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.