An ambulatory electronic health record (EHR) can be provided to the physician practice through one of two different models:
- Web-based-- also referred to as a "hosted EHR" or the "ASP Model" where the physician accesses the EHR through an Internet connection
- Client-Server (C/S)-- the traditional model where the EHR server may physically resides in the physician's office
Both models are considered to be acceptable, but each has inherent pros and cons to consider. The traditional model of choice has been the “client-server” model. In this model the EMR software is installed on a server that is typically located in the physician’s office. The physician and staff access the EMR through computer devices that are connected to the server through a local area network (LAN) set up in the office. The computers may be connected wirelessly to the network if desired. This model has a few similarities to loading Quicken on your home computer and then using Quicken to pay bills online:
- After loading Quicken onto your computer you will periodically be advised by Quicken to take "updates" to fix known "bugs" in the software. Similarly, you will load the EHR software onto the server in your office and physically download any updates to fix "bugs" that the vendor discovers and fixes.
- Microsoft periodically advises you to take security updates on your home computer. Similarly, the EHR server will need to take periodic updates from Microsoft.
- You may later decide to upgrade Quicken to its latest version, and then purchase and install the Quicken upgrade on your computer. Similarly, you will want to upgrade your EHR software periodically, usually every 12-18 months.
- You may decide in the future to purchase a new home computer that is faster; you will have to then load the Quicken software onto that new computer and transfer all of your old Quicken data to the new computer. Similarly, you will need to periodically replace the EHR server with a newer one that is faster, stronger and/or meets future recommended requirements of the EHR software. And make sure your data gets transferred as well.
The web-based model is gaining popularity. In this model the EHR software is located on a server at a remote location designated and hosted by the EHR vendor. The physician and staff access the EHR through the Internet on computer devices in the office. This is analogous to online banking that you access on your home computer and use to pay your bills online (instead of using Quicken). Using this analogy:
- You will not physically have to take updates because the bank will update the software themselves
- Microsoft will not ask you to take Microsoft security updates to the online banking server because the bank hosts the server and will do that themselves
- When there is an upgrade to the online banking software, you do not have to purchase and physically load that software on your computer because the bank does that on their server that you are simply accessing.
- If the online banking server is too slow you will not have to purchase a new server, the bank will do that (if enough customers complain)...and they will migrate your data over to that new server)
Here is a comparison chart for these two EHR models:
Personally, the business side of me is strongly averse to allowing a 3rd party vendor to take care of the “heart and soul” of my practice (i.e. the revenue dollars and the clinical data). Hence, in private practice I would strongly favor keeping the server in-house. However, the clinic I currently work at is a small part of a large academic institution. For our ambulatory EMR I am leaning toward recommending a web-based model. The presence of an institutional IT Department whose primary purpose is to support the education of thousands of students, not to understand and dedicate the resources needed to provide a high level of clinical IT support required for a clinician using an EHR. And I know who is most likely to get trumped down the road when conflicting priorities arise!