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We live in an iPad age in which we can summon information and maneuver it with our fingertips. It should therefore be no surprise that Electronic Health Records (EHRs)—one of the most visible byproducts of the digital shift—generally are moving toward a cloud-based model in place of a physical server. Nevertheless, questions still remain as to which server model better suits the needs of practicing clinicians. Ahead, Mary Ann Fitzhugh, Vice President of Marketing for Compulink Business Systems, Inc., and Michael Sherling, MD, Chief Medical Officer of Modernizing Medicine, answer questions about cloud versus hosted server models and how the shift toward cloud-based servers will impact the way we practice medicine.

Is your EHR a client server, hosted model, or both? Can you explain the differences and your company's rationale for selecting the one it did?

Ms. Fitzhugh: Compulink offers both. It really is the practice's choice of how they would like to deploy EHR and their situation. Some practices have virtually no IT support and having their EHR vendor assume responsibility for everything makes sense. However, for larger practices, who can bring IT in-house, hosting their own software may financially make more sense.

Dr. Sherling: Client-server products were designed when server-based technology was the only thing out there. It is based on a system where each server needs its own copy of the EHR software. Now that there is cloud computing with its myriad advantages, EHR companies that are clientserver based are cutting corners to offer a so-called hosted solution. It's the same product but instead of the server being in your office, it's in their data center. Because there are multiple copies and versions of the software, it is harder to interface with other software products and difficult to maintain and thus performance suffers.

An Electronic Medical Assistant (EMA) runs on a true cloud-based system, a newer technology in which one set of code powers one or one million users. This allows the client to experience reduced costs upfront and over time, scalability, and access to patient data from anywhere, anytime, on any device. There is really no choice for a modern software company as to which solution is better for its clients. It's like asking if you would prefer to bank in person or bank online. Online banking is cloud based, allowing users to take advantage of convenient features such as bill pay and direct deposit anywhere, anytime. Who would want to have to drive to their banks to deposit money, or hand write checks to pay bills? Likewise, client-server (also marketed as hosted) models are out-dated and will be phased out because user access to the data is more limited.

What are some of the common areas of concern from physicians regarding the server model your company uses? what are the top three myths of SAAS, and how might You respond to them?

Dr. Sherling: There are many myths and untruths regarding software as a service (SaaS). The first myth is that it is the same as a traditional hosted model. It isn't. Any problems the program has with a client-server model, it will have with a traditionally “hosted” model and then some. Because of multiple instances and versions of software, hosted and client server models spend time and money to maintain the added hardware needed to run the software. These costs are passed down to the customer. True cloud-based systems have one instance of software that just makes interfacing easier, updating the software easier, and brings costs down.

The second myth of SaaS is that it is more expensive over time for the client. Though it is true that a clientserver model is much more expensive upfront, the companies that offer this try to justify it by claiming that a SaaS system will be more expensive over time. But it shouldn't be forgotten that client-server systems will require the physician to continue to pay for support in perpetuity. There are also likely to be software updates and fixes that will have to be purchased fairly regularly. So, a client-server or traditionally hosted system has recurring fees as well; they are just hidden. With EMA, the physician knows how much he or she will be paying per month for an all-inclusive service, without having to dip into bank accounts for upfront costs.

The third big myth for a SaaS system is that it isn't customizable. Now we discussed that client-server systems have different versions for each client and that adds to cost, so other EHR companies may try to justify this by saying that their product is more customizable, which just isn't true. In fact, EMA harnesses cloud-based technology to take each client's data and silo it, so that the software completely adapts to each individual user. Our users get all of the customization with none of the additional cost.

Ms. Fitzhugh: Usually with an onsite solution, the concerns we hear are IT-related, specifically that the practice has no local IT support to help install and maintain the servers and the network.

Some of the inherent “cons” of the SaaS model that we sometimes hear concerns about include:

1. Performance—specifically how well the app will perform over Internet connection. This is a big concern in specialties where they are interfacing to diagnostic equipment in their office and having to move lots of images up/down to the cloud.

2. Cost—When they do the long-term math, any vendor's SaaS over a two- to three-year period will inevitably cost more than purchasing software plus server hardware outright. This is even true if you factor in IT maintenance. It's the reason a lot of large clinics/practices choose onsite.

3. Customization—While not necessarily an issue with our hosted solution, some SaaS solutions don't really allow for extensive customization. They're more “black-box” solutions where the practice must live with the standard product.

Again, we offer both models. The features and functionality of our product are identical with both solutions. Just as with everything in technology, there are “pros” and “cons” for each deployment model. The practice just needs to decide which set of “pros” align best with meeting their needs.

As the discussion is starting to move in the direction of cloud-based systems, how Do you see EHR technology evolving?

Ms. Fitzhugh: EHR is definitely moving to the cloud. How fast and how functionally rich the solutions are depends on how quickly some of the technical challenges, like acceptable performing image management, are resolved. But, while new to healthcare, cloud-based solutions have been available in other industries for over a decade, yet not every business has chosen to go cloud. Sometimes there are financial or functionality reasons why you want the software running onsite or on a server under your control. We don't think it will be any different for EHR, which is why we will continue to offer both alternatives to give practice owners a choice of what makes sense for their business.

Dr. Sherling: The cloud itself is evolving, enabling EHR technology to become even more powerful and elegant. Using technologies like Amazon Web Services, Modernizing Medicine can elastically add servers as needed during peak usage times. That means EMA is equally fast no matter how many users are logged onto the Internet— there are no slow times—eliminating the last advantage client server systems may have had over SaaS. The cloud will allow data and connectivity to be managed by IT professionals, freeing up physicians to do their jobs and not worry about their EHR.

Mark Kaufmann, MD is co-chair of the Dermatology work-group for CCHIT. He is on the Medical Advisory Board of Modernizing Medicine.

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