Most EHR products, or technologies, in both the hospital and ambulatory market are currently deployed through a local client/server paradigm. The client software is installed on users' PCs and the server software, including the data storage, resides on site in the hospital data center or the clinic office.
However, with Web 2.0 and Cloud Computing upon us, web based EHRs, Practice Management and Billing systems are sprouting all around. Is this the future, or is this customary cyclical IT hype?
A little bit of both and, as usual, the real answer depends on accurate definition of terms.
The first term we need to define is Software as a Service (SaaS).
In the classic (legacy) paradigm, software was built using a Client/Server model. The Server software is proprietary and runs on a big server machine. The Client software, also proprietary, usually runs on each user desktop and connects to the Server software via a local network, or a virtual private network if the server machine is located outside the local network (in a remote data center instead of under the lunch counter in the office).
SaaS, strangely enough, also uses a Client/Server model. The Server software is also proprietary and runs on a big server machine. The Client software runs on each user desktop, but it is not necessarily proprietary. In most cases the Client software is nothing more than a browser. Whether the client is a browser, or a proprietary client, SaaS software is accessible on demand over the Internet, and this is the main difference in paradigm. The SaaS Server may reside on site, but usually it resides in a remote data center, far away.... in the Clouds.
So what is a Cloud? A Cloud is a little drawing used in network diagrams to symbolize the Internet. Thus Cloud Computing really means computing over the Internet. It doesn't really matter where your servers are and it doesn't really matter if your client is a browser or a proprietary program. As long as the Client and Server communicate on the Internet, you are engaging in Cloud Computing.
Simple? It should be, but the current hype in the industry creates the illusion that Cloud Computing is a novel idea and somehow has something to do with the Amazon Cloud, or some Google service application.
Not so. Just like in the good old sky, the computer world has many types of Clouds.
First there is the Private Cloud which refers to having your Server on site, in your own data center, or even in a commercial data center where you rent some rack space.
If you don't want to invest in servers and routers and load balancers and lots of techie employees, you can rent all the computing power you need from such folks like AT&T, Amazon and a myriad of other players. For a little extra cash, they will manage your Server software, including updates, patches and everything your, now unemployed, IT guys used to do. These are the famous Clouds, and as you can see there are various degrees of Cloudiness.
When we talk about EHR, the most common type of Cloud is a "Vendor Cloud" - web based EHRs where the vendor manages the Servers in their own data centers, or in rented data centers. This is the athenahealth model and more recently Practice Fusion, Ingenix CareTracker, Quest360 and an ever increasing number of new entrants and old timers transitioning to web delivery systems.
How about the industry veterans who recently began to offer their Client/Server software as SaaS? Are these new products, or questionable advertising? Neither. You should know by now that all software is really Client/Server. All it takes to jettison an application to the Clouds is to remove the Server from the user's office and make it available to the Client on the Internet. And “on the Internet” does not necessarily mean in a browser. That's exactly what folks like eClinicalWorks and Allscripts MyWay and many others are doing now. Just like the purists' SaaS and Clouds, these non-browser based systems are basically renting out computational and IT resources, by hosting the server machines in their very own Clouds, and some, like Synapse EMR, even in the famous Amazon Cloud.
There are differences, of course. Systems built for the web from the get go are able to share resources better and need much less infrastructure. For example a natively browser based systems will store hundreds or even thousands of different customers in one data base and can get by with one instance of the Server running with multiple redundancy and load balancing. The original Client/Server products still require one server per customer, albeit a virtual one these days, and maintenance is no small feat.
So now that we understand the reality of Clouds, which one is better? The simple answer is that how an EHR got to the Clouds does not matter much. In both cases your capital expenses and IT needs are drastically reduced. In both cases you can access your software from outside the office. It may be a bit tricky for the Client/Server Cloud, but it's still doable from most places you would want to use your EHR, and with the advent of mobile access on iPhones and Blackberry, you really shouldn't have to bring out the old laptop on the golf course.
Maybe, the web based EHRs are better suited to the new interoperability requirements? After all they already reside on the web and there's nothing more common than a browser, right? This is only partially correct. Automated exchange of data on the Internet does not occur through browsers. The biggest interoperability advantage web based EHRs have is due to the inherent aggregation of all customer data. Instead of hundreds of data bases, they only have one. Instead of hundreds of "communications" pipes, they only need one. While a web based Cloud needs only one pipe to other Clouds, the Client/Server Cloud needs as many pipes as they have customers. The onus is on the Vendor, not the customer.
Well, how about modularity and choices for the customer? Unfortunately, this is another misunderstanding. Modularity and availability of plug-and-play EHR modules is made possible only if the EHR vendor decides to allow it, be it web based or not. The fact that you can access the EHR through a browser does not mean that you can plug in another piece of software that you can also access through a browser. True, if the EHR vendor decides to open the platform to others, it is easier to create new modules for a browser client than a proprietary client, but only slightly so.
The take away for anyone searching for the perfect EHR is to beware buzz words, Clouds and Vapors in general.
The 800 lb. Gorilla in the Clouds is of course Security and Privacy and peace of mind. We will look at those in a future post.......