EHR Delivery Models: ASP & Cloud Systems vs. Local Servers

These days, all data seems to be moving towards the ‘Cloud’ with delivery of computing as a service rather than a product. With the advent of cloud computing and remotely hosted applications (ASP), is there still a place for a local server to run an EHR in a medical practice? What are the benefits (and challenges) of ASP/Cloud systems in comparison to local servers? Is either option better in specific types of practices or is this just ‘technical lingo’ that further complicates the choice of your EHR?

Here are a number of points to consider:

  • Cost is often cited as being lower with the ASP/cloud systems as one does not need to install additional servers on-site to run the EHR software. However not all of the costs are offset. If you have a wired or mixed wired/wireless network that connects all of your computers together , you still have the expense of managing switches and the network which may include a network server and any billing/administrative software that you run in the clinic. When discussing an ASP/cloud system with a potential vendor, ask them to explain how much of your existing office infrastructure you can give-up if switching from a local server system (e.g. integrated billing software with the EHR). An important consideration in your location of practice is the cost and availability of high speed internet access and whether you need to add a second connection (from a different provider) if your primary internet connection goes down. This is an additional monthly cost over and above local server systems;
  • Always available connectivity is a prerequisite for an ASP/Cloud system. If you cannot connect to the database, you cannot operate unless you keep a local copy of your database on site in your practice in the event of an internet disruption. You may decide to purchase a single internet connection with a high guarantee of up time, however if you decide to add a second connection for redundancy (in case the first goes down), make sure that the provider does not use the same network fibre as your primary Internet service provider. In that case, you may lose both connections in the event of a network failure;
  • Backup and upgrades are much more easily managed with cloud/ASP systems than local servers. Simply put, it is not your problem. It is the vendor and service provider’s responsibility to ensure that the software and database are always up to date and backed up. There are multiple fail-safe systems in commercial level server facilities that minimize the risk of you ever losing your data. Local server systems require someone to do daily backups and ensure that a copy of the data is also stored securely off-site. This can be accomplished using tape or disc backups or remote backup services via the Internet. However, you should intermittently test your data and restore a file from your backup to ensure it is working properly. There are many instances of backups not working when the crucial time comes to restore a system;
  • Browser vs. client software. Have you noticed how online applications such as Google Docs have begun to feel more like computer software applications that you would have loaded on your computer. They are fast, flexible and use menus and buttons without windows launching for each new task. There is a strong argument to be made for the speed and flexibility of local client software that works like you work, however the browser-based software services are getting better all of the time using new advanced programming languages. This should not be a limitation, however make sure to give the EHR a solid test run to confirm that you are comfortable with the way it works;
  • Security of data. Physicians like to have sensitive clinical data directly under their control, something that has been strongly in favor of local servers and many philosophically are just not comfortable with the concept of remotely stored patient information. This is an individual decision that each practice will have to make. A useful article is available on AmericanEHR to help understand the difference between Privacy, Security and Confidentiality of data;
  • Response to natural disasters — In the event of a significant natural disaster, having one’s data stored remotely can be an advantage, particularly if an office is flooded or charts are destroyed. ASP/Cloud systems have the advantage here – Read the following article on disaster response;
  • Performance is an area in which the local server systems have a distinct advantage. There is a difference between usable performance and full speed office performance. Even sub-second delays can feel like an eternity if one if used to charting at a certain speed. Cloud/ASP systems are improving all the time, however do your homework and if possible test the system in a live setting similar to your practice to ensure that you are comfortable with the performance and response times.

Two additional resources:

In a Sept 2011 Webinar on AmericanEHR — Selecting the right hardware for an EHR-based practice — Dr. Eric Goldberg leans towards the local server for a large physician group with onsite technical support, however Dr. John Maese feels that the ASP/Cloud system is a better potential option in a small practice where onsite support is not financially feasible.

The California Healthcare Foundation published a report in 2006 titled ‘Physician Practices: Are Application Service Providers Right for You?‘ This is still relevant and worthwhile reading if you want more detail on the ASP model.


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