A Perspective On: Cloud-Based Modular EHRs Offer Advantages for Meaningful Use

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By John Haughton, MD, MS, Chief Medical Information Officer, Covisint

Physicians who seek to obtain government incentives for "meaningful use" of electronic health records have two options:

They can use a legacy client-server EHR that has all of the components associated with Meaningful Use, or

They can utilize "best-of-breed" EHR modules (often secure-cloud based without up-front hardware costs) that are certified to meet Meaningful Use functional criteria.

There are advantages to a best of breed approach that can be tailored to meet the specific needs of physician practices and enable them to leverage their existing technology investments rather than "rip and replace" to accommodate a one-size-fits-all EHR that may not be ideally suited to address a practice's requirements. The comprehensive EHR can seem appealing because it means that the practice only needs to deal with one vendor and one deployment, but many best-of-breed options can be combined and provided through a single vendor that takes responsibility for integrating all the components seamlessly and providing maintenance and support.

Health IT, healthcare reimbursement and the delivery of care are undergoing transformational changes - moving from islands to communities of care, shifting from volume incentives to payment becoming increasingly dependent on effectiveness and outcomes. In times of great change, there is a huge risk in acquiring systems that may not meet the demands of evolving technology, even if the systems seem inexpensive. Just ask the folks who bought discounted "buggy-whips" at the dawn of the auto age, or the folks who bought "main-frames" just as the personal computer hit the market.

Legacy health information systems designed for local storage and use vs. distributed, secure connectivity are simply harder to integrate with other systems and with connected patient care. Cloud-based (native) EHRs provide a superior combination of functionality, flexibility and interoperability, while minimizing the cost and effort of converting to an EHR. Ultimately, a best of breed cloud system can lead to better patient care more quickly and at a lower price point for practices. The concern to date, has been, "how does the practitioner manage various vendors with different systems connected together?"

This concern goes away, when a practice licenses software from a vendor or supplier that will take responsibility for the effective utility of the overall solution, not just a single component part. The good news is this model, with flexible IT from multiple sources combined with singular point of responsibility, is much easier to access in the market in 2011, than even a year or two ago.

While some vendors offer cloud-based versions of their comprehensive EHRs, there is a big difference between a true cloud solution and merely taking a server based application and moving it to a hosted environment on the Internet so it can be called cloud-based. Transferring a traditional EHR to the cloud doesn't resolve its inherent interoperability limitations - physicians should expect that the inability of a client-server EHR to interface easily between disparate systems will carry over to its cloud-based counterpart.

The bottom line: Decide whether a functional approach with flexibility for the future or a single supplier EHR with inherent limits in flexibility best suits your practice's needs. Don't assume that an out-of-the-box, full-featured EHR will morph into a highly configurable, flexible EHR simply by moving from a client-server model into the cloud - the architecture for the "cloud" interconnected system is fundamentally different from the "island" single software application.

For example, while legacy client-server EHRs can provide a wide array of traditional features, they may lack the capabilities that are increasingly becoming essential to respond to the transformation of the healthcare delivery system now underway. Many of them don't include the analytic and reporting capabilities needed to demonstrate meaningful use, and most don't have built-in mechanisms to engage and empower patients to become active participants in their care. Moreover, these systems may suffer from inadequate tools for population health management, such as chronic disease registries usable in day-to-day patient care, or quality-related tracking and reporting functions. Additionally, providers who buy legacy client-server EHRs usually pay a high, upfront licensing fee plus an annual maintenance fee and are forced to rely on expensive, scarce health IT experts to incorporate even minor changes.

We've heard stories of folks who have purchased an EHR and are now being told they essentially have to purchase it again for the "meaningful use version." Typically, physicians are interested most in documentation speed and flexible, secure retrieval of information anywhere on any device (smart phone, tablet computer, PC or desktop computer). They may not want or need lots of useless bells and whistles included in some of these legacy products, and they certainly want to avoid the inevitable expense, integration challenges and productivity drain when forced to bolt-on additional capabilities needed to successfully navigate their rapidly evolving needs.

For a physician looking to acquire an EHR to position the practice to navigate the growing forces or change, including qualifying for meaningful use payments, today's flexible alternative is to license a cloud-sourced, modular EHR with "plug and play" components certified for meaningful use. Many solutions are inexpensive and offer a single point of responsibility for making sure the system components work together. Instead of paying an upfront licensing fee, physicians pay a monthly subscription fee just for the EHR components they need. For example, a practice could start with e-prescribing and quality reporting modules as they build toward the full functionality needed for meaningful use.

Some connectivity vendors already offer such a service -- allowing practices to choose from a menu of applications to fill in technology gaps based on their timetable and budget while leveraging their existing, well-performing technology investments. This approach gives physicians tremendous flexibility to meet their most essential needs while sparing them the burden of rolling out an EHR all at once, before the true value of each piece exists for the practice.

Initially, cloud-based modular EHRs generated concerns about security and workflow, but real-world experience quickly debunked those issues. Physicians and practice managers can now be confident that these security issues have been dealt with in other industries, such as banking that have used cloud-based applications for highly sensitive data for more than a decade.

Of course, security and privacy are critical in healthcare. When considering a cloud-based EHR, practices should explore a vendor's security track record. As for workflow, a good cloud-based platform should allow seamless, secure single sign-on to a myriad of cloud-based applications that eliminates the need for multiple passwords and cumbersome shifting between various applications. In addition, the EHR should provide access to a 360-degree view of a patient.

In short, physicians don't need to spend tens of thousands of dollars per practitioner on a legacy EHR to qualify for meaningful use or to prepare for the challenges ahead. For a cost of $200 per month or less, a modular, cloud-based EHR (and there are many out there) provides all of the required functionality plus many other flexible features that conventional systems just can't offer. The biggest risk right now for the practicing physician pursing the meaningful use incentives from the federal government is spending lots of money on an EHR that could be obsolete before installation is complete.