As you consider how to finance an EHR, you may wonder whether you should have your software and data hosted on a remote computer server. That approach requires a smaller upfront investment than an in-house client/server network does. However, physicians who have used these application service provider (ASP) EHRs are divided over whether they deliver patient data fast and reliably enough to support top-notch care in a high-volume practice environment.

One physician reported that, even with a fast DSL connection to the Internet, “the waiting times after every click” in his ASP-model EHR “felt like torture.” So he switched to an in-office client/server system, which gave him much better performance. Another doctor was using a CCHIT-certified EHR that accessed the server over the Web. He had a fast, business-grade cable connection; yet, he wrote on a bulletin board for EHR users, “The application is very slow and at times is not even workable. I am always late on my appointments because of the slow speed of the system.”

Other physicians are very happy with the performance of their ASP-model EHRs. S. Hughes Melton, a family physician in Lebanon, Va., says that his e-MDs EHR loads Web pages in less than two seconds, except during periods when the vendor does upgrades. His practice has a fiber-optic connection, but its download speed is no faster than the cable link of the doctor with the “unworkable” EHR. Family practitioner Peter Forman, a soloist in Delmar, N.Y., uses a Verizon FiOS link, and the pages in his remotely-hosted Allscripts MyWay application load in less than a second.

Internet connections are getting much quicker and will soon be a non-issue for ASP-model EHRs, except in some rural areas where broadband is not yet available. However, several factors besides download speed can affect performance. Chief among them is the nature of the application you’re using. As we’ll see later, it’s important to know whether or not your EHR software was designed for the Web.

The other thing to bear in mind is that EHRs are still a work in progress, whether they reside on your own server or a remote machine. “The density of documentation and information that a physician has to navigate is the real barrier, rather than response time,” notes internist William Bria, president of the Association of Medical Directors of Information Systems (AMDIS).

Optimize your bandwidth

That said, your Internet connection is still critically important to your ability to access patient information. While Bria believes that most physicians are willing to tolerate download times of two seconds per screen, other experts note that doctors expect pages to be available as soon as they click on them. Depending on your connection and software, an ASP-model EHR may load a page in anywhere from one to four seconds.

So what kind of connection should you have if you want to improve performance? Dialup is way too slow, and you should also ignore residential versions of DSL and cable. But business-class DSL and cable connections, which come in multiple bandwidths, can be fast enough for an ASP-model EHR, several experts say.

Several factors affect speed. If you have DSL, for example, performance varies inversely with your distance from the local phone company hub. A DSL connection is effective up to about 10 miles from the central office.

The performance of cable modems is not affected by distance. But the available bandwidth drops as more computers, medical devices, and scanners use the connection, either within your practice or in the neighborhood. The same is true of DSL. So the advertised speeds of cable and DSL may be considerably higher than the actual data transfer rate.

Think of the bandwidth of shared connections like highway traffic. If it’s a two-lane highway, a certain amount of traffic will clog it up, and data will move slowly. A four-lane highway can accommodate more traffic before it slows down. But in either case, the speed of your connection is not under your control.

That’s the No. 1 reason why many practices get a T-1 line, both to access the Web and to connect their satellite offices. “On a dedicated pipe, there’s no one in that last mile but you,” notes Sheri Rose, a telecommunications expert and a partner in the Louisville, Ky., consulting firm Commonwealth Leverage. “If you’ve got a T-1, you’re guaranteed 1.5 megabits per second.”

Have a backup

Practices should have a backup system in case the Internet connection goes down, experts say. Consultant Michael Uretz, executive director of the Seattle-based EHR Group, recommends that practices get both DSL and cable connections, in case one is interrupted. If you have multiple links, you can add on a service like Ecessa, which provides “load balancing” to ensure that if one connection is overburdened, the load is shared with the other line.

Rose of Commonwealth Leverage points out that T-1 vendors are much more likely than cable or DSL vendors to provide you with “service-level agreements.” These contracts provide penalties if your uptime is not close to 100 percent, and they also promise very rapid repairs if there is a problem.

If you plan to have a wireless system in your office, make sure it’s business class. If your wireless connection is poor, says Bria, “you’ll have a nice fat pipe coming into your office, and you’ll never realize the benefit of it.” A top-of-the-line wireless setup, including the latest wireless cards for your laptops, a couple of transmitters, and a first-class router, will cost a small practice under $2,000.