Internet connectivity and the future of EMRs

Increasingly, physicians are considering moving their practices from paper to an Electronic Health Record (EHR) platform. Many factors weigh in this trend – advances in technology making such EHR tools more usable; a higher profile (and therefore an increased awareness) of EHRs seen in trade shows and medical conferences; and government incentives put in place by the 2009 ARRA/HITECH act giving physicians up to $44,000 for “meaningful use of certified EHRs.”

Most practices are still using paper charting – though some processes, such as billing and scheduling, are frequently done electronically, even by small practices. Not surprisingly, EHR vendors are stepping up their competition, trying to sign up as many physician practices as possible in time for the 2011 availability of Meaningful Use funding. For some vendors, whose products are based on a local in-clinic installation requiring on-site personnel in order to get things started, the backlog has grown to several months.

One of the differentiating options between different EHRs is whether they are locally-installed (referred to as “legacy client/server” systems), or are hosted and accessed via Internet connectivity. An objection raised by vendors who offer locally-installed legacy systems is that “you don’t want to have to rely on the Internet,” implying that the Internet is unreliable, slow and prone to failure.

As we have mentioned in numerous articles in this blog, locally-installed systems have many more points of potential failure (as well as potentials for security breaches) than an Internet-based EHR. With a fully-Internet-based EHR (such as Practice Fusion), the main critical point of failure is Internet connectivity. So the question is a valid one: what is the future of Internet connectivity, and how fast of an Internet connection is needed in order to use a full-fledged web-based EHR?

The National Broadband Plan
One of the campaign pledges of the Obama administration was to build a national broadband infrastructure in the U.S., such that everyone everywhere had access to the Internet. This was seen as an important piece for the economy, as well as health care specifically. The Federal Communications Commission (FCC) has been tasked with building this, and the National Broadband Plan specifically addresses the need for such a national infrastructure in healthcare.

Broadband access in the U.S. is quite high in most regions, with remote and rural locations having the lowest availability – a national broadband map illustrates this nicely.

For physician practices, the cost of Internet access is a “cost of doing business,” like telephones and other utilities. But the speed of Internet needed will determine the cost, and finding the minimum speed required to run an EHR will impact a physician’s budget. Granted that, given the FCC’s intent to make broadband access ubiquitous, reliable and inexpensive, the cost of a given connection speed is likely to come down over the next several years. However, “how much bandwidth to buy” is still a consideration facing EHR-using medical practices.

The amount of bandwidth needed is a function of how many users a clinic anticipates needing Internet access simultaneously, as well as technical elements of how an EHR is built. For instance, by design, Practice Fusion is built in a way that minimizes Internet traffic when someone is using the product, and therefore the experience rivals what one sees with locally-installed applications – we have seen that users having as low as a 512K DSL Internet access have been able to use Practice Fusion without much difficulty. More commonly, commercial T1 service, or cable-Internet, are used. In-office wireless has not been a rate-limiting step either, and even use of cell-phone-based 3G connectivity has been adequate to run Practice Fusion.

Medical imaging
The biggest demands on bandwidth (and therefore, the responsiveness of the experience) are with images. Medical images – such x-rays – often are digitally stored in huge files (an MRI scan may consume many gigabytes of data, and files up to a terabyte have been seen with some medical studies). And therefore the technology to access these files is challenged by bandwidth concerns. Viewing an image can be done in a way that only downloads the detail to the appropriate level of zoom that you are using – similar to how Google Earth works. And numerous medical-imaging vendors offer viewers that are quite nice and consume a minimum amount of bandwidth (Practice Fusion is engaged with several of them currently).

On the other hand, uploading a medical image can be quite bandwidth-intensive. A local digital medical-imaging device (like a CT scanner in a hospital, or a digital x-ray machine in an orthopedist’s office, or an ultrasound device in an obstetrician’s office) creates the files, and then needs to upload the entire file to a web-hosting store in order that other physicians in their offices outside of the imaging center can see them. Sometimes a large center, like a hospital, may wish to keep all their own digital images, and simply allow viewer access by outside physicians’ EHRs through a local linkage. Others, like ambulatory orthopedics practices, may want to upload their files to a web-hosting service, and thus have their ow
n (or other referring physicians) EHRs connect to that web-hosting service for viewing.

However, uploading is only a need for a small number of centers, and the bandwidth needed by them would need to be higher (again, a business T1 line can suffice, though the upload may need to be done in overnight batches). But for physicians – especially the small ambulatory practices that have embraced web-based EHRs like Practice Fusion – medical imaging viewing is really the only concern here. And if you have enough bandwidth to use Google Earth satisfactorily, then you have enough bandwidth to do medical image viewing.

Putting it all together
The “objection” raised by some EHR vendors that the Internet should not be relied upon is mainly just sales talk. A robust, reliable, and inexpensive broadband Internet is a national priority, and the FCC is working hard on its National Broadband Plan.

EHR vendors that are entirely Internet-based, such as Practice Fusion, place a great deal of attention making sure that the technology used is one that results in an experience rivaling locally-installed systems (sort of like making a car that is high-performance, but also fuel-efficient). The real decision points a physician should make when choosing an EHR system should be more around product features, Meaningful Use certification, ease-of-deployment, and (of course) cost.

Robert Rowley, MD
Chief Medical Officer
Practice Fusion EMR