Pros and cons of cloud based or web based EMR systems

As if medical practices don’t have enough to worry about with EMR implementation, now they have to decide what kind of EMR system to get: a client-server-based system or a web-based system. The former is the kind that most of us are familiar with. You purchase a computer server, buy a license for the EMR software, install said software on your server, and you’re ready to go.

But recently there has been a lot of buzz about “new” web-based EMR systems, also known as cloud-based EMR, that allow the user to pay a monthly subscription fee to access their EMR rather than having to purchase it. And since any computer can use the internet to ‘run’ the EMR, there isn’t the need to purchase more expensive servers and their associated hardware and software.

So, is cloud-based electronic medical records really a new thing, and is it really better?

In fact, running software across the internet is nothing new. Also known as Application Service Provider (ASP) or Software as a Service (SaaS), some major software companies have been offering this service to their clients for over a decade.

Depending on the nature of the business, these can run across the web using a simple web browser or a secure internet connection. Since this information is often stored across a network of data storage centers, it is considered to be hosted in the ‘cloud’ and in no one particular place at any time (sort of like the ambiguous nature of an electron cloud).

And many of you are already (unknowingly) running your EMR systems as cloud computing if you have a centralized data center and use it across multiple office locations. If you are seeing patients in a satellite office and entering information into your EMR system, this process is actually happening back at your central office across your wide-area network (WAN). The main difference between this and true cloud computing is that many (if not most) of your devices have a more direct connection to your network than a truly web-based system, which always must store and recall data across the internet.

Choosing a particular vendor does not necessarily limit your choices. Jim Messier, of MedFlow Inc., says that their EMR solution works as either a client-server system or a web-based system, as do many of the EMR systems out there today. “Client-server systems are not passe and are often preferred by larger practices or those with multiple offices. But for smaller groups with fewer sources, the same software can be run as an ASP or SaaS, and the user experience is essentially the same.”

Tera Roy, Specialty Director, Ophthalmology at NextGen Healthcare, says that, “With or without stimulus dollars, healthcare is headed to the cloud. Our newest releases are all based in the cloud, like NextGen Mobile, Patient Portal and Health Information Exchange, and we plan to keep introducing more of these Web-driven alternatives. They will play a critical role in breaking down barriers for small practices to achieve the full benefits of automation.”

If cloud-based systems are cheaper to set up, why doesn’t everyone go this route? Mr. Messier points out that, similar to deciding between leasing or purchasing a car, it helps to crunch the numbers. And for many practices that commit to a long-term relationship with their EMR system, there is usually a better return on their investment if they buy the EMR system rather than pay a monthly access fee, with a typical break-even time of about five years.

Here are some pros and cons of cloud-based or web-based EMR systems.



  • Less up-front costs for licensing
  • No server hardware or software to purchase/house/maintain
  • Possibly easier to transition to a different system
  • More cost effective for solo/small group practices
  • Better support
  • Easy to set up hot-site in case of disaster
  • Host companies typically have more sophisticated security measures/data protection
  • Vendor more likely to meet HIPAA regulations than the practice can
  • Onus more on vendor to meet Meaningful Use
  • Good for physicians who are not office-based or travel a lot


  • Customizability limited
  • Latency or lag time accessing information across web/ slower response time
  • Patient information may be compromised if co-mingled with other clients
  • At the mercy of the vendor regarding backups, security
  • More expensive over the long haul
  • Captive client – host controls your data
  • Practice is dead in the water with internet outage
  • May not be viable for rural practices with limited internet options
  • Practice can lose data if vendor goes out of business
  • May be impractical for uploading larger imaging files
  • Bandwidth limited by practice’s internet connection

Peter J Polack is an ophthalmologist who blogs on medical practice management and electronic medical records implementation on Medical Practice Trends.

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  • Martin Young

    You have not mentioned that cloud-based EMR’s like Practice Fusion can draw on other revenue sources and offer services to doctors for free. Doctors who do not want to be exposed to advertisers can pay for the priviledge.

    • Helen Phung

      Thanks, Dr. Young. Practice Fusion is entirely free for providers – no monthly access fee. Electronic Health Record systems like Practice Fusion protect patient data well beyond paper systems at several levels. There are four levels of physical security to even gain access to our servers. We designed our system this way so we would not be susceptible to outages beyond our control. We manage and own all of our entire infrastructure so that it can be backed up in realtime, which enables to us to confidently provide a robust service level agreement (SLA) with our users (99.9 percent uptime) and describe our setup accurately as a “private cloud”.

      Analysis paralysis is a big factor right now because there are just so many EHR vendors competing in the sector. And it is so difficult to get price quotes and demos from most of them – it’s a confusing process for buyers, especially the majority who are looking at health IT for the first time. We encourage our community to reach out to other doctors within our network to get feedback.

  • Dr Sam Girgis

    I work in a New York City hospital system that has multiple hospitals in 5 different boroughs throughout the city. Each hospital has their own EMR, and they are not inter-linked. I can see a cloud based EMR allowing the different hospitals to be able to inter-link their data and EMRs. I am wondering if the VA system’s EMR is client-server or cloud based? I think the country is eventually headed to a universal EMR… similar to the VA system. Whether that system is server-client based or cloud based is yet to be determined.

    Dr Sam Girgis

  • Mary Pat Whaley

    Great coverage of the pros and cons!

    Mary Pat

  • Frank Rezny

    You have very correctly identified the pros and cons of ASP vs locally installed client server regarding costs and relative resource requirements, there are a number of other considerations when looking at remotely hosted data services. There are more delivery methods that simple web browsers for remote data. Many systems will employ Citrix or Terminal Services. Others make use of a rich client. Web based delivery has severe limitations (ya ya ya, we’ve all heard about web 2.0) when compared to TS and rich client. The quality of user experience and efficiency is much greater with the rich client model. Software that is designed specifically for the task provides users with the ability to more effectively slice and dice information to make it easier to spot the important elements for a clinical decision. Web browsers do not offer the flexibility of interactively updated windows displaying realtime information based on the users inputs.
    Terminal services delivery of the rich client functionality has limitations that become frustrating to the user constraining the selection of simple peripherals not the least of which is printers. Terminal services are said to require lower bandwidth making it more appropriate where Internet service availability is sketchy. This, I am increasingly convinced, is not at all true. As we move more imaging into our medical records, higher pixel depth and larger screens the bandwidth edge that terminal services has becomes mythological.

  • MassachusettsPCP

    May I emphasize “who controls the data?” Your charts are often legally owned by the web-based EMR, unlike the WAN/locally installed EMR. Decide you don’t like the web-EMR? Make sure your contract indicates you get those charts back.

  • horseshrink

    I prefer to start at a more basic level. From my recent post on an ONC blog:

    As a life-time geek, avocational web designer, code writer and daily physician EHR user, I do not see how current EHR technologies are mature enough for prime time. Perhaps there’s a hope that pushing this thing off the cliff will force it to fly. Maybe.

    I’ve also come to conclude that the best way to catalyze the EHR industry to create products that “meet individual needs and expectations” is standardization of data.

    Example: the world wide web. Data constructs are standardized sufficiently that users can change browsers at will. The WWW doesn’t have to change it’s data configuration because I changed from Internet Explorer to Opera.

    Unfortunately, when clinicians buy EHR products now, they marry a database structure, for better and for worse. Divorce is too expensive.

    Don’t like your current EHR? Too bad.

    New product cost + data migration cost = prohibitive cost.

    Might as well just dump it all back to paper and move on. After all, a doc can see more patients with a paper chart than an EHR, and paper is cheaper to buy/maintain. It’s also more reliable and easier to use.

    When a clinician can change EHR products as easily as any computer user can change browsers, market competition will unleash the innovation needed to drive quality up and cost down.

    When docs are finally presented with irresistible EHR technologies that make them faster, smarter, safer and more profitable, no federal programs will be needed to carrot/stick them into lining up at the door to buy them.

    Sadly, proof of the EHR industry’s immaturity is the very existence of the federal carrots/sticks in the first place.

  • Scott W. Blevins

    Perhaps its me, but the article seems to be biased towards server-based systems. Based on experience, I would suggest that many aspects of the Server-based EMR compared to Cloud based EMR are often left out of the equation, such as: Server based software vendors charge sometimes just as much or more for their maintenance and upgrade contracts than the monthly per provider cost for Cloud-based EMR. What about IT support cost for server based software? Often times when comparisons are made, the total cost (or, apples to apples) are not taken into account. A huge problem with server based software (particularly, for smaller practices) is the smaller practices do not update, maintain, or back-up their data. It would not be uncommon to find an early EMR adopter, to be using a 2005 version of a software, which does not meet requirements for e-Prescribing, much less “Meaningful Use”. How about 5010 transaction codes sets and ICD-10? Some practices are having to scrap their PM systems or buy new hardware, server, and software just to meet these requirements. With cloud-based updates, there is no additional cost, concern for the practice about needing to perform updates, back-up, security, etc. With the number of changes being imposed by the government for both PM and EHR, and the need to keep up with or meet these requirements it is a “No-Brainer” – The right Cloud-based software wins over Server-based any day . What good is a typical break-even of 5 years, if your Client-based Server is out-of-date tomorrow? The only individuals who would recommend a Client Server product are those vendors who only offer Client-based and the IT (employees or consultants) who need to justify their job.

  • William Halverson

    As much as I like the elegance of the cloud based approach, living in California we know we will lose our network in an earthquake someday. We even know and prepare for the loss of our data center. Every hospital unit has its own downtime PC so we have treatment plans and medications available for the downtime event. I would expect every practice office has some such downtime plan, too? So until the cloud has the ability to keep the important patient data we need for ‘downtime events’ on a local PC somewhere where it can be printed on short notice, I doubt the cloud solution will be that widely adopted.

  • Shawn Bolan

    I think the choice is almost a no-brainer for independent practitioners. They can’t afford the time and money to support their own server software. In order to fulfill MU, the lowest barrier to entry are free cloud-based EMRs such as Practice Fusion.

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