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Cloud-Based vs. Client Server — What Is the Best EHR Infrastructure?

MediTouch® is an EHR based on HealthFusion’s® private Pure Cloud® technology. Our team had a choice when we developed the MediTouch EHR®. We could have adopted either the more traditional client-server model or the more modern Web-based, cloud infrastructure. For our team the choice was simple – The Cloud won hands down. The purpose of this blog is to discuss why we made the decision to develop our physician office software: EHR, billing, scheduling, clearinghouse, and patient portal based on MediTouch® Pure Cloud® technology. I will also try to review what some of the proponents of client-server systems promote as benefits, and evaluate the merits of the client-server case.

Since we are pitting our cloud technology, Pure Cloud®, against the traditional client-server model in a battle for the best EHR platform, I thought it would be helpful to research what others are saying about the benefits of each system. I simply Googled “cloud vs. client server EHR” and reviewed the first group of entries. You can do the same. The first 4 entries included 2 blogs from authors that did not seem to have a pre-formed opinion, one blog from a company that sells only client-server EHRs, and another company that seems to be pushing the cloud.

In a cloud-based EHR system, a practice’s data is stored on external servers and can be accessed via the Web, requiring only a simple computer with an Internet connection. In the case of MediTouch® that computer can be Mac® or Windows®, desktop or laptop, Windows® tablet or iPad®.

Client-server systems store data in-house, requiring that a server, hardware, and software be purchased, installed, and maintained in the physician’s office. While in-house servers have traditionally been the norm, more practices are increasingly switching to the cloud.

Cloud-based EHR Systems: Pros vs. Cons
ProsCons
Less or no up-front costs for licensingCustomizability limited
No server hardware or software to purchase/house/maintainLatency or lag time accessing information across web/ slower response time
Possibly easier to transition to a different systemPatient information may be compromised if co-mingled with other clients
More cost effective for solo/small group practicesAt the mercy of the vendor regarding backups, security
Better support (IT department included)Captive client – host controls your data
Easy to set up hot-site in case of disasterPractice may find it difficult to function if there is an internet outage
Host companies typically have more sophisticated security measures/data protectionMay not be viable for rural practices with limited internet options
Vendor more likely to meet HIPAA regulations than the practice canPractice can lose data if vendor goes out of business
Onus more on vendor to meet Meaningful UseMay be impractical for uploading larger imaging files
Good for physicians who are mobileMore expensive over the long haul
Works on the iPad® (MediTouch® is one of a select few)

Let’s discuss the Pros and Cons and see if the MediTouch® team has found solutions that overcome some of the Cons of a cloud-based EHR system.

First the Pros — Per the table above, with a cloud-based system your practice does not need to purchase any software or hardware; you simply subscribe to the system. With MediTouch® there is no EHR start-up fee or training fee. We will train your staff every day, every month, and every year you subscribe to our software. Client-server companies will sell your office a week of intensive training, you will need to cancel patients, shut down your office, and make sure that you never hire a new employee, because they will charge for additional training, especially one or two years into your lease with the vendor.

  • With the cloud, your practice does not have the responsibility of maintaining expensive hardware. Your responsibilities related to data backup and your HIPAA legal liability for your data are reduced to zero.

  • It is easier for cloud EHRs to support your group. Our J.D. Power and Associates® award-winning customer care team can use our advanced tools to securely “see into” your practice’s MediTouch® account, via the cloud, to troubleshoot any problems and offer assistance with Meaningful Use, electronic prescribing, or charting.

  • Data servers require maintenance, backup, and security — most physicians understand that they should not place a server in a closet or an unsecured storage room, and that it is best to have a professional on staff to assist with these server-related tasks. If you do not have a large practice that can afford a full time IT professional, then the cloud always wins. Even if you do have a sophisticated IT team, we still think the cloud is a better solution. In large practices with IT professionals already on-staff, those professionals often play an important role in implementing the MediTouch EHR® system and defining the new workflows for dozens of users across many physical locations.

  • If the physician is mobile (what doctor isn’t?), then a cloud EHR is really the only fast and easy way to access patient records from multiple locations – including home and when traveling.

  • Client-server systems do not work natively on the iPad®; so if you are one of the 80% of the doctors who believes you will ultimately use a mobile tablet, then the cloud is by far the best choice. With the cloud you don’t need to upload new patches, updates, or code sets.

We love the cloud — so I can keep spouting the Pros related to cloud computing, but let’s take on the Cons.

The Cons to Cloud Computing — MediTouch® Overcomes Most All of Them

  • Customizability limited — Just not true with the MediTouch® system. Our system is more customizable than most client-sever systems. With MediTouch® you can customize each portion of the SOAP encounter, create customized touch-forms, care plans, and blueprints (templates) with the MediTouch® Grand Central easy charting system.

  • Cloud-based EHR vs. Client-server EHR
  • Latency or lag time accessing information across the Web/slower response time — Have you seen our pages refresh; they redraw as fast as client-server pages, and most all of our pages redraw in sub-second timeframes. We are fast – and, by the way, were you ever on a Windows® computer that was slow, of course you were. Client-server does not always equal speed, in fact a physician recently switched to MediTouch® from Greenway® (client-server EHR) because his system was too slow and ours is much faster!

  • Patient information may be compromised if co-mingled with other clients — This depends on the way your vendor sets up their database and the level of expertise of their programmers. HealthFusion® has been “in the cloud” for 13 years, and we have never had a provider from one practice see the data from a client in another practice. It is easy to prevent co-mingling of data, you should know this based on your own intuition; if co-mingling was a major issue then not a single soul would perform online banking interactions or shop on Amazon®!

  • At the mercy of the vendor regarding backups, security — This is true and this is a matter of trust. You need to ask yourself, who is better equipped to house and backup your data? Our team of IT professionals that house your data in specialized redundant data centers protected by biometric access devices in addition to lock and key, or your staff that are experts in medical care, but may not be experts in HIPAA data security and backups. With MediTouch® your data is backed up to 2 distinct physical locations – I don’t know of any practice that can boast that type of redundancy.

  • Captive client – host controls your data — With MediTouch® this is not true – you are always in control of your data – you can download any chart with just a couple of clicks and store it in an electronic format. Alternatively, you can subscribe to our “Download My Patient Records” service that stores your data in the secure HIPAA compliant Amazon® Cloud for secure download to your office computer in an encrypted format weekly.

  • Practice may find it difficult to function if there is an Internet outage — We agree with this statement; although even in the client-server world, connections to the outside world via the Internet (such as lab connections) have now become an important part of the EHR experience. Our suggestion to users is, if their Internet provider (ISP) has frequent outages, buy a cellular-based “Wi-Fi” card from their local cellular provider. Those cards cost around $50 per month, they can connect 5 computers, they won’t go down when or if your ISP is down, and they are also great when you and your family travel!

  • May not be viable for rural practices with limited Internet options — We agree with this, if you cannot get a reasonably fast internet connection, whether it is via cellular, DSL, or Cable – then do not use a cloud solution. But there are very few practices that cannot connect to the Internet at a decent speed these days.

  • Practice can lose data if vendor goes out of business — HealthFusion® / MediTouch® has been in business for 13 years and is “here to stay”. Our business just keeps getting better and bigger. For doctors that have that fear, we provide the “Download My Patient Records” service. It makes those docs that worry about this issue feel much more comfortable. With “Download My Patient Records”, your data sits on the Amazon® Cloud in addition to ours, so even if our Pure Cloud® was “shut down” the data would still be available to our users on the Amazon® Cloud.

  • May be impractical for uploading larger imaging files — Your practice should not have many large files, it is a waste of storage to save images that are very large in size. Our users upload documents in just seconds and are able to save and view tens of thousands of documents without any delay. We even have clients that upload video files; the user clicks “upload” and walks away, takes care of a patient or answers a phone, and returns to find their file uploaded. MediTouch® users can login while the files are uploading and continue to use our system during the upload; so whether they are large or small files, MediTouch® is up to the challenge.

  • More expensive over the long haul or, “I won’t ever own my system with HealthFusion®, but I will own ‘my client-server system’ in five years.” — Another “old wives tale”. Simply not accurate and here’s why:

In five years you will maybe own a system (if there is no tail on your lease), but it will be an old system. In five years your client-server vendor will be selling you the next and latest version of their system — How else will they stay in business? In fact, when you own software, especially in a dynamic industry such as electronic health records, I can assure you that the system you have 5 years from now will be very different than the system you have today.

Remember each time you buy software, let’s use Windows® as an example, you own it, but you don’t own the next major version. With Windows® you may not have purchased every new version, they usually come out every 3 years, but I can assure you that you are not working on the original DOS Microsoft® version or Windows® 3.0. Microsoft® has a lot of cash in the bank right now, and the way they made that money is every few years they make their old software obsolete. I can assure you that will be exactly what happens to you if you buy software on a 5 year lease. With HealthFusion® you are always getting the latest version, and you won’t ever pay a fee to upgrade to the next major version — like you would if you bought a server-based system.

Either way I can assure you that 5 years from now you will continue to make payments on EHR software — isn’t it best to go with a Web-based system that is updated every 2-3 months and that does not require a 5 year commitment. Remember, with our system it is much easier to opt out; that means that each month we must work hard to continue to earn your business, purchased client-server systems earn your business one time for five years, with our system we must continue to perform every month, every year — the bar is higher for us and that is better for you.

MediTouch® Pure Cloud® Beats All Comers

In the battle between MediTouch® Pure Cloud® technology and traditional Client-Server models, it is clear that the Pros of the cloud clearly beat the Cons. Unless you are a rural clinic that cannot get relatively fast Internet speeds, MediTouch® has overcome all of the Cons of the cloud and leverages all of the Pros to deliver the best EHR infrastructure in the business; we simply knock the socks off of the client-server model.

Seth Flam DO


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