Cloud EHR: a complete buyers' guide
According to a recent report, cloud EHR systems account for a majority of the market share and are also the fastest growing method of deployment in the EHR market.
Despite the growth in the availability of cloud-based EHR systems, practices are still left with many questions regarding how a cloud-based system functions. In this guide, we’ll address:
- What cloud EHR is and who should consider it
- The pros and cons of cloud computing in healthcare
- What features and characteristics you should look for in cloud EHR
- How much EHR costs and what to include in a software budget
- Which cloud EHR vendors to consider
EHR systems are offered in the cloud or on a server-based methods of deployment. For server-based EMR software, system software and clinical data are stored on local servers. In a cloud-based system, system software and clinical data are stored on off-site servers and is accessed through the web.
The cloud (or web-based) EMR versus server-based EMR debate has been a long-standing debate among EHR users for as long as vendors began to offer viable cloud-based EHR products. Unfortunately, when searching for objective information regarding the comparative benefits and disadvantages between cloud vs client server EHR systems users should be careful of distinguishing between claims that are primarily used for marketing purposes and those that are based on actual evidence.
The following discussion contains an objective discussion of the benefits and disadvantages of adopting a cloud-based EHR.
The benefits of cloud EHR
One of the advantages of using a cloud-based EHR involves the fact that they allow their users to access up to date clinical data from multiple locations. Since clinical data is stored in a remote location and accessed through the web, these data can be accessed from desktop systems, tablets, or smartphones. For multi-site practices and those with clinicians or administrative staff who are not at their desk often this type of mobility can be a valuable tool to increase productivity and more effective decision making since everyone with a connected device will be “in the loop.”
Reduced IT capital investment and cost
Since data storage and software deployment are maintained off-site, practices using a cloud-based system can reduce initial capital investments in hardware, server space and on-site network personnel it follows that cloud systems can be implemented and operated at a lower cost. Further since all software files and reside in the cloud new installations, maintenance, data migration or software updates are generally less costly when compared to a server-based since the vendor can carry out these tasks on their side with little effort and without the need to deploy an IT team on site to carry out these tasks.
Scalability refers to the ability to expand an EHR system to better serve a growing practice. For practices that may anticipate scaling up to more service lines and more staff, a cloud-based system may be more in line with their organization’s goals as a cloud system can be expanded with relatively little effort and cost when compared to an on-premises system. In a cloud-based system since users can access remotely or anywhere within a site with an internet connection, new users and workstations can be added by simply adding new user accounts, whereas with an on-premises system the system’s internal network must be reconfigured to accommodate staff workstations or other connected devices.
The disadvantages of cloud EHR
When considering the challenges of cloud computing in healthcare, there are a number of issues that one can consider disadvantages, namely hidden costs and reliability are often cited as disadvantages for cloud-based EHRs.
Cloud-based EHRs are generally required less investment in a technology infrastructure and IT staff, as such, they generally cost less to operate. However, with a cloud-based EHR that is offered on a subscription basis, the vendor may require the user to purchase access to add-ons or other features and support. Further, the bandwidth on the practice’s internet connection may need to be upgraded to support a large amount of data the system will process. In this case, it is important for practices to be certain that the total cost of ownership of a cloud-based system is known
One of the disadvantages of cloud computing in healthcare involves the fact that cloud-based EHRs rely on an internet connection to access the EHR software and to retrieve data. Therefore, practices that do not have access to a reliable high-speed internet connection may be betters serviced using an on-premises system. Slow or unreliable connection speeds can cause cloud-based EHRs to experience lag time in system functionality and outages. However, problems such as this can be avoided early in the selection process by making certain the vendor clearly explains their product’s bandwidth requirements.
Cloud EHR and security
Security is often cited as a primary concern about cloud-based EHR systems with practices asking: Can confidential patient information be securely stored in the cloud? Certified cloud-based EHRs, like server based systems, must be HIPAA compliant. Further, cloud storage providers which work with cloud-based EHRs also must comply with its obligations to protect personal health information under HIPAA. As such, confidential patient information can be surely stored on the cloud given that the vendor and the cloud service providers’ data handling and security practices comply with HIPAA.
The question of cloud EHR security is one that deals with three parties: the user, the vendor and the cloud storage supplier. For data in a cloud EHR to be secure must follow the correct protocols when handling data and allowing access to the system. In this respect the data handling and access protocols are similar to that of a server based system in that data should not be exposed to unnecessary risk of a breach by allowing unauthorized users access to the data stored in the system.
One the vendor side, security measures for data stored in the cloud include measures such as role-based access, data encryption, and access monitoring. On the practice-side security measures include ensuring all data is encrypted and the use of strong password and access protocols.
The cost of a cloud EHR varies by the type of system and the features included. Generally, cloud EHRs are priced on a ‘per user per month’ model, though some providers charge per record, event, or encounter. Initially, this makes them less expensive than on-premise solutions as they lack the upfront license fee that on-premise systems require, though if long-term expenditure is a key factor for you you may want to look at when cloud EHR fees ‘break even’ with perpetual license costs.
There are also a handful of free cloud EHRs available for download. ‘Free’, however, often only extends to a certain number of features or users. These systems can use pop up ads in the system to monetize the product, and charge extra for more advanced features. Further, a practice may be required to pay for data migration, support and training.
Although prices vary widely regarding the monthly subscription cost of a cloud EHR, one study indicates the five-year TCO for an cloud-based system was $58,000 with upfront costs of $33,000.
Briefly, a cloud EHR budget should incorporate the following costs. For more detail. see our in-depth piece about how to set a realistic software budget.
- Out-of-box price of EHR: some vendors will differentiate between prescribing and non-prescribing users for monthly fees, so have absolute clarity on your user base before you calculate your baseline figure.
- Cost of new hardware: this isn’t just an on-premise concern! If you’re implementing an EHR designed for use on tablets, for example, make sure this cost is added to your budget.
- Support and maintenance fees: as your EHR is hosted on your vendor’s servers, you will often be asked to pay a monthly or yearly fee for upkeep.
- Implementation costs: sometimes implementation support is included in the out-of-box price of your EHR. Other vendors will charge for implementation consultancy, customization, data migration and training.
- Staff overtime: whether actively involved in the implementing your EHR or simply putting in extra hours to offset the inefficiencies brought on by installing the new system, you’ll be processing a lot of staff overtime during the project.
When using a cloud EHR, your data isn’t stored on your servers but on those operated by third-party companies. When one goes down, you can’t rely on your IT team to get it back up and running. It’s out of your hands.
This means that you should be looking for a SLA that guarantees extremely low levels of downtime, and outlines a structure for compensation should this level not be met. If your system goes down, it impacts both your practice’s ability to provide suitable care for your patients and your revenue stream. You should also map out the security standards you expect your vendor to provide, and specification of your rights to end the contract should these terms be breached.
You should look for vendors who offer comprehensive support packages for the same reason. Self help materials and a user forum will be of limited use, and aren’t conducive to fixing issues quickly. Instead, look for personalised, 24/7 phone or email support.
Elsewhere, cloud EHRs aren’t much different to on-premise EHRs. You can check our detailed requirements and features guide for more information, but on a basic level, cloud EHRs should contain the Institute of Medicine’s eight core care delivery functions:
- Health information and data,
- Result management,
- Order management,
- Decision support,
- Electronic communication and connectivity,
- Patient support,
- Administrative processes and reporting,
- Reporting and population health.
Further, practices should look for systems with patient portal capability and access from mobile devices.
The following cloud EHR vendors represent some of the highly rated systems available.
Practice Fusion provides a cloud-based EHR offering a standard EHR and practice management system in a dashboard interface. Reaction Data, a Utah-based research firm conducted an EHR satisfaction survey of 900 physicians. Their findings report that Practice Fusion rated highly with 70% of users happy with the vendor and would recommend the vendor to their peers or colleagues.
Recently, Allscripts announced it was acquiring Practice Fusion and would abandoning the free EHR software business model that Practice Fusion had relied on to gain is a loyal following. The service will now charge a per-month fee per clinician.
eClinicalWorks web-based EMR is an integrated system offering practice management, patient engagement, telehealth, data analytics and population health features among others.
In the Reaction Data survey mentioned above eClinicalWorks had a high customer rating, with more than half (53 percent) of respondents who use eClinicalWorks’ EHR were classified as “Advocates,” and said they would recommend their vendor to a peer or colleague.
Drchrono’s web-based EHR is a fully integrated EHR with medical billing software programs, RCM and practice management platform. Drchrono’s features also include iPad, iPhone and Apple Watch compatibility.
Athenahealth’s cloud-based EHR provides users with a standard suite of features. In addition to core EHR functionality, the system also provides users with the benefit of fully-integrated practice management and billing solutions. The system was recently Rated #1 by KLAS for practices with 11-75 providers.
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