EHRs in the Cloud: Hiding Flaws Don't Make Them Disappear

September 24, 2012

EHR cloud computing is an out of sight, out of mind idea - you won't worry about what you can't see at your medical practice.

This week, I conclude the discussion prompted by Tom emrTECH's comments that: 1) Cloud vendors can choose to improve performance in a variety of ways including by housing your data in a data center in your geographic vicinity; and 2) there are drawbacks to and headaches associated with deploying EHR in your own office.

Using any EHR raises the question of redundancy. With a locally installed EHR, numerous options exist for remaining operational after a system fault: from mirrored local servers to real-time mirroring of data to an offsite location to a complete offsite clone of the software.

With a cloud-based EHR, the only redundancy that is available to the user is to maintain multiple connections to the Internet obtained from different service providers employing different technologies so that a failure of one vendor's last-mile service would be unlikely to affect the other's. Beyond that, one must rely on the cloud vendor to design and implement effective strategies to maintain availability.

How many of you have ever tested your backup strategy?

How many of you have a redundant connection to the Internet?

And a wireless backup to the wired backup?

And backup power for every network hub, router, modem, computer and refrigerator in your office?

And LED headlamps for all your staff?

When were they last tested?

Finally and without question, locally installed software can be a headache so I would like to emphasize a point that I have made in the past. The computer hardware and software that is available today, while relatively more advanced that of 20 years ago, is still hopelessly rudimentary in absolute terms. It is not necessary for software to be so difficult to install, maintain, and update but it is. The explanation is that the operating systems and programming systems were designed for ease of use by the programmer not for maintainability and they have neither the means nor the incentive to correct the problem.

Those of you who are older might remember a Pontiac model from the 60s with a transverse V-8 engine. The freeze plugs for the rear bank of cylinders were, of course, located on the engine directly opposite the firewall. When a freeze plug failed, it was necessary to pull the engine to replace the $0.50 part that required one blow with a hammer to install. Detroit, after much encouragement from the Japanese, has learned the lesson and now builds products that are both more reliable and more maintainable.

The computer software industry has yet to learn this lesson and yet to develop the tools and techniques that would enable them to solve the problem. To them, the cloud is the solution. Reverting to a 20-year-old to 30-year-old computing model allows them to move the hard-to-maintain software to where it is close to them.

There is no question that an "out of sight, out of mind" solution can make the end-user's life easier but it does nothing to advance the overall state of software. If you are normal, once it is "out of mind" you won't think about it again until it causes a problem and then it will be too late.

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