Electronic Health Records
Important topics seldom discussed at EHR conferences
Each EHR deployment alternative has its own trade offs and issues that must be understood and addressed – or else.
By Arthur Gasch and Bill Andrew I
t’s what we don’t hear at EHR and HIE conference presentations that gets our attention. We hear the assertion that Web-based EHRs are superior to other alternatives for smaller practices, but we don’t hear much about their bad points. One provider’s solution is another provider’s problem – particularly when 100,000 primary care physicians (known as priority primary care physicians, or PPCPs, when they sign up with regional extension centers) are involved. The “single-deployment approach is best for everyone” assertion being propagated is a dangerous and potentially expensive myth. In our opinion, there are three major deployment approaches each practice should consider. 1. Deploy EHR on an offi ce server; 2. Deploy EHR as Internet service and access it from a Web browser in the physician’s offi ce (software-as- a-service, or SaaS, approach); and
3. Deploy EHR as a service, but from either an offi ce- based Web server or a remote Internet-based Web server (“blended deployment” approach). Judging from regional extension center (REC) request for qualifi cation (RFQ) documents we reviewed, some government-fi nanced RECs clearly favor the second, Web-based SaaS approach. While a good choice for many smaller physician group practices (because it eliminates in-offi ce server management and back-up issues), this approach also has important limitations that must be addressed to avoid adverse impact on offi ce operations when Internet access is lost,
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when the EHR application is updated, if an application service provider (ASP) Web-site breach occurs or if the application needs to be customized to meet offi ce work fl ow.
Loss of Internet connection
Internet interruption risk varies geographically. Cable Internet interruptions can sometimes take days for cable companies to repair. Without secondary broadband Internet access, patients are left stranded in the wait-
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ing room, and next-day sched- ules may have to be cancelled and rescheduled. Physicians should
Arthur Gasch and Bill Andrew are founder and executive VP, respectively, of MSP.
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make contingency plans to access secondary Internet pathways in order to be able to keep operating. Don’t count on modern technology or settle for only one Inter- net connection because reliability is a problem in both metropolitan areas and most of rural America. In the SaaS Internet approach, the demise of the EHR application developer and possible disputes with the third-party ASP provider are contingencies to plan for. Special contracting language is required to mitigate the situation when the ASP and EHR developer are two different organizations. If the ASP provider and EHR developer are one, issues still remain. All practices need to get a second opinion from outside law fi rms with healthcare practices.
Blended SaaS eliminates interruption risk The blended SaaS deployment approach can circum- vent Internet loss. It operates by accessing an Internet Web server (generally through port 80), supplemented by an offi ce-deployed EHR SaaS Web server (generally through local host, on port 8080). If/when Internet ac- cess is lost, the offi ce-deployed Web server stands in for the remote Web server that can’t be reached. Some SaaS EHRs run the offi ce-based Web server as the primary EHR Web server, using the Internet one primarily for backup. Blended SaaS deployment eliminates Internet interruption risk. The trade off is increased cost (of de- ploying an offi ce-based SaaS EHR Web server) and loss of simplicity (since managing an offi ce-deployed EHR Web server is now required).
EHR responsiveness trade off Web-based SaaS approaches are generally less re- sponsive than their offi ce-deployed EHR counterparts.
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