EHR in the Cloud: Is It Right for Your Practice?

Practices and vendors embrace the next phase of medical IT, but it’s no panacea.

BY JERRY HELZNER, SENIOR EDITOR

Think back about three or four years when ophthalmology practices, under increasing pressure from the federal government, first faced incentives to convert from paper medical records to an electronic health records (EHR) system. At that time, making such a conversion required major up-front investment, on-site servers, local IT support and practice responsibilities ranging from security, to maintenance to HIPAA compliance. No wonder so many practices, especially smaller ones, were approaching this scenario with dread.

Then, seemingly out of the blue, companies such as athenahealth, MDIntelleSys and Practice Fusion began offering what were termed “cloud-based” EHR systems. These were Web-based and promised low up-front investment, remotely hosted servers with accompanying IT support, and freedom from such responsibilities as security, maintenance and HIPAA compliance. In its simplest terms, all a practice would need to do to enter the cloud was have a reliable Internet connection, receive some staff training and pay a monthly subscription fee. With that accomplished, a practice could meet its obligations to demonstrate meaningful use of EHR.

Cloud Gets More Crowded

No wonder, then, that even major EHR companies that had established their credibility by developing highly functional ophthalmology-specific client-server systems began to offer cloud-based options of their own.

This effort was initially undertaken primarily with an eye toward the smaller-practice market of one to five physicians seeking fixed-cost, low-maintenance solutions. However, Tera Roy, specialty director of ophthalmology for NextGen Healthcare, says her company is now ramping up a major outreach and marketing initiative to develop cloud-based EHR solutions for practices of all sizes. This ramp-up includes “multiple data centers across the country that host our servers and are capable of reaching most remote areas nationwide,” she says.

With EHR players such as NextGen making this kind of commitment, is the cloud destined to take over EHR in ophthalmology? Or, are independent IT consultants who favor no single EHR company or system now pointing out reasons to temper some of the enthusiasm over the cloud? This article attempts to present a balanced overview of the potential advantages and disadvantages of cloud-based EHR. It’s a concept that has found a solid niche, but it may not be for every practice.

The ‘Rent or Buy’ Question

Jeff Grant, founder of HealthCare Management and Automation Systems (HCMA), may be based in tiny Shell, Wyo., but mention the name of almost anyone or any company involved in ophthalmology-specific EHR and he either knows them or their product.

“I am agnostic when it comes to the choice of cloud-based versus in-house servers,” Mr. Grant says. “I will recommend in-house servers for some practices.”

The EHR choice is all about the specific benefits that the practice wants to achieve, he says. He likens it to the “rent or buy” decision people make when they look for a place to live.

“With the cloud you are going to be paying rent — forever,” he says. “When you buy an EHR system, you are essentially making an investment that may be more cost-effective in the long run. But if your goal is to free up money that you can use to grow the practice, then that is one specific benefit of choosing a cloud-based system.”

The choice of an EHR system must be “what best fits the practice,” Mr. Grant says. He asserts the system must function efficiently and not disrupt patient flow.

“Seeing one less patient a day adds up to $70,000 in lost revenue in one year,” Mr. Grant asserts. “So before you say ‘I must have cloud,’ think of what you want from any system that you are going to implement.”

Dr. Montzka checks an OCT image on the MDIntelleSys EHR system.

As the co-founder and CEO of MDIntelleSys, one of the first companies to develop an EHR system specifically for the cloud, Daniel P. Montzka, MD, is a passionate advocate for the broad capabilities of what he calls “true cloud” EHR. These are systems designed specifically for the cloud and not merely adapted from client-server platforms. He may have a bias, but his experience and accomplishments in the development of EHR systems merit attention.

Carla Johns enters data on the terminal of the practice’s Medflow Cloud EHR system.

A Different View of Rent vs. Buy

Dr. Montzka takes issue with the rent vs. buy analogy. “I do not think it is valid to look at client server vs. cloud as a buy vs. rent arrangement,” he says. “Buying software is not like buying a car. An EHR Software license is not an asset that can be resold or traded in if it’s not working out. I would look at the cloud-based model as ‘pay-as-you-go,’ with a far more predictable cost over time. Both options have short and long-term costs that need to be carefully analyzed. Many physicians fail to fully account for the long-term maintenance and consulting services required to manage client server systems.”

Cloud EHR: A Niche Solution?

Ronald Sterling, an ophthalmic EHR consultant based in Silver Springs, Md., generally agrees with Mr. Grant that, with the cloud, “you will always be paying.” He cautions that practices that choose to be cloud subscribers must be aware of all the conditions of the agreement, including possible fees for storage of records even after a practice closes its doors.

“A cloud-based system can be very good for smaller practices because they won’t have to worry about security, records back-up and a host of other issues,” Mr. Sterling says. “But the cloud will not take over EHR.There are many good reasons for some practices to have office-based systems.”

Those reasons especially apply to larger practices. For example, an eight-location ophthalmology practice with 30 doctors and 200 total staff is probably not a good candidate for a cloud system. “A cloud system could be charging a fee of $750 per doctor per month,”Mr. Grant says. “That’s just not feasible from a cost standpoint.”

Building in Redundancy and Reliability

Another reason for choosing an in-house installation would be lack of reliable Internet service in the area where the practice is located. However,Mr. Sterling notes that cloud-based systems are becoming more reliable as vendors and practices have learned to build redundancy into them.

“The vendors now have back-up servers available that can take over if the primary server goes down. Many practices are building in redundancy by having backup Internet access — maybe one connection with the phone company and one with the cable company,” Mr. Sterling says. “You could even switch to a [wi-fi] ‘hot spot’ in the office. New techniques have been developed for maintaining an Internet connection.”

One EHR company, Medflow, now offers Medflow Cloud, which is cloud-based but also offers an on-site backup terminal that allows a practice to continue to access patient charts even if the Internet connection goes down.

NextGen continues to support the client-server option for larger and middle-sized practices that do not want to rent services or live in the cloud,Ms. Roy says. Yet, for those practices that choose the cloud, NextGen endeavors to ensure dependable Internet connectivity.This includes moving to the latest VMWare and Microsoft technology, full back-up on a daily basis and 24/7 monitoring, she says. However, Ms. Roy cautions it is up to the practice “to choose the right Internet service provider, which is critical to the success of their cloud-based experience.”

Building all this reliability and redundancy into a cloud-based system does come at a cost, as the independent consultants are quick to note.

Larger Practices and the Cloud

Dr. Montzka, still a practicing Florida retina specialist, had enough technical knowledge of his own to develop a traditional client-server EHR system for his own practice. He then sold similar systems to a few colleagues before he made the decision to totally redesign the software for the cloud. This led to a fortuitous meeting with a partner, Roland Feijoo, whose company, Extensys, had complementary capabilities. This synergistic combination led to the formation of MDIntelleSys.

MDIntelleSys now has more than 150 “true cloud” clients in North America, including some larger, multi-location practices. “Our system is not just for the smaller practice,” Dr. Montzka says. “It’s very scaleable. There is really nothing too big for us to tackle.”

Rebuttal to Cloud Critics

Dr. Montzka takes issue with those who make general criticisms of cloud-based systems, although his rebuttals specifically refer in to the capabilities and policies of MDIntelleSys.

“There would be no issue about fees for the long-term storage of records with us,” he says. “Our contracts are meant to protect the practice. We will give them their records. We don’t tie them to us in any way. They always have an out if they so choose. I believe that’s one of the reasons why we have such a high retention rate.”

Dr. Montzka points to the adaptable template in the MDIntelleSys system that is unique to every patient and that can document small differences in individual patient examinations. “Cloning of claims has become an issue,” he notes. “The adaptable template makes that less likely to happen.”

The MDIntelleSys EHR system encompasses many smaller, doctor-friendly features that have made it a success, Dr. Montzka says. “It’s the doctor who determines the patient flow,” he says. “By offering a true, cloud-based system, we can provide more features that are attractive to the doctors.”

Judging Overall Costs

Selecting an EHR system “is all about running the practice and clinical decision-making,” consultant Ron Sterling says. “The cloud makes a tremendous amount of sense for the smaller practice, but it’s still not a 100% slam dunk that a cloud system is going to be cheaper. You must take into account the full costs of a cloud system, including communication lines, special software and creating a reliable Internet connection.”

Mr. Sterling cautions that practices should not make decisions based on a vendor’s impressive technology.

“This is not just a technical exercise,” he says. “Ophthalmic procedures can be complicated. They require coordination.Whether you choose the cloud or in-house, it really comes down to what software works best for you and your practice.” OM