"Which Electronic Medical Record system should I select?" Among physicians and managers in small-group practices today, there is no more common question. Hundreds of options blur your vision and the demonstrations seem to run together in your memory. And lately, another vexing question has emerged: Whether to purchase or lease EMR software outright and install it on servers in your office via the traditional client-server model, or subscribe to an Internet-based system maintained in "the cloud."
This white paper will examine the key differences between these models, and offer some guidance on making your selection.
WHAT IS 'THE CLOUD'?
When EMR vendors began offering their products via the cloud, many smaller physician practices may have been puzzled. Some think that the cloud is simply technology parlance for the Internet. In fact, it refers to a method of computing whereby the critical applications are hosted remotely and accessed by end users via the Internet.
Practices have long been accustomed to hosting critical software applications on servers in their offices. After all, that is how they have accessed their practice management systems - the IT backbone of medical practices - for 20 years.
But a cloud-based EMR, where all the practice's data is hosted remotely, raises questions about data access and security. To understand how a cloud-based EMR works, consider how much you are already doing in the cloud. Many people conduct much of their banking via secure websites that allow them to access all of their private financial information, transfer funds, check investment accounts, and pay bills. Users of social networking sites like Facebook and LinkedIn post everything from their kids' baby pictures to their professional resumes to their thoughts on politics. And millions have used Web-based e-mail systems such as Gmail for all manner of personal and professional correspondence for many years.
All these services are offered up in the cloud. You do not have any software loaded and running on your computer to use these tools.
The cloud is really just a giant client-server model: a distributed application structure that partitions tasks between the providers of a service (called servers) and the clients. A client (a user workstation or PC) initiates communication sessions with the server by requesting a service function. In the cloud, the server providing the service - for example, EMR service - is hosted remotely. Your Web browser is the client.
WHY THE CLOUD IS GAINING POPULARITY
Cloud computing is a paradigm shift in data center and IT management. It's an opportunity to completely transform how your practice and your people work. The cloud makes it possible for you to grow and expand rapidly and generate efficiencies and cost savings by paying as you go for the services you use. Cloud-based EMR services for small and mid-sized practices are typically offered as complete software packages provided over the Internet, eliminating the need to install and run an application on your own computers and simplifying maintenance and support. Sometimes this is referred to as "software as a service," or SaaS.
For practices of 10 or fewer physicians, the cloud-based solution is a common choice for several reasons:
• Generally, there are no retained earnings in a practice this size, so any new investments must be financed externally or the physicians take a hit against their current earnings. Low up-front costs are more palatable and less complicated.
• IT expertise and resources in smaller practices may be nonexistent or retained on a project-by-project basis. The cloud model does not require sophisticated technology infrastructure that must be built and maintained by expert, costly IT staff.
• A cloud-based EMR does not require a special facility or environmental considerations because on-site servers are unnecessary. Although the EMR is mission critical, smaller practices often do not invest in disaster recovery solutions for client-server model systems. The practice understands why it is essential to back up their system and may even store a backup off-site, but may not have a documented plan for restoring their system in the event of a disaster. These considerations are unnecessary for practices with cloud-based EMRs because backup and disaster recovery services are central to the cloud.
• Because the critical functions of a cloud-based EMR are hosted remotely, the system can be accessed from anywhere a user has a good Internet connection. Many physicians enjoy being able to review charts even when they are not in the office.
The advantages of cloud-based EMRs over traditional client-server models are clear. Still, any departure from tradition raises questions. Is the cloud secure? Who really owns my data? What happens to my data if the cloud vaporizes? What are the questions to ask about data security? Understanding the key factors when engaging a vendor will help determine your success in selecting and adopting a cloud-based EMR.
DATA, COST, AND SERVICE
Fear of losing control over critical data is often a stumbling block in cloud adoption. The truth, however, is that cloud computing can give you as much or even more control over your data than you get with a client-server EMR. Cloud providers offer a plethora of options for protecting the data entrusted to them - often more than your in-house IT staff or budget could make possible. In all situations, however, data sovereignty should belong to you. Stay away from cloud providers that cannot guarantee that your data won't be mined or used for another organization's commercial purposes.
Implementation can be expedited in a cloud model. Startup takes less planning, fewer costly IT resources, and comparatively little up-front cash.
An encrypted high-speed Internet connection provides your practice with access to data and applications without having to manage software changes or invest in server hardware. Updates are automatic and managed by the vendor so you won't need staff to work over a weekend to install software, migrate files, or test data conversions. And you'll always be on the most current version, without requiring additional infrastructure investment.
Although there are start-up costs, there is no up-front software license to purchase or lease with the SaaS cloud model. While you won't be paying a software maintenance or upgrade fee, you will be paying a monthly subscription or service fee.
You'll want to work with a vendor that earns its monthly fee by providing excellent service and customer support. Just as you would check references of a prospective new employee, contact other users of any vendor you're seriously considering. Have peer-to-peer conversations - physician-to-physician, manager-to-manager, nurse-to-nurse - about the practices' experience with the product. Ask about the training and implementation. Ask how long it took after the providers were trained on the EMR for them to achieve the same productivity levels they had met prior to the EMR implementation. Ask about interruptions in EMR access and how the practice accommodated patients during any such downtime.
The nature of cloud-based service offers flexibility, unlimited scalability, and access to data from anywhere, anytime. In order to determine how mobile-friendly the service is, have the vendor perform a mobile demonstration for you. You'll need to know how the EMR performs on whatever mobile devices, including tablets such as the iPad, your providers might use to access the data.
YOU'VE OPTED FOR A CLOUD SOLUTION: NOW WHAT?
As you narrow your search across vendors and solutions, the following questions will help guide you to the solution that best meets your specific practice needs:
Implementation: You want your vendor to be there as a partner with you during the often-challenging implementation and transition period. So ask:
1. What information can be converted into your system from our legacy applications?
2. Will there be a project manager (and backup) assigned to our office?
3. Do you supply a detailed deployment checklist?
4. Do you recommend a go-live all at once or in stages?
5. Where does the training occur? At our practice? At your location?
6. Who is doing the training? Do they have U.S. healthcare experience? 7. Do you provide training demos for new employees? How is this done?
Service and Support: These are critical areas to your ongoing success. Start by requesting to see the standard Service Level Agreement (SLA). Examine the basics - guarantees of 99.9 percent up-time and customer support extensive enough to meet your current and future needs, whatever they may be, if necessary, should be included. Also ask:
8. What has been the history of system downtime? 9. How many times has the system been down in the last two years and for what durations? 10. What is your policy for responding to support inquiries?
Ease of Use: Your providers have to be able to learn the system quickly, and using it has to come natural to them. Otherwise you risk a physician revolt and long-term productivity reductions. So ask:
11. How much effort is required for each physician in creating and modifying templates?
12. How do doctors and nurses process telephone messages and internal tasks - for example, relaying test results to patients and returning patients' phone calls?
13. What kind of reports can be automatically generated?
14. What other products/software are required for use in conjunction with the EMR (drug database, patient education, voice recognition, etc.)? At what costs?
15. What interfaces for diagnostic results are available?
16. Do you offer a native iPad app?
Who Besides You? Bigger vendors aren't always better. But a larger size vendor is generally more likely to be around long-term, has the resources to provide all the necessary technical upgrades, and is more likely to have a lot of experience with practices like yours. So you should ask:
1. How many total practices nationwide are using your system?
2. What size are the practices?
3. What specialties are represented by your user base?
4. Is the product certified to qualify for the federal incentives for purchasing and "meaningfully using" an EHR?
5. How many practices have left your company and why?
6. What is the ownership of your company?
7. What is the No. 1 reason practices choose your system?
8. Are any physicians involved on a day-to-day basis with R&D, implementation, training processes, etc.?
9. How do you integrate ideas submitted by end users for upgrade consideration?
WHAT TO LOOK FOR IN THE DEMO
Before you even schedule vendor demonstrations, write down your “must haves.” For example, in one practice, the system must track all Pap smears for outstanding results while automating patient notification of results. Another practice required its EMR to incorporate point-of-sale purchase of retail items. A 10-physician internal medicine practice needed its EMR to incorporate voice recognition software to ease the transition for keyboard-phobic physicians.
Can you identify your top 10 requirements? Specialists' needs differ from primary-care practices. For example, having an interface to the lab results for the bulk of patients (75 percent to 80 percent) is an absolute requirement in primary care, but perhaps less so for specialists.
Among most practices' must-haves today is the ability to satisfy the government's criteria for receiving federal stimulus dollars for incorporating a qualified EHR, which include a demonstration that the practice is "meaningfully using" the system. Incorporate the government's meaningful use criteria to determine how your use of the EMR system will address specific objectives. For example, collecting the smoking status on all patients age 13 and older is one of the objectives, so ask the vendor to show you how its solution prompts you or your staff to ask patients about their smoking status, document the responses, and generate the collective data for reporting.
It is easy to get distracted during a demo with features and functions. Many solutions have polished user interfaces and many demonstration specialists have perfected their skill at showing off the sizzle in their system. If you begin the demo preparation with the end in mind by articulating your objectives and vision for your EMR implementation, you will identify the solution that will have the greatest opportunity for successful use in your practice.
Remember that there are certain factors within your practice that will help determine success. The providers' comfort level with integrating technology tools into their daily work flow is first and foremost in considering which solution is a best fit. The partners' perspectives considering up-front investment, the amount of IT support a practice is willing to take on, and the availability of a fast, reliable Internet connection are other critical determining factors in a cloud vs. in-office client-server decision.
For organizations that have the wherewithal and staff to maintain a data center (multiple servers, perform regular data backups, manage often-complex software upgrades, and attend to the details of technical troubleshooting) a client-server model is a viable choice, but may still be cost prohibitive. Practices that find start-up investment in a data center daunting, or do not have adequate IT support, will find clarity in the cloud.
Rosemarie Nelson has experience in information systems as a medical office manager, and as a consultant to physicians. As a healthcare consultant with the Medical Group Management Association, Nelson regularly conducts educational seminars on a variety of healthcare technology and operational topics. She has also authored numerous articles and helped create new informatics products for physician practices in the Office of the Future consortium. Previously, she was vice president of business development for Health Care Data Systems. She holds an MS in health services administration from New School University in New York.