Web-hosted EMRs

I was recently speaking at a conference, extolling the virtues of EMRs, when a slightly frazzled-looking doctor stood up and asked, “Who’s going to manage all the hardware? I’m no IT expert - and even if I were, I’m too busy with the practice to work on networks and servers. Are there any systems that can help?”

The short answer is yes. At least partially.

They are called ASPs, which stands for application service provider and it refers to a system where the practice purchases the use of EMR as a monthly service, accessed over the Internet.

With an ASP, the EMR application, the database (where all the patient data is stored), and computer responsible for running it (called a server) all reside in a central location outside the physician’s office, and are maintained by the EMR vendor or other third party. Clinicians and staff use a secure log-in over the Internet to access the EMR - not unlike the way they would access a secure banking site (although ASPs offer much tighter security). In contrast, with a client-server EMR system, the practice purchases and maintains the server locally.

Time and money

While ASPs don’t eliminate all your hardware chores (you still have to take care of printers, scanners, and workstations), they do allow you to outsource the care and feeding of the all-important server to an IT pro.

This can be a significant time and money saver. EMR software updates (which can be really challenging for a client-server) are done by the ASP and included as part of the monthly service charge. The ASP also is responsible for doing nightly backups of your patient data - a crucial function often done poorly (if at all) by small practices maintaining their own systems. And with an ASP, since you don’t need an EMR server, which is typically the most expensive piece of hardware in an EMR system, you don’t have to worry about the cost and hassle of replacing it when it runs out of steam every three to four years.

Hospitals have figured out that ASPs are easier to support. Almost without exception, those that are offering EMRs to their local docs (as part of the Stark Law relaxation) only offer them via ASP.

How it works

In terms of functionality, ASPs work pretty much the same as the traditional client-server system. In fact, most of the leading EMR vendors offer you the choice of either ASP or a client-server. A caveat: Certain EMR functions, like voice recognition, need local processing power on a PC and may require some technical workarounds to work with an ASP. Be sure to ask your vendor to specify (preferably in writing) any functionality differences between their client-server and ASP offerings.

However, from a financial perspective, ASPs and client-servers are quite different. With a client-server, one purchases a perpetual license to the software, much like you do when you buy a copy of QuickBooks. Assuming that you finance the EMR, after the payments are done, your remaining financial obligation to the vendor is your annual support payment, which typically covers new updates and help desk support. Annual support fees range from 18 percent to 20 percent of the retail cost of the software.

In contrast, with an ASP, there is no upfront cost for the software. You pay a monthly fee, just like the fees you pay to get DSL or cable Internet access. And like DSL and cable, you pay the monthly ASP fees as long as you are using the service. The fees range from $350 to $750 per provider, per month. In addition, many vendors recommend purchasing either a full or fraction T-1 line to ensure a reliable, high bandwidth connection to the Internet. This can run another $500 or more, per month, depending on the size of the practice and the number of workstations.

The ASP fee is inclusive, covering help-desk support, software upgrades, daily database backups and any server maintenance. Training and implementation costs - which are typically one-time fees - are not usually included in the monthly fee for an ASP.

The bottom line

So which is better? Like most things in life, it depends. From my perspective, the ASP vs. client-server decision primarily revolves around how much IT support a practice is willing to take on. For practices that have the wherewithal and staff to maintain a server, do the backups religiously (and make sure that they work), attend to the details of technical troubleshooting, and managing complex software upgrades, a client-server is a great choice - and less expensive. But, if the tasks described above are daunting or terrifying, then ASP is a better choice for your practice.

Bruce Kleaveland is president of Kleaveland Consulting, a management consulting firm focused on healthcare IT. He can be reached via physicianspractice@cmpmedica.com.

This article originally appeared in the April 2009 issue of Physicians Practice.