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Contributing Writer · Mar 9, 2010

SaaS Electronic Health Records (EHRs) are stepping onto the main stage

At last week’s HIMSS trade show, one of the clear messages that emerged is that SaaS-based (software-as-a-service) Electronic Health Records(EHRs) are stepping onto the main stage as the most likely way that smaller and solo practices will be able to adopt EHRs in a meaningful way, in time for the 2011 ARRA/HITECH incentive moneys. Dana Blankenhorn (from ZDNet) commented on this, as did John Halamka (CIO at Harvard and member of the Health IT Standards Committee).

SaaS-based software has also been referred to as cloud-based computing, web-based software, ASP-delivered software, and other terms (not all exactly the same from a technical standpoint, but often used interchangeably). So what is this new “hot buzz” all about and why is it important in the world of Health IT?

Elimination of IT burden
SaaS-based software is internet hosted, and accessed through an ordinary web browser. That means that the vendor, not the clinician, bears the burden of all the back-end heavy lifting – servers, always-available access, security and safety of data, and backup of data are all issues that are removed from the clinician.

This is a significant difference compared to legacy client/server software, which require a local installation onto a server, the maintenance of a secure local network (with perhaps a Citrix layer to access it from outside the confines of the office and network), and local policies for safety and security, as well as data backup. This generally requires the need to hire an IT consultant, and adds “hidden” cost to the whole EHR installation.

An interesting side-note here is that the computers which run the software (the clients) can have less expensive operating systems with a SaaS approach. In a local area network (a LAN), all the workstations that access the local server need to be able to become members of a Domain, which is established by the server. Windows (any version) Professional version needs to be installed; the Home versions of the operating system is not able to join Domains. There is generally about a $100 additional cost for the Professional version of operating systems, compared to Home versions. With a SaaS-based EHR, all one needs is a browser and an internet connection – joining a domain is not required. Therefore, any off-the-shelf computer with a pre-installed Home version of the operating system will work.

Version control
Another limitation of a locally installed legacy client/server system is that, once it is installed, then it is “set.” Upgrades and bug fixes require the application of a patch, or installation of a new version. Often, a fee (per upgrade, or per year) is charged by the vendor for this support.

From the standpoint of a vendor, support is challenged by this. When there are a variety of versions of a product locally installed “in the field,” then support is more difficult.

A SaaS-based EHR avoids this issue of “version control” – everyone, by definition, is on the same version. When changes or upgrades are deployed, everyone receives these changes on their next session log-on. From the standpoint of support, this is much easier, and feature fixes as well as bug fixes can be managed quickly, and deployed to everyone at once.

Customizable UI, per role, per specialty
One of the criticisms made about SaaS-based EHR products is that they are “one size fits all.” This may really limit the usability of a given product. Therefore, a customized, specialty-specific EHR may work better, given that the workflows faced by different specialties are, in fact, quite different.

Using modern technology, it is possible to capture many elements of a user upon login, and create a product that delivers a view (the User Interface, or UI) that can be very individualized. Within a given medical practice, different users have different needs, depending on their role – what a front-office check-in staff member and scheduler needs are different than a back-office nurse, which is different from what the clinician needs.

Similarly, what a Family Physician needs from an EHR may be quite different from what an Orthopedist needs, or what an Oncologist needs. Such workflow needs are beyond simply presenting a different set of charting templates (though that is certainly a start). Though not fully actualized presently, modern SaaS-based technology can move in this direction – the result being that, upon login to a SaaS-based product, the features presented by default (the UI) will vary depending on specialty, role, and individual preferences.

Learning curve
One of the biggest fears about moving from a paper medical record environment to an electronic one is the concern about a prolonged learning curve and a consequent dip in productivity. This dip in productivity (i.e. income stream) can be significant (e.g. 20%) and can last a long time (e.g. months). This is especially concerning for small primary care practices that run very close to the margin – small perturbations in income stream can mean running at a loss. In a fee-for-service system, life as a primary care physician is often a mad hamster-wheel life, with little time for much else other than processing high patient volumes through the office (worthy of an entire tangential blog topic thread). Anything that introduces a slowdown in this frenetic pace is worrisome.

Yet these precise practices are the ones that the Office of the National Coordinator (ONC) wants to get on board with EHRs. Even if the EHR is SaaS-based (minimal IT infrastructure costs), and free, the worry about work slow-down during the adoption phase is an obstacle to adoption and use of an EHR in a meaningful way.

Thus, regardless of the style of EHR deployment, the burden is on EHR developers and vendors to create products that minimize the learning curve. Usability is paramount. Incorporation of user suggestions into the product is very important.

A lightweight, intuitive, responsive EHR is the goal for all us of who are creating the tools needed in order to achieve the transformation of U.S. healthcare from a paper-based legacy to a modern electronically-connected one.

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