computing, the practice’s computing burden is minimized and focus can be redirected back to medical care. Maintenance is the responsibility of the cloud provider off site and you are usually unaware when it is being performed. Data center duplication ensures the practice that if the data center goes down, computing will be shifted instantly to another data center and operations will continue locally without any indication that there had even been a problem.

One of the most widely cited advantages of cloud computing systems is that they require minimal on-site hardware and software. You are purchasing a service, not computing assets. Therefore, upfront costs are minimized and financing is usually unnecessary. Much of the expense becomes a business expense and is deductible during that year rather than having to be depreciated over many years. Because you are purchasing a service, the annual costs are predictable and known up front. You do not need to maintain a significant IT staff locally. Cloud computing options are available to ophthalmologists now.

Some traditional EHR companies can now arrange for off-site housing of the EHR by a cloud computing ASP company, or in some cases at their own facilities. Many hospital systems will provide their EHRs in a cloud-based system where the hospital IT staff maintains the software and hardware at a central location. Some groups of ophthalmologists have come together to centralize their resources and operate as a cloud. For the most part, these options are using software that was initially designed for a Peer-to-Peer setting but is being used in a cloud format.

Some EHR software has been designed to take advantage of a cloud-based design. This type of software enables improvements made in the software to become available to all users instantly. Usually, this software is not purchased as an asset that needs to be financed and depreciated but rather as a service that is a monthly business expense. At least two ophthalmology-specific EHR companies already have multiple installations currently in operation. Some of the larger companies also report that they are developing cloud-optimized versions.

Caveats for the Cloud

The same care that is necessary in selecting traditional software should be exercised in selecting a cloud-based system.

►Make sure the software you’re purchasing has been certified for “meaningful use.”
►Check out the financial stability of the EHR company. You want to make sure the company is going to be around for the long haul.
►Conduct site visits at offices similar to yours to see the software in operation. Ease of use and training are key considerations. Find out how long it took the sites you visit to become fully functional. Find out how the EHR has improved operations at the site and how it may have complicated operations.
►Upfront costs and long-term costs are key. Many cloud-based options require very low initial costs, but the monthly fees can be large. Make sure you know how much the system is going to cost you on a monthly basis. Have your accountant and business consultant review the true costs of the system. The initial cost of a locally housed Client-Server system is not the total cost, as a monthly software maintenance fee (usually 1% of the purchase price per month), local maintenance fees, local IT personnel and network operation costs must also be factored into the true cost of the system.
►Have an attorney experienced in EHR implementation review your contract. Your contract should make sure that you are in control of how the data you generate is used and accessed.
►Be certain that the EHR will communicate effectively and efficiently with your other office software, especially your practice management system. Cloud-based EHRs should be able to interface with your other systems whether they are Client-Server or cloud-based.
►Make sure you have a plan for managing all of the images that we have in ophthalmology. Often, a separate PACS or image management system is necessary, but sometimes that is part of the EHR. The speed and ease of operation of this system is a critical component of your workflow. You must be able to view all the images that you need to view in a manner that you are comfortable with. This also should be reviewed at site visits.
►Have a plan for managing your legacy data. Often, scanned images will be able to be viewed in the new system, enabling your office to be truly paperless.
►Be sure to review the cloud provider’s systems for data back-up, disaster recovery, HIPAA compliance and security.
►You need to have outlined and planned for a realistic exit strategy in case of an unanticipated event. It’s important to prepare well ahead of time for such contingencies as the vendor going out of business, your practice splitting up or the conversion to a new system.

Explore All of Your Options

The old KISS (keep it simple) axiom should be a guiding mantra when thinking about EHRs. The installation of an EHR system can be one of the most disruptive events that will ever take place in your clinical practice. It is important to approach it carefully and deliberately. Discarding a system can be even more disruptive than installation, so your decisions and planning are critical.

It is my belief that the clear direction office computing is taking is to be more cloud based and less locally Client-Server based. Cloud-based systems are newer and might be harder to find and evaluate, but they exist, work well, have satisfied customers and therefore need to be carefully evaluated. Perhaps a hybrid of the two approaches will emerge — even if you do decide to install a locally housed client-server system, ask about the vendor’s cloud-based plans. Find out if will you have the opportunity to convert and what will be involved. OM

David E. Silverstone is in private practice in New Haven, Conn. He is clinical professor of Ophthalmology at the Yale School of Medicine and the assistant chief of Ophthalmology at Yale-New Haven Hospital. He has been using EMR for 25 years and lectured extensively on it. He gave the first talk on cloud computing at an AAO meeting.