In January, the federal Centers for Medicare & Medicaid Services (CMS) rolled out a new fee schedule for providers taking care of patients with two or more chronic conditions. Within weeks, Privia Medical Group, a 310-provider multispecialty medical group based in Arlington, Va., had electronic health record (EHR) templates for the documentation and coding requirements as well as a 20-page tutorial with screen shots.
To Andrew Aronson, M.D., Privia’s chief medical officer, that responsiveness is one of the key reasons the group chose to work with the Watertown, Mass.-based athenahealth for its health information technology needs. “Any update or rollout of new information goes on behind the scenes and is pushed out to all our offices,” Aronson says. “It is released quickly and we are off to the races in implementing the new revenue stream. We are not driving a 4-year-old model car anymore. We are constantly driving the newest and coolest as far as technology goes.” He adds that having each physician office purchase and support its own hardware and EHR software is an “antiquated approach.”
Privia is not alone among midsize and large physician groups and independent practice associations in taking a second look at either an application service provider (ASP) remotely hosted EHR from a vendor such as eClinicalworks or a software-as-a-service (SaaS) model from vendors such as athenahealth or Practice Fusion. (The SaaS model involves a single, integrated database that is delivered as a service to multiple customers simultaneously via the Internet. In an ASP model, the EHR is delivered over a secure Internet connection but involves multiple separate instances of an application, and customers could be on different versions of the software.)
The Orem, Ut.-based KLAS Enterprises has done ambulatory EHR perception reports for almost 10 years, and has seen the pendulum gradually swing from almost no cloud adoption to much stronger interest, notes Erik Bermudez, a KLAS research director. “Ten years ago they would say if they got angry at their EHR, they felt better if they could kick a server in the basement,” he says. “They were at peace knowing it was all behind their four walls.” But that perception has gradually changed. Although many doctors may not understand the distinction between ASP and SaaS models, when KLAS has asked physicians about the umbrella term of remotely hosted EHRs, practices ranging up to 100 physicians are now open to it, he said, “although name recognition and a vendor’s size and reach continue to be important criteria for large practices. Practices with hundreds of physicians that have a CIO tend to have an interest in keeping data in-house,” he adds.
Concerns about data security might be misplaced, Kosiorek added. People tend to correlate moving records to another company as a point of fear. But security in the cloud provider’s environment is most likely better than in your own office, he says. Cloud-based systems have a vested interest in keeping things secure. If they have a breach, it will impact their reputation forever. “Small to medium-size practices have limited means to invest in security, so they are trusting their IT staff to have all the bases covered with security,” he said, “and the smaller the staff, the tougher that is to take on.”
Rodger Prong, executive director of Oakland Physician Network Services (OPNS) Inc., a 425-member Michigan independent physician organization, notes that many of its members are adopting the free (with advertising) or low-cost cloud-based Practice Fusion EHR.
“I had a lot of suspicion of this platform at first,” Prong admits. “I ignored it for two to three years. The old saying is you get what you pay for. But then I saw several positive independent surveys of doctors. What creates traction is what interferes with physicians the least,” he said. Prong said the process of migrating data to Practice Fusion from other EHRs has gone well.
The OPNS doctors using Practice Fusion have interfaces to an organization-wide registry and data warehouse. “We like the fact that they do enterprise-wide changes. It helps us not have downstream problems with interfaces,” he says.
Prong said that with some EHR vendors, interface costs are exorbitant. “If they don’t make enterprise-wide changes, then we have different versions out there and every time they change something for a doctor we wind up incurring additional cost to get the interface operational,” he says. “Practice Fusion gave us one price per interface for our entire group. We only pay them once and it works for everybody.”
You don’t see software in other industries developed in this client/server manner anymore. The mentality that the cloud is a new thing is curiously specific to healthcare. Derek Kosiorek
Some provider organizations decide to subscribe to remotely hosted EHRs to avoid costly hardware upgrades and IT personnel costs. East Georgia HealthCare Center Inc., a federally qualified health center with nine facilities and 23 physicians, had been a customer of eClinicalWorks (eCW) for several years as part of the Georgia Primary Healthcare Association, which managed the software from an Atlanta data center. “As EHRs became more robust, and contained more information than we originally used them for, we started running out of resources,” says Herb Taylor, East Georgia’s IT director.
“Computing and processing speed started getting slow. So we could either spend a bunch of money on hardware upgrades or evaluate cloud-based options. We went with eCW in the cloud. It was a smart decision for us financially and with the IT staff we have.”
Taylor says that performance has improved dramatically. “At the time we moved, a year ago, with 130 employees, we were averaging about 20-40 tickets a week about people experiencing slowness,” he says. “Now we get only a few tickets a month, and those are in the more rural sites and have more to do with latency with the Internet service provider.”
Taylor says the cloud offers him better disaster recovery protection than he previously had. “You as an individual provider won’t have funds to truly be redundant in a disaster situation,” he says. eCW is so big on a national scale it has sites in multiple locations, he added. The data is encrypted at rest and in transit. You gain the benefit of a larger-scale organization. He also keeps a storage-area network on site, so if there is a disruption, users could keep working and then upload data to eCW’s site later.
For Taylor, it all comes back to financial security. “You may be able to spend that $300,00 to $400,000 to get where you need to be this year, but where are you going to be in five or six years when it is time to upgrade all that hardware again? That was the big factor for me. No matter what happens, I am paying x amount of dollars to eCW. It was a no-brainer for us with 23 providers to pay the monthly fee,” he says.
Another physician group that recently signed a contract with athenahealth is Healthcare Network of Southwest Florida, which has 25 physicians and 250 staff members. In the next six months it will migrate from a GE Centricity system it has been using for the last several years.
Larry Allen, the organization’s chief information officer and vice president of information technology, was attracted by the fact that athenahealth can do 12 software upgrades a year. Like Privia’s Aronson, Allen talks about some of the advantages of the economies of scale a SaaS vendor can offer on the business side. “Let’s say an insurance carrier requires a modifier on an ICD-9 code. When they make that change, you see claims denied, and you have to go back in and reconcile and resubmit it,” he explains. “With athena, the first time any provider in their cloud has that denial, they flag it and put a business rule in the system so that the next time we code that, we would see an alert that this claim will likely be denied and a modifier code is required. And the claim gets successfully processed the first time.”
Allen said there are pros and cons to consider. “One of the advantages of having your own database is that you can make modifications to it that are unique to your group,” he says. On the other hand, with a cloud-based solution, the vendor can study EHR usability issues across all its practices and then make changes that impact all the practices at once, instead of single install of Epic, for example.
Privia’s Aronson says another advantage is that by studying keystroke click variations among Privia’s providers, athena can help its practices with work flow and train them how to become more efficient in terms of keystrokes. “We have 100 separate practices in our medical group. If they were all on disparate EHRs, we would have no idea what our benchmark was, or be able to compare one to another.”
Users also perceive a mobility benefit because they can access the EHR over the web, whether at home or working away from the office. “I can log onto athenanet anywhere I have web access, Aronson said. I don’t have to be in the office. That is huge for our providers. They want to get out of the office at the end of the day and finish their notes at home at night, and not have to go through virtual private networks,” he said.
MGMA’s Kosiorek says that one key challenge is working through contract language with the cloud service providers. “That is the biggest issue groups are going to have with cloud-based systems,” he says. “Who owns the data and what format you get it back in if the relationship ends? The contract has to be rock-solid about what happens to the data.”