Cloudburst: The New Frontier for Electronic Health Records

Health IT has attracted tremendous attention this year— specifically the use and adoption of electronic health record ("EHR") systems as an effort to digitize medical information. For the first time ever, the US is developing a national health IT policy, derived from overarching health policy priorities and care goals, and fleshed out by "meaningful use" objectives and measures.

We should not underestimate the change in direction and perspective in the health IT sector. Previously, system vendors centered EHRs on specific features and functionality, with the idea that customers wanted an all encompassing, self contained practice management package. Now, they're focusing on achieving meaningful use results through data reporting. And whatever architecture that can help them achieve these results, they deem legitimate.

Also, vendors are taking a different approach to the certification process and the Certification Commission for Health Information Technology ("CCHIT"), historically the only certification pathway for EHRs. Under the 2009 American Recovery and Reinvestment Act ("ARRA"), access to HITECH stimulus money requires a Department of Health and Human Services ("HHS") Certification.

As many as ten or 12 organizations beyond just CCHIT could provide certification pathways, and address different types of products such as hosted, web-based SaaS (software as a service) services, open source approaches, home-grown solutions, or certified pieces of stand-alone software that might be assembled into a unified dashboard, for example e-Prescribing systems.

Meaningful use and HHS Certification are more likely to encourage collections of tools, referred to as “project” (rather than “product”) certification, which might include local hospital systems in combination with ambulatory, web-based EHRs, all of which will achieve the interoperability and data-reporting goals envisioned by the HIT Policy Committee.

The concern over cost
Throughout this transition, one of the biggest barriers to EHR adoption has been cost, a barrier that has been particularly problematic for smaller group and solo ambulatory practices, where the majority of physicians are located. Not surprisingly, EHR adoption has been lowest among the 80 percent of physicians who practice in groups of nine or less.

Some observers speculate that the cost of EHR adoption will outstrip the HITECH incentives, topping out at $44,000 over several years as add-ons to CMS billing. For example, a recent Managed Healthcare Executive article claims:

Avalere Health predicts small physician practices with little capital will be worse off financially should they take the offer and implement an EMR system because the incentives and penalties outlined in the Reinvestment Act won't offset their costs. Researchers forecast a $124,000 investment over five years with incentive payments only adding up to $44,000. Penalties would be assessed starting in 2015 and amount to $5,100 a year, which is probably less than the cost of system maintenance.

Smaller practices have resorted to several strategies to address these concerns:

• Implement partial, not-yet-certified electronic solutions to move their offices from paper to an e-platform.
• Choose to wait and not switch to electronic records
• Align themselves with local hospital systems, or other better capitalized organizations like risk-taking IPAs, in order to engage in group purchasing, or subsidies for their EHRs.

Unfortunately, when a physician chooses to piggy back onto a local hospital’s efforts, he also is stuck with that hospital's vendors. An ambulatory practice faces a different workflow than a hospital setting, and is not necessarily suited to a hospital's choices in EHR vendors. Systems often can slow down workflow and lead to resistances in adoption. Examples of physicians dismantling EHR systems feature in several areas across the country.

Problems with scalability
To understand the scalability of a health IT system, it is important to understand the kind of technological platform it is build upon. Over the past several decades, technology has undergone a series of evolutionary stages, as hardware has grown more powerful and cheaper, and software has leveraged these improvements. Client/server systems replaced mainframes, which allowed distributed microprocessing environments. The subsequent shift to web applications and web services opened Internet-based networking.

The next phase, still in its infancy, is cloud computing, which not only leverages these prior computing and networking waves of technology, but also embraces deep innovations in storage and data management in order to tackle "Big Data"

Most “big vendor” legacy EHRs are built as client/server systems, and function on local networks. Though touted as scalable, these systems require larger and larger networks to work on larger scales. Service and maintenance charges inflate costs, and, often, the software fails to deliver on its promises. After investing over a billion dollars, UCSF Medical Center, for example, pulled the plug on its GE Centricity EHR system. And Kaiser has invested over $4 billion in a local system (a customization of Epic), and, although robust, no one outside its network can access it. These legacy systems often have stiff and clunky interfaces, which cause errors that result in worse medical care. The previous legacy EHR certification process under CCHIT specifically did not measure usability as a certification criterion.

Iowa Senator Charles Grassley has confronted HIT vendors on legacy system failures, sending a letter of inquiry to Cerner Corporation recently.

Where can we look for solutions?
How can vendors make EHRs affordable for private practices? How can they scale EHRs upwardly without breaking the bank? The key is to recognize that building larger local networks is not a scalable solution. Instead, the solution should be recognizing that the Internet already boasts massively-scaled networks.

Web-based applications can be built intrinsically for scale, and can maintain safe and secure data segregation. For example, when you use online banking, you see only your own checking account and not someone else's. You can access your statements, even if several million other users are using the system simultaneously.

Practice Fusion is an EHR built on a web platform moving to a cloud platform. Scalability, though not to be underestimated nor taken for granted, can be built in the background without burdening or costing the end user. All 21,000 users access their EHRs through the Web. Practice Fusion does all the work in the background so that there are no limitations experienced by the end users.

Size of practice simply doesn't limit the ability to use the Practice Fusion platform. A one- or two-physician practice can use the system as easily as a hundred-physician practice because great effort is made to build a scalable, flexible product that performs briskly for all users.

Web-based EHRs offer significant cost advantages. They don't require whole server- and local-network infrastructures, which make legacy systems so problematic to implement. Typically, physicians utilize these for a monthly subscription fee.

Practice Fusion offers a free option – in-product advertising similar to what you find in trade journals subsidizes this. Alternatively, instead of ads, customers can choose a low-cost subscription of $100/physician/month.

This kind of technology makes available an affordable EHR option to any physician—or physician group of any size—in the U.S.

The only thing, then, that determines the utility of a given web-based EHR for a particular practice is whether the features and interfaces address the practice's real-time workflows. Extensibility is not a limiting consideration, whether to multiple sites, multiple providers, multiple specialties, or patient sharing – Practice Fusion has built technology that embraces all of these.

Some web-based EHR applications focus on very specific audiences, and have interfaces adapted for the workflows faced by those specialties. Practice Fusion emerged as an ambulatory EHR particularly well suited for primary care practices. Smaller practices, loathe to adopt expensive, local network-based legacy client/server EHRs, have been the most avid adopters to date.

A variety of specialty practices have also adopted Practice Fusion, as well as larger practices and networks. It continues to build features and interfaces that address the kinds of workflows encountered by these various specialties.

When choosing an EHR system, physicians should avoid the serious limitations of legacy client/server systems. Cost escalation inherent in scaling-up a local network is prohibitive, the interfaces are often problematic, and the interoperability question remains unanswered.

Instead, practices should look towards the new generation of web-based EHR systems that offer significant cost and scale advantages. Though still young, companies such as Practice Fusion are rapidly building features and interfaces that address all the workflows encountered in the various settings of medical care.

Recently, a Practice Fusion customer made the following comment: “As a small family practice office, we don’t have an IT department. I am the IT department! So it was very important that the EMR we chose was user friendly and did not require extensive computer hardware changes or computer software knowledge to run. Again, Practice Fusion fit that requirement perfectly.”

The future is here, and it's in the cloud.


Robert Rowley, MD – Chief Medical Officer, Practice Fusion, Inc.