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DOCtalk by Dr. Gregg 3/18/12

March 18, 2012 News 7 Comments

Between Heaven and Earth


In the main HIT arena …weighing in at a hefty XX pounds …with more paper system knockouts over recent decades than current scorers have been able to track …the current world champ for health information technology …. LOCAL ”HEAVYWEIGHT” HOSTI-N-N-N-N-N-N-G!!!!

And, the challenger …tipping the scales at ….well, no one’s really sure how much a cloud weighs …with a nearly perfect record in just over decade (or just under depending on who’s keeping the scorecard) …the number one contender … CLOUD ”FLOAT LIKE A BUTTERFLY” COMPUTIN-N-N-N-N-N-G!!!!


In a fun verbal match the other day, I was sparring with one of my mostest favoritest ever tech support gurus over the value of local hosting for HIT versus the developing wave (some might say tsunami) of cloud-based services and tools.

His opening shot was that cloud-based services were great for certain things, but not so much in the world of health.

I countered that cloud-ed services and tools were so end user friendly, especially for us onesy-twosy docs, as they’re much easier on our limited tech support capacities and paycheck-to-paycheck incomes.

His shot to my right kidney was that if your Internet access goes down, you’re hosed.

I covered with my right elbow and the fact that redundant Internet access avenues could almost always allow a quick reconnect to Web resources.

Starting a ringing that continues in my left ear today, he connected with an uppercutting, “Even though cloud server farms are redundant and backup generators with stored fuel are on hand to last for weeks, it has occurred that cloud services have gone dark, even for some techno-giants.” He landed with his “Complex systems have complex failures; that’s cloud computing” quote.

I tried to protect my head with a rising left and a “Being prepared for when the cloud REALLY fails” reference along with the fact that there are clouds that can protect clouds, like Backupify, (though it isn’t designed to do any of the cloud chores we were brawling about).

He shot a roundhouse from the right. “It may be OK for some companies to be down for a bit, but are you OK with the possibility that you could go down? I mean, it sounds good for the vendor to say ‘We have a 99.9% up time,’ right? But, that small percent becomes humongous if it happens to you in the middle of a busy practice. What if you have no access to any patient data for an hour, two, maybe a day or two?”

I gave him a fairly feeble body blow with my, “Well, we just pull out the old pencils and paper and struggle on the old-fashioned way for a bit. We still remember how to write”

Jab, jab…”That may be OK for you as you’re just one guy, but what if you had several or dozens of providers? If the disconnect lasted for any length of time, like with Microsoft’s Azure failure last month, that could lead to a whole heap of data re-entry and a whole lot of ‘best guess’ health provision with clinicians unable to access relevant patient data during those interim pen-and-paper patient visits.”

Bob, weave, duck and cover…”I guess I can’t answer for everybody, but from the cost and upkeep involved with local hosting, it’s gotta be easier and more cost-efficient to live life in the cloud. Sure, I do really like knowing I have my patients’ data right here in my office, but it’s not as if I haven’t had our own server troubles. I mean, we’ve had downtime, too. ”


I had to get back to patients, so the call, and the bout, ended. Judges scored it 10-9, 9-10, 10-10: a draw.


However, it led me to an idea, probably springing from my ever-growing “app me, baby” orientation: Why couldn’t there be a middle ground, something between the cloud and the local host? Why couldn’t there be an app that would, if my cloud turned dark or Internet connection failed, allow me to continue to at least enter patient health and PM data into a local digital barebones skeleton? That local app could allow the temporary, locally-stored data to be extracted and directed into the correct slots in the real system once the Internet was back or the cloud had again become accessible (i.e., white and fluffy)…you know, without the pen-and-paper intermediary.

Sure, access to historical patient data might be temporarily unavailable, but back in the day I never put off a patient when their paper chart got misplaced. And, it wouldn’t have to be completely seamless; it might take a little personnel time to get the data swapped over. But, it would make it far less cumbersome than a paper-based backtrack. Such a local app could easily minimize the disruption to seeing patients, allow ongoing digital data entry, and facilitate data reconnect thus enabling the advantages of, and minimizing one of the objections to, the cloud for us little guys – maybe even for bigger folks, too.

This could be a real haymaker punch for cloud-based EHRs. Something between the cloud and the local host. Something between heaven and earth.

From the trenches…

(PS – I understand MediNotes used to have something similar, but that’s sort of moot, eh?)

“Sure, there have been injuries and deaths in boxing – but none of them serious.” – Alan Minter

Dr. Gregg Alexander, a grunt in the trenches pediatrician at Madison Pediatrics, is Chief Medical Officer for Health Nuts Media, directs the Pediatric Office of the Future exhibit for the American Academy of Pediatrics, and sits on the board of directors of the Ohio Health Information Partnership (OHIP).

Comments 7
  • What happens when your cloud _company_ goes down? Not the cloud, but the company itself?

    Or if they don’t want to play nice? Or go out of business? Need me to cite examples?

    Cloud computing benefits the vendors more than the doctors. It makes it that much harder to escape. The IT overhead of locally hosted solutions is exaggerated, imo.

  • Yes… what an elegant solution, a “local barebones skeleton” is exactly what I was thinking, it would give you a local capability for data entry and access and cloud based storage. And I was also thinking MediNotes, yes they had a “satelite” capability that allowed data entry at a remote location and the ability to merge that data back into the golden database afterwards.

    We did something similar to this years ago with Lytec Medical (though we moved the database from one location to another rather than merging it), we collaborated with Lytec to build a scaled down installation of Lytec which could be used at a remote location and then we had a utility that would move the data to the main office location so that the billers could work with it after hours.


  • Well said, Dr. Gregg. I couldn’t help but think of that old saw “perfection is the enemy of good enough” or something like that! If we waited until everything was perfect, we’d never get anything done. But then, there will always be somebody who focuses on the glass as half-empty, even if it’s it 0.01% downtime. Carry on! Take your best shot now.

  • Take a look at what Gmail is doing with HTML5 for the offline access you’re talking about. You can do your Gmail even without a connection and then when the connection comes back it syncs everything up. At least that’s the idea.

    Interestingly, Google was doing this with its Google Gears product a while back as well, but it had its own issues. The HTML5 replacement to Google Gears is still a work in progress, but they’re working on doing the ideal solution that you describe for email. So, it’s not too far fetched to say that it could be done for EHR. The only problem is that given the current EHR environment and the complexity to deploy such a solution, it’s unlikely to happen soon.

  • Dr. Gregg,
    Great post, I fondly recall many debates like the one you described when I was a “favoritest ever tech support gurus”…

    I think it is fair to note that technology has existed for years to do just what you are looking for. I like to refer to this as “sometimes connected” technology – essentially technology that is designed to work if you are online or offline then synchronize automatically if necessary. Sure it took the M$ guys years to get it right with Outlook but this is a perfect example of a system that just works regardless of if the internet is there and takes care of the synch’ing when the connection comes back without doing anything. Sounds similar to the google is doing with gmail and HTML5 for offline access.

    Although the industry we are in is slightly different than the EMR space it is also under pressure to “get to the cloud”. I spend a significant amount of time debating, defending, and educating on the value of medical imaging or clinical content management hosted vs. cloud based. I am fully in support of a strategy like you outline, we often refer to it as the “Hybrid model”, essentially a system that is onsite and operates onsite, backs up and synchronizes to the cloud (so the cloud could be used if the onsite system fails) but the onsite system is the primary system of use unless there is failure. The cloud based system is a fully redundant and scaled solution that could replace the onsite but is really only present from a business continuance perspective.

    Keep up the great work!

  • To set the record, their are time Cloud hosted servers and applications are a good thing – but not the always best for EMR.

    With EMR. You substitute some of the maintenance costs for inhouse IT by having to purchase and pay for a 2nd internet connection and higher end router. If you dont think you need a 2nd internet line when using cloud based hosted solutions, you will realize that you indeed do when the internet goes down during the day you are seeing 40 patients.

    It is amazing to me that the industry and physicians see Cloud based servers as LESS EXPENSIVE than local servers. It simply is not the case in my expereience.

    Physicians often view it cheaper because it is a monthly fee for service. Inhouse servers are an asset purchase – upfront cost, that can also be spread out over several months or years via leasing or loans or credit card 0% offers.

    Physicians need to have their accountant or trusted financial advisor do the comparison of the TOTAL COST OF OWNERSHIP for each over a 3-5 year period and then realized the true cost of cloud vs in-house systems.

    Most EMR vendors provide specs out there for servers that are overkill – I often have to beat up the SW vendor into conceding that their specs a simply set to accomodate their largest conceivable installation. The other reason is that they WANT cloud based customers because that gives them much, more CONTROL and REVENUE

    EMR Var

  • To the point of are you ok with the possibility the cloud could go down even if there is 99.99% up time. What are you going to do then?

    Let me ask you this, what are you going to do if there is a possibility that there is a fire in your office and it burns down?

    Same concept, just because bad things CAN happen in RARE instances doesn’t invalidate the concept or the ability for a solution to better help a practice..

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