Is The Cloud The Best EHR Model For Small Practices?

Over the last few years, the use of EMRs in medical practices has grown dramatically, with over 50 percent of office-based physicians now using such systems.  However, physicians still face major barriers in adopting EMRs, including costs, usability issues and impacts on doctor productivity.

One way of reducing the complexity of EMR installations — doing more for less — is to go with a Web-based model of EMR  use, argues “The Cloud: The Best EHR Solution for Small Practices.”

This model, also known as “software as a service” (SaaS) stores patient data in the cloud, accessible from any secure device connected to the Internet.

Not only does the cloud/SaaS model make it easy to access patient data,  it saves practices having to come up with a large up-front installation fee to set up software on site. Instead, practices pay a monthly fee which is predictable (and usually, manageable).

The price difference is very striking. The average cost of a client-server implementation over five years ranges from $30K to a whopping $80K per provider, not including the cost of training, interfaces, patient portals and conversions from other systems, the white paper notes.

But cost isn’t the only reason for small practices to go with a cloud/SaaS EHR. Increasingly, physicians are going mobile with care, via smartphone and tablet. As the Bring Your Own Device phenomenon explodes, practices are going to want an EHR which can easily be accessed and used via the Internet.

Read this paper to learn more about mHealth and how a cloud/SaaS solution can support your small practice’s mobile strategy while protecting critical data offsite in the event of a disaster; being sure that your data is encrypted at rest as required by Meaningful Use; and even how doctors can use voice to chart notes.

Of course, there are many who still argue against a cloud based EHR. They have their reasons that are worthy of consideration. An in house client server EHR does have its advantages over SaaS EHR. You have to weigh the pros and cons of each. Then, you can make a great decision for your organization.

About the author

Anne Zieger

Anne Zieger

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.


  • That’s great news for a small practice. Now if only the claims process (and claims approval) could move quickly in that direction, everyone would save money.

  • I’m interested in seeing the data to back up the savings claimed in favor of SaaS systems. When installing an EHR, a practice is most likely going to need a network of computers, and in the case of even the SaaS sometimes, is going to need to install some software. The only component missing from this equation the client-server needs that the SaaS is free from, is one extra computer to serve as the practice’s server when installing a client server system. Though often the server is not a standalone computer in a closet but is instead just one of the computers already in the mix. So with both the SaaS and client-server systems we need a network installation, hardware installation, and, sometimes for SaaS, always for client-server, a software installation. Given that most software installation is done by a click-and-go wizard and is thus the least costly measure of the three I’m not seeing a lot of cost savings here. Purely in the context of installation costs and not the multitude of other differences between SaaS and client-server systems I think they’re pretty even.

  • I don’t have any desire to read a 5 page white paper on this topic, but I’m curious, did they define “small practice”?

    My experience has been, a 4 provider practice still thinks of itself as “small”.

    I lean more toward the client/server model, but in a truly small practice, a cloud based EHR can make sense.

    I define small as no more than 5 users.

    I haven’t seen a C/S setup as easy as @Andrew Cox mentioned, but the flip side is, the cloud based EHRs usually get crippled when a tool bar is installed in the browser…which can happen easily by accident.

    I think in the longer run you’ll find the costs are similar. And if payment are what you want, that can always be arranged to reduce the lump sum needed for equipment.

  • Andrew,
    Your description definitely underestimates the costs of doing a proper in house server. I do know of some practices that have used “a computer already in the mix” as the server, but the only reason I know them is because they’ve had some catastrophic loss of data because they used that method. A practice would be crazy to host their EHR on a desktop computer. Is it possible to work, yes, but it is ripe with all sorts of issues that come back to bite them.

    There are a few areas that client server costs more. The server being the most expensive part. Although, there’s a lot of different expenses that most people don’t realize to host your server in your office. Not the least of which is creating a server room that works well for a server. Not to mention, backups, server updates, software updates, etc. It can be quite expensive and if not done right can be a real liability for the practice.

    Another example of added costs can be with interfaces. Interfaces can often cost more with a client server install than with a SaaS EHR. Not always, but it can.

    Those are a few examples. There are certainly more.

    I looked at the whitepaper and it doesn’t make a specific definition of small. Although, I think most people say below 5 doctors is small.

  • I disagree that it is “crazy” to host an EMR system on a workstation that is both server and client. Most desktop computers these days are exponentially more powerful than they need to be to run a small practice EMR system. Proper backup of such a computer is easier than it has ever been. On the Apple-based systems I support we often clone the boot drive to a second internal or external drive while maintaining sound data backup policies to external drives which are stored offsite and rotated. In the case of a drive failure the server computer can be rebooted from the secondary cloned drive in a matter of minutes so the office is back in operation quickly. I’ve encountered many offices using cloud-based EMR’s where an internet outage renders them unable to see patients, in some cases for days. Also, cloud-based EMR’s are more expensive in the long run because you pay the monthly fee forever. Mention a “free” cloud-based EMR and my response is that this is not a sound business so you should plan for that business to fail. Cloud-based EMR’s might be the right choice if the true risks and costs are understood and accepted but, right now, the cloud is much more the buzz phrase of the moment than a superior option on all counts.

  • Scott,
    How about when the power supply dies on your desktop? Or the network card? Just making the hard drive redundant doesn’t approach the redundancy and reliability that’s built into a server.

    Of course, there are a lot of ways to screw up a local server install as well, but it’s really scary for someone to install their EHR on a workstation.

    Certainly there are pros and cons to cloud based EMR vs client server. For me it’s mostly a wash unless you live in certain circumstances. For example, if you’re in a rural area with poor internet connection, you shouldn’t do a SaaS EMR.

  • John,

    With the Mac-based systems I support we don’t encounter equipment failures very often but even if we do I can repurpose another workstation in the office to act as a server very quickly with the most significant time component being the time necessary to restore data from the backup file. We can also purchase a second computer solely for the purpose of being a backup server if the client wants to be really proactive. Hard drive failures happen in all types of computers whether it is considered a “server” or a “desktop” and these failures are, by far, the most common cause of downtime. Lightning strikes and other failures are quite rare, in my experience. Some can justify the expense of a true “server” to protect against these events while others find it prohibitive.

    My main point is that we have the reliability we need for a small office that wants 2-10 workstations to run without prohibitively expensive hardware and that cloud-based systems with their higher long-run costs are not their only option. Above 10 workstations I counsel my customers to use dedicated servers with hardware RAIDs or some other solution which will get them access to their data should a failure occur.

    You are certainly correct that there are circumstances, such as the availability of a fast internet connection, which can point someone clearly in one direction or another. In the end, all available solutions will have ongoing costs and it is our job to help the customer choose the solution that they will gain the most benefit from.

  • does every one have to go to EMR / EHR,,, Im a small podiatry mobile unit and we are very different from a office based practice and very different from a family practice,,, we are mobile daily to assisted living homes rest homes ,,etc,,, WE see were it would on decreasing some paper storage yet not all, and our encounter form is very complex,, that is our template for the patient encounter and billing sheet that is specific to our practice services,,, trying to decide if EMR is for our practice,, and it appears it would have to be in the cloud and we would have to have a remote mobile hot spot in most of our rural areas to have internet access,, now we have a paper encounter,, a paper billing sheet that is customized for our type services,, I do not see how we can integrate this paper templates into the EMR,, and we send the customized billing sheet to our billings,by hand,, best regards ,, form some what confused at this point ,, if we even need a EMR system,,,

  • If you submit to Medicare you will face increasing penalties in the form of reduced reimbursements if you do not adopt an EMR which is certified for meaningful use. Your mobile situation does not necessarily dictate that you have a cloud based solution as you could use laptops and a wifi network (different from a mobile hotspot and not connected to the cloud) to create a mobile computer network. As for other requirements that would force you to adopt EMR I would recommend you contact your state’s podiatry association. I have not encountered anything that would exempt you from the Medicare penalties based on the mobile nature of your practice. Both the non-cloud and cloud-based solutions I represent allow the end user to customize the EMR template so I think replicating your paper process electronically will be less difficult than you might imagine.

  • Cloud is the best way to go whether it is a small, medium or a large practice. However, I am concerned about these numerous SaaS EHR providers. How safe and secured is the vendors Saas offering?? What is the long-term viability(financial) of these SaaS EHR vendors? Are they there to stay? Given that there are so many EHR vendors and cut-throat competition, I am waiting to see how many of them go out of business.

    So, practices whether small, medium or large must have a due diligence process while going with a cloud offering to make sure the vendors financial viability and long term commitment. One might argue, the same risks is associated with C/S EHR vendor. Yes, but at least you have own the software and data in your premise or co-located data center and normally the source code will be in a escrow (you should negotiate for that). So my advise to those who are already with SaaS EHR vendors, ask for weekly data dump ( in CCDA, CCR or whatever other formats). You have at least your data.

    So, yes cloud is the way but do your due diligence on the vendor.


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