By Ryan Howard

May 2010 – Web-based Electronic Health Records (EHRs) are stepping onto the main stage as the most likely way smaller and solo practices will be able to adopt EHRs in a “meaningful” way, in time for the 2011 ARRA/HITECH incentive moneys.  Web-based software has also been referred to as cloud-based computing, SaaS, ASP-delivered software, and other terms (not all exactly the same from a technical standpoint, but often used interchangeably).  Rather than seeing web-based record keeping as an example of a fundamentally different approach, it might be appropriate to see it as a different generation of its client/server predecessor.

For the small practice, the differences add up to viability.

Elimination of IT burden

Web-based software is accessed through an ordinary web browser. The vendor, not the clinician, bears the burden of all the back-end heavy lifting. Servers, always-available access, security, and safety and backup of data are removed from the clinician’s responsibility.

This is a significant difference from client/server software, which requires local installation, the maintenance of a secure local network, and local policies for safety, security, and data backup. This generally requires IT resources and adds hidden costs to the EHR installation. However, client/server systems on a local network are not dependent upon an internet connection. With a web-based EHR, practices need to plan for connection disruptions, even if rare. Practices may be able to get an SLA (Service Level Agreement) with their internet service provider that will guarantee more resources to maintain an internet connection. Also, users might want to have wireless 3G cards for their laptops, which run on cell phone networks and are a good backup.

The concern over cost

One of the biggest barriers to EHR adoption has been cost, a barrier that has been particularly problematic for smaller and solo practices (i.e., the majority of U.S. physicians). Not surprisingly, EHR adoption has been lowest among the 80 percent who practice in groups of nine or fewer physicians.

These smaller practices have resorted to a couple of strategies:

  • Wait and not yet switch to electronic records, or
  • 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 piggyback onto a local hospital’s efforts, he also is stuck with that hospital’s vendors. An ambulatory practice faces a different workflow from a hospital setting and is not necessarily suited to a hospital’s choice in EHR vendors. Systems incompatible with a practice’s needs can slow down workflow and lead to resistance to adoption.

Version control

In the client/server world, users test updates and prepare for changes entirely on their own schedule. However, ugrades require a patch or installation of a new version.  Often a fee is charged by the vendor (per upgrade, or per year). In turn, users are true “owners” of their data and not dependent on version updates prioritized by a web-based vendor.  A larger practice, which can afford to manage its own software, may opt for a client/server system.

A web-based EHR takes a different approach to “version control” – everyone 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 web-based EHR products is that they are “one size fits all.” Some are, but they do not have to be. A customized, specialty-specific EHR may work better, given that the workflows faced by different specialties are, in fact, quite different.

It is possible to capture elements of a user upon login and deliver an individualized view (the User Interface, or UI). Within a given practice, different users have different needs – the needs of a front-office check-in staff member are different from those of a scheduler or a back-office nurse. Similarly, what a Family Physician needs from an EHR may be quite different from what an Orthopedist or Oncologist needs.


Then there is the issue of security. Even a solo practitioner is obligated to safeguard patients’ Protected Health Information (PHI). Client/server systems are deployed locally. This means that computers on premises (or backup systems) contain PHI and are a security risk.

Web-hosted EHRs avoid this burden. Additionally, access to data within a web-based EHR can be controlled by well-defined user roles and access levels, the enforcement of strong login passwords, stringent user authentication and user inactivity locks. Physicians, nurses and administrators can each have specific permissions for accessing data. There can also be a separation of data belonging to each practice. Users can log into a web-based EHR anywhere they have access to the internet, making records always securely available to them.

A lightweight, intuitive, responsive EHR is the goal for many who are striving to transform U.S. healthcare from a paper-based legacy to an electronically-connected one. The EHRs that have dominated the landscape until now seem to have been built with large institutions in mind – they are self-contained, proprietary, all-in-one clinical/financial packages, which are expensive and are locally installed into a closed client/server network. These are non-starters for the smaller and solo practices. These practices need solutions that address their unique needs by exploiting current technology, such as web-based interfaces. These clinicians need to understand all the value propositions in the space, as they are changing rapidly, and not simply view EHRs as large, expensive systems.

About the Author

Ryan Howard is Chairman  and Chief Executive Officer of Practice Fusion, Inc.  With an extensive product management, engineering and marketing background, Mr. Howard’s technology approach to electronic health record topics and practice management drives the rapid business growth. Previously a Senior Director of Product Management and Professional Services for Grand Central Communications, Saqqara Systems and InterTrade Systems, Mr. Howard has brought over a dozen SaaS-based products to market. He also worked with Brown and Toland Medical Group in San Francisco, performing extensive HIPAA implementations, and is a former Board Member of the Haight Ashbury Clinics. Mr. Howard is an expert on healthcare IT, integration, SaaS software and EHR technology.

You may reach Ryan Howard at (415) 346-7700 or


Leave a Reply