Local EMR vs. ASP based EMR. Which is the right EMR solution?

Which is the right EMR system? The local office network based EMR with a server and clients (computers connected to the network) or the ASP based EMR in which data is stored off site at a distant location and is accessed either via a private network connection or via the Internet? Before I debate each scenario, I think it is important to ask what physicians want and require from an Electronic Medical Record system. In the ideal world, this question becomes a non-issue. The tools should become transparent in the care equation. It ultimately should not matter who provides the EMR system, only that the data is secure, transportable between systems and that the vendor is financially sound and providing a level of support that is necessary in a mission critical setting such as physician practice. Rather than debate the benefits of each type of EMR solution, I will list drawbacks of each type of system. If you have already chosen an EMR and feel strongly about either local EMR or ASP (Application Service Provider) EMR, please share your thoughts by clicking on the ‘Comments’ link below:

What are the drawbacks of a Local EMR system?

• Clinic/physicians are liable for data integrity, security and privacy;
• Physicians recognize that there is an increased burden of guardianship for the data stored locally in their offices, however this is a burden that many physicians are willing to assume to protect the privacy of patient information;
• Security of data and backup is not the core business of the physicians/clinic. What happens if the server crashes or the system goes down. How does one recover the data?
• System maintenance is time consuming/costly. Physicians are required to negotiate their own service contracts and software has to be updated on multiple computers;
• Local EMR systems tend to lack interoperability with other providers/clinics. As a result there is limited ability to share information resulting in a need for software to broker information between systems;
• It is time consuming and difficult for physicians to understand quality and what to look for in a vendor;
• Vendor sustainability is a concern. What happens if a vendor goes out of business.

What are the drawbacks of an ASP based system?

• System responsiveness is a concern when using remote databases.  Does the system respond quickly enough in a clinical setting to provide  care?  This is highly dependant on the quality of the network connection;
• Physicians, as guardians of the patient record, are concerned about data stewardship and access issues. Physicians are concerned about the viewing and interpretation of information by individuals who may not understand the context of a specific patient encounter. This results in questions of accountability in situations in which other providers add data to the medical record and co-manage care. In a centrally managed ASP based EMR, governance issues are critical. Who decides what a specific physician is able to access and what data is viewable by other providers? How will a physician’s job change as other stakeholders, such as colleagues, patients and regional authorities are able to view their care decisions? How much information is being collected about the populations that physicians serve and what is being done with that information?
• Big brother Issues. Physicians have concerns regarding the manner in which providers of ASP based systems will use information stored in central databases. There are significant concerns that access to this data might lead to: Monitoring of performance; Additional remuneration initiatives or potential penalties based on outcomes; Micro management with others watching all activities for errors; Patient privacy breaches with the physician being held accountable by their peers and the public.

These are not simple issues. What do you think? Are there certain factors that make one system the obvious choice over another. What are the advantages of each system over the other. Please share your thoughts by clicking on the 'Comments' link below.

Comments

[geoff]

The pitfalls of an ASP solution far outweigh any benefits.
The importance of medical record stewardship is only becoming apparent now that there is a choice of stewards.

I find it hard to believe that an ASP vendor could resist the temptation of doing some data mining to sell data. Doctors have given license to the pharmacies to sell Rx data(it does not have to be that way, New Zealand changed that recently) and if we do nothing now we accept the ASP providers and all their potential shenanigans.
This is patient data - the patient comes in, says he's having an affair, says he's drinking too much - sensitive topics. It's our duty as physicians to protect this data, just look at your local College bylaws. By physically giving up control of office data, we open the door for a lot of abuse.

It would be easier for police and government to gain access if records were centralized. That has big implications in terms of abuse by state authorities.

The private sector cannot be allowed to take over control of a patients healthcare data. The temptations are too large.

[John Fernandes]

ASP is BY FAR the easier solution to use for EMR from the Physicians' perspective. It is really nice to be able to log into a patients' chart from home to look something up, do a Medical Legal or Insurance Report, etc., etc. "Login" is a bit of a pain, but this can be managed again by proximity detectors, etc.

Stewardship is an issue, however, I think that this issue can be easily managed by a contract of sufficient scope that would be signed by the ASP Vendor. Breach or the contract by any means would not be something that any smart Vendor would want to test in court!

[Michael Rath]

As an inducement to buy his product, I have already been offered a (small) fraction of the money the vendor plans to make by selling our data to interested third parties.

That was enough to kill the deal.

[Karim Keshavjee]

I think a discussion of ASP vs LAN is incomplete without a discussion of the benefits of both. Making a choice between ASP or LAN simply on the basis of the drawbacks of each is like making a choice between two medications on the basis of their side-effects. It’s not possible to choose without also considering their efficacies.

BENEFITS OF ASP

There are several benefits to ASP that people don't think about because they consider the solution in isolation. The reality is that EMRs are very, very costly. The total cost of ownership is derived from 3 things: 1. Cost of hardware and redundancy of hardware to ensure business continuity (a doctor can't afford to have her system down for more than 10 minutes during clinic hours); 2. Cost of Software; 3. Cost of support, training and maintenance. These three combined can exceed $50,000 for a physician over 3-5 years.

When you look at it from a system perspective, it may end up costing physicians $2.5 billion to invest in EMRs in Canada --a very hefty price to pay when you consider that Canada Health Infoway has $1 billion over 5-7 years for the ENTIRE health care system in Canada.

In that light, we can look at some of the benefits of ASPs. Assuming that the hardware, software and support costs are about 1/3 each (not an unreasonable assumption), if an ASP can drop some of the costs in each of those categories, it may start to make financial sense.

HARDWARE COSTS. First, switching from workstations to thin clients (low cost computers with no local harddrive or CPU), can save a lot of costs --as much as 50% or more of the cost of workstations. Having a central server can save the biggest chunk --as much as 66% of the cost of a server, especially for smaller clinics of less than 6 doctors (the more doctors you have the lower the per-physician costs of the server and therefore the financial benefits of an ASP are lower). Overall, you can save about 50% of the costs of hardware.

SOFTWARE COSTS. Software costs don’t really go down much with ASPs, but upgrading software is much easier and so those costs do go down somewhat, but that is not a substantial cost in any case.

SUPPORT AND MAINTENANCE COSTS. Hardware support costs can go down substantially with an ASP. When a workstation goes down, you need a qualified technician to come fix it –minimum cost $200. When a server goes down, you need a more qualified technician –minimum cost $1000. In an ASP with thin client workstations, when a workstation goes down, you order a new one and replace it yourself. The server doesn’t go down because redundancy is built in.

Overall savings for an ASP are about 30-40% over a LAN solution for small clinics. When you consider that 80% of physicians in Canada still practice in groups of 6 or less, this can add up to substantial savings.

BENEFITS OF LAN

The LAN is a proven model that has been used extensively for decades. There is increasingly more support available to maintain them and they are much more reliable today than they ever were. The cost of technology in recent years has dropped substantially and of course you can now use thin clients in the LAN environment as well. In the LAN, data is under your control at all times, since it is on your premises. You can establish your own security and you can limit access to the Internet for your staff. With a LAN approach to EMR, you can upgrade your system whenever you want, not when your vendor decides its time. Resources to re-train your staff are more readily available at your convenience. You can make changes to your network, such as adding peripherals, easily without hassle and you can use devices such as handwriting recognition and voice recognition easily.

THE TRADE-OFFS BETWEEN ASP AND LAN

ASPs can lower the total cost of ownership for EMRs, especially for small medical practices. For small clinics where affordability is important, the ASP may be a very good solution. In spite of the anecdotal information about ASP vendors wanting to sell your data and ASP vendors secretly selling your data, most ASP vendors do not have the experience nor the capabilities to sell electronic medical record data for two very cogent reasons: 1. EMR data is inherently ‘dirty’ and is not analyzable to a great extent and 2. Most people who get access to clean EMR data don’t know how to analyze it because it is much more complicated than they expect and don’t have the capabilities to analyze it anyway. The ASP vendors who are going to last are the ones who stick to their knitting and work on getting the costs down low enough to provide high quality service to small clinical practices at an affordable price.

LANs give you more flexibility, options for peripherals and control over when you’ll upgrade your software. However the costs are a bit higher and the onus is much more on the clinic physicians and staff to make sure they are maintaining the equipment at its peak performance. The per-physician costs of a LAN do come down substantially when the number of doctors goes up, as costs of the server are spread over more physicians. The LAN solution is a good solution for the larger clinic.

[Tim Janzen]

Karim:
Your analysis mirrors some of my research before we implemented our EMR in August 2005.

As Clinic Manager of a 20 physician family practice group, I was commissioned with finding a solution that would allow us to create a global patient chart that could be accessed by physicians from any point of contact (Clinic, home, hospital, Internet cafe) and see the patient information in real time; while linking our three clinic sites (one new and completely chartless in August 2005) together by email, scheduling and billing systems.

In the end, we were able to partner with a new IT business in our city and created a hybrid ASP EMR. Our 9 servers are located at a remodeled bank vault in the industrial park of our city. They are monitored continuously by IT staff and all "back-end" work can be done in their facility.

The front-end machinery in the Clinic consists of thin clients in exam rooms and for Clinic staff, while physicians adn Administration have PC's on their desk. These PC's are currently configured as "dumb terminals" for the majority of their duties but can be made to act as functional PC depending on physician and software requirements.

Our Clinics are networked to the servers by use of T1 lines (expensive but unbelievably fast and reliable) and ADSL lines as redundancy.

One of the major reasons we went this route was we believed that we could achieve a reliable system that was cost-effective and used the incredible technical skills of the IT staff that we did not possess. In the end, we created a system that allows users to overview the entire clinic in real time and give physicians access to patient charts immediately.

And we did for less than our POSP funding over the next four years. There is no way we could have run this system locally with the level of reliability we've achieved.

[Scot Mountain]

One of the drawbacks of in house LAN systems that hasn't been mentioned is the potential for theft of the server and the medical records contained therein. This potential has been highlighted by the theft last week of computers containing personal information about employees from the Vancouver Coastal Health Authority.

Obviously computers are a target item for thieves breaking into a medical office. With an ASP system, all they get is your computer, without any access to patient files (as long as they don't find your password). With a LAN system, in addition to providing your own IT support, you have to provide your own security to prevent theft of all your records.

[Dave]

To assert that an ASP vendor would sell patient data to a third party is irresponsible. Reputable (the key word here) companies realize that in order to gain wide acceptance as a work flow tool, physicians need to know that their data is safe from the prying eyes of both Big Brother and big time advertising agencies. Most ASP vendors include a clause in their contract stipulating that the physician owns their data and that nobody can have access to it unless written authorization is in place. Even then, only the patients themselves would have access to sensitive information.

I would argue that, given the possibility theft within a practice plus the added cost of managing a LAN, an ASP application is the best solution for any physicians looking to implement electronic medical records

[Allan Horii]

One issue with ASP based EMRs is the reliance on a dependable internet connection. I shudder to think how many times my broadband connection (cable) has had "service interruptions" lasting anywhere from a few minutes to several hours. For example, today our office lost internet access for most of the afternoon (likely due to the major windstorm and power outages in the region, I would guess). Our EMR stores its data locally on our server, but backs up the data on a remote server off-site with the vendor every hour, so we were not unduly inconvenienced by the lack of an internet connection.

[James Busser]

I find Karim's post to be balanced and the best starting point. herein I add to it, and offer extra context for some of the other replies.

Many issues apply to both approaches and it is a matter of one approach being more vulnerable than the other.

1) re theft of office technology... use of an ASP only protects that which resides purely on the ASP, people should not forget that
i) local computers can contain cached information, word processed and other forms of information not on the ASP
ii) ASP hardware is not immune to theft
iii) a non-ASP server can be co-located into a physicial setting more secure than a doctor's office

2. uptime...
i) users of ASP *are* vulnerable to an extra layer of disconnection and traffic, over and above the local network (which can fail in either design)
ii) users of ASP have no control themselves over redundancy, which an ASP may or may not offer, and which may or may not have been tested to work (nonASP users can better control this, but may skip the cost and trouble of deploying redundancy)

So there may be a cost-saving to ASP at the expense of less control over uptime. It is incumbent on both approaches for the office to have downtime contingencies (for example always having at least 1-2 days of appointments cached and/or printed locally etc). I woory that many don't.

3. Backups
No control over what or how the ASP backs up. You could negotiate to hold copies of data dumps but this would only be meaningful if it could be reconstituted. Likely no cost savings because Amazon is offering to host gigabytes of storage buckets for small charges and an open source group is looking to supply scripting that could gnotarize data backups, encrypt it, and upload it into an Amazon or competing storage service (I would nevertheless maintain a duplicate local copy of encrypted backups on CD/DVD or tape).

4. Privacy & security - doctor is responsible but in an ASP solution has little control over what is done. Wrt the comment "[to] assert that an ASP vendor would sell patient data to a third party is irresponsible" it is more a matter that the ASP *could* and it may be hard for anyone to know, unless it can be engineered for the clinical people to lock the ASP managers out of the data and to only temporarily unlock it for brief periods when necessary (e.g. with a temporary password that is then changed back).

I don't know that the ASP fundamentally offers anything a LAN doesn't, other than an economy of scale traded off against the level of user control and flexibility.

[James Busser]

PS higher audit requirements could erode some of the cost savings of those ASP solutions that are not under the direct control of doctors.

The case for this would derive from logical application of the recommendations of the BC Privacy Commissioner on Outsourcing (as found on the Ontario Bar Association web site):

http://www.oba.org/en/pri/apr05/Outsourcing.aspx

[Alan Brookstone]

As an adjunctive commentary to the ASP vs. Local EMR discussion, this is an excerpt from a web site that has been established in Ontario to support physicians in group practice.

"I’ve been involved in the IT wars (and others) for a decade, and I have the scars to prove it. When we originally began talking about PCR and IT we felt that services to patients could be improved if doctors were able to share information, coordinate activities, and improve efficiency by using electronic medical records to aid in the treating of their patients. We envisioned physicians’ offices linked electronically with labs, pharmacies, hospitals, and most importantly, other physicians’ offices. That was ten (10) years ago! How have we done? Well, for a variety of reasons, many of which I would be happy to privately detail, this is only now beginning to happen." Click on the link to read the full posting. Link: Lesson III: Local Solution vs. ASP

[Gunther Klein]

PS: (RE - PATIENTS MAY HAVE AN OPINION ABOUT ASPs)

Have a look at the following website:

Link: NHS Confidentiality

It appears that patients in the UK not only may elect to opt out of the national medical database, but they may actually ask their GP to keep their records on paper (!).

The moral: The physician remains the ultimate 'data controller' / custodian / data stewart of the medical record of the patient, even when he or she chooses to contract this out to a third party. In the event of a breach the 'I was just following orders' defence will not protect us.

Once the media and the public in Canada cotton on to the data security issues surrounding ASP solutions, data centralization and the sharing of medical information, we might well find ourselves in a position where we have to defend existing ASP solutions and reassure the anxious public. The issue might have as much to do with emotion and trust as with IT techonology.

So, when it comes to choosing an EMR solution, think carefully how you position yourself now.

[Alan Brookstone for EMR Vendor]

The following is posted on behalf of an EMR vendor who provides useful suggestions regarding the decisions to make when selecting between an ASP vs. Local Solution EMR system.

Every purchase of a Local solution should include in it a support agreement where the costs for data maintenance, and recovery are clearly identified. It is just not hard for a vendor to provide data maintenance, and recovery remotely. This is really not an issue for a Local solution.

Data maintenance costs should be clearly laid out our front. An experienced vendor should be able to put this in writing with associated fees for this. The advantage of the local solution is that you can choose to leave it all to the vendor (like with ASP), or choose to assume some of that responsibility and work yourself, or a local supplier of these services.

A local solution does not mean updating all computers in your facility. There are solutions out there, that the server gets updated and all the workstations are updated automatically.

ASP / Local - at the core they are still a software solution. Therefore being ASP does not mean anything in regard to interoperability, or sharing of data between systems. Therefore don't be fooled that ASP means this will happen. The software at the core must support sharing of data between system. Exporting from one EMR to another is no easier with an ASP than with a local system. It is more dependent on the software and the vendors at both ends of the equation.

The quality of the vendor with ASP is likely more important than for local. With an ASP solution you are relying on the vendor to do more for you. How good is the software, how responsive to your unique needs and work flows is the vendor. So to say that the quality of the vendor is not a concern for both ASP and Local is not correct.

Vendor stability and sustainability is a concern for both ASP and Local. There are so many ways to measure this, and which way is correct. Just because a company has an ASP solution means nothing in this regard. Therefore it should not even be part of the comparison of should I go Local or ASP.

While on this topic though, what things should be considered for vendor stability. We have seen EMR vendors go under in Canada, and we have seen many companies (emr & otherwise) go under in North America.

Size matters, but there is still no guarantee. A large multi-national can decide to pull the plug on their product with little concern, where a smaller company it is their business so they are not going to pull the plug. Obviously too small is a concern too - but what is too small?

Public vs private. I do not believe this is a item in the measurement at all. What is more important is the management team, what is their business model, what do they spend on R&D, what new features do they deliver over the past 10 or more years, what is their road map for the future, what history do they have on actually delivering on their future.

Is the company burning money every month, or being profitable. A company burning money every month is some day going to have to stop. At some point the money will run out. So public or private it does not matter.

A key issue for the future, is what do physicians that use the software think about the feature set, and support by the vendor. Big media splashes, and pushes by a company with deep pockets does not mean that you will want to buy into that 'dream'. Either way, a vendor that has proven performance, proven system, that continues to evolve, providing good support, and reliable systems is likely who you want to go with in the long run.

[Neil Levitsky]

Some important points raised above, and it does seem, on the surface, that ASP is easier to maintain and has less cost for a solo practitioner or small (2-3 docs) group.

One fact has been left out of the discussion - the cost of local vs ASP changes a lot when you look at an Open Source EMR as you only have to pay a service provider for maintenance. I'm in Ontario, and researching EMRs, and a local server with Open Source software is by far cheaper than any ASP. I also have concerns about accessing data on an ASP is there are storms, etc and the internet connections go down. As well, if a disadvantage quoted for local servers is the security question, in case computers are stolen, I would assume that any server with an EMR would have the data encrypted - that isn't hard to set up, and I assume is included in most EMRs.

[Addendum - Ed] - Some people are promoting ASPs by saying the advantage is to be able access your records at home or other locations. But my understanding is that most EMRs on local servers allow you to do this as well!

[Michelle Greiver]

My group has a local server, which is maintained at the hospital. All offices access remotely, making us probably a "pseudo-ASP". Offices all maintain a backup internet line, which is essential for this model. The cost of the second line does not apply to local server (unless your server is in a colleague's office and you access remotely; in that case it does apply).

One of the things we learned was that you have to manage your server professionally. We have an IT manager in charge of this. There is a cost to us for this management, and this is spread over a much larger number of users for the ASP model. I don't know how this is done in small clinics with a local server: no management, the doctor does it, a staff person does it, the teenager next door does it, it is outsourced remotely to the EMR company, or a professional IT person does it. Server management needs to be factored into the decision as well.

Michelle

[James Carson]

Solo practice on high speed internet x 4 years:

ASP = Always Slow Poor_me

[Alan Brookstone for Chris Leenhouts]

The following comment was submitted by Chris Leenhouts and is posted on his behalf:

The problem with local connection reliability to use an ASP is easily and inexpensively minimized by purchasing a second back-up line from a different Internet supplier. Anyone who has ever had major damage done to their premises and computer systems will appreciate how quickly you can recover when using an off-site ASP.