Home Forums Discussions General Discussion Amazing Charts May Be SaaS

Maybe I missed the thread, but I thought there would be a lot more discussion about the possibility of AC in a cloud. Just wondering what others think about Jon's Status Update

Below is a quote from the Update.

Okay with me, as long as we always have the option to host on our own servers. I use a few "cloud" services and they are frequently down for minutes to hours. Not good for a busy practice.

If using the cloud will guarantee uninterrupted speed, I favor it!

The option of a cloud based version of AC makes a lot of sense to me. The key word being "option" (it would certainly not be my choice). There are good reasons to have the program in the cloud, and there are good reasons to have it on our own machines. So long as we get to choose, everyone wins. I think (and hope) that Jon B is saying is that a cloud-based version of the program may be offered to those who choose it.
His post also mentions a "single, turn-key" service which implies that users could sign-up and have appropriate hardware delivered to their offices, open a browser, and begin using the program. I think that concept has a lot of appeal to prospective EMR users who are wary of the knowledge needed to set up their own network, etc., and may not want to deal with many of the IT office issues we all deal with daily. One important factor will be the choice of a knowledgeable, trustworthy, and reliable service provider to handle the product.

Ac's simple SaaSy version of itself I suspect will be attractive to end users who want functionality without infrastucture headaches... those with multiple sites...and those burdened with excessive overhead.

I didnt consider a SAAS solution 3 years ago because i was limited locally to a subpar DSL connection. Today I would certainly try AC in the cloud. My landlord finally upgraded (when HE decided to try Practice Fusion) I now have ridiculous speeds up and down (yup AC tech support called it "ridiculously fast"....yeah we bad...) I use a cloud scheduling software and changed my phones from landline to IP. In 6 months only twice have I come in and oh *&%$ ... no internet connection. My niece smuggly pulled out her iphone and scheduled several patients via 3G, all IP phones were previously set to forward to my cell if no connection. In both cases, internet connection was restored within an hour. My lesson, have a backup plan... a devise suitable to for data input with mobile broadband or wifi can easily keep you going until the more secure connection is re established.

SaaS is liberating. When it works. And fortunately the internet pipelines are getting faster and more reliable. While comparing my landlord's MU wizard on P.Fusion - i found the experience not at all unsettling - hated the pop up ads .. side note - you eventually get over it just like with google or facebook or practically every "free" service on the internet ... you learn to filter the ads so long as they are not too offensive or garish. My loyalties remain with AC but if offering SaaS proves too costly to recoup ... just consider.

Liberating technologies help small businesses. Imagine having off site schedulers ... to extend hours available for pt to schedule and free up day time staff for other tasks - off site document management - all your updox faxes neatly tucked into the chart with flags waiting for you at the beginning of the day - night call or holiday coverage leaving messages attached to patient records - centralized backoffice services for AC users is a simple set up for groups in the cloud.

If security, data ownership, performance and price are "Amazing" I would give it a try.

Agreed. As long as there is still the onsite version.

No way would I opt for a cloud version!!! I worked my behind off learning how to install and service my network!! And there is still so much left to learn. It's like when I did my surgery rotations. The Chairman of the Department's favorite quote was "Being on call only every other night deprived us of the opportunity to see and treat more cases". These young whipper-snappers have it too easy as it is. Simplicity be damned!!!

There is nothing simple about the cloud. Anyone who believes so is either easily fooled or enjoys those blinders they are wearing. Furthermore, I don't think everyone is aware of what Jon Bertman is really saying in his post.

I'll have a more in-depth post later. I'm busy attempting to stop myself from causing catastrophic bodily and psychological harm to an accountant right now.

JamesNT

Since my internet went down yesterday, I am very leary of cloud solutions. Yes, you could have a backup internet provider but at what cost?

One thing it would do for me is the ability to unify two practices. I would need to merge the two databases, but, I am not willing to make that jump for now.

We've been providing "AC in the Cloud" for seven months now, and I have Gino to thank for provoking the thought during dinner @ ACUC 2010. The technology then was more enterprise focused, and had not matured to where it is now, so there were several things to overcome, and the most challenging has been getting the pricing to scale to what our advisory group of Doctors see as the key element.

Gino, JBS, and others encouraged me to talk to folks about the possibilities at ACUC 2011, and JB was kind enough to ask me to spend some time with him and another Doc to talk through how it could be done.

Lori and I so enjoy the folks that we have met through the AC user community, we chose to invest the time and capital in June of last year to implement AC in the cloud. We demonstrated the platform to JB and some of the AC folks a few weeks later, and went into production in July of last year.

One of our inspirations was a Doc that wanted to use AC across both her private practice, and patients she saw in a clinic setting. Using our hosted platform and Updox, the practice is consolidating document flow, multiple fax numbers, and giving her peace-of-mind.

In July we did a group demo for some of the Doctors on the board who had expressed interest, and that volunteer focus group input drove our next generation implementation.

We have learned lots of tricks and twists along the way, and that is why we 'soft-rolled' the offering. We now know which lab apps will lock up a 64bit machine, some of the interesting things that AC can do after server patching, and several other tidbits you gather along the way.

It sounds like JB and AC are focused on a different offering in the marketplace, and we welcome them.

I love finding elegant solutions, and based on another user request, we will be offering a disaster recovery solution soon so that you can fail-over to the 'cloud', keep your practice running, and eventually have your AC server restored to your hardware, or even replacement hardware shipped to you.

A cloud solution is not a good fit for everyone, but it is advantageous for certain practices, groups, and circumstances.

So where is AC in the Cloud, or is this what you mean by soft-rolled?

In the world of IT, cloud computing is just another word for outsourcing. And what everyone needs to understand is that we have done this before. We have seen this before.

In the 1990's, outsourcing was in the form of companies firing their own in-house IT staff and allowing another company to send their people in to run the show. In some cases, if the outsourcing company did not have staff in that area, the customer company would fire their staff and the outsourcing company would then hire them at reduced wages and benefits. So, quite literally, you would go to the same place and do the same job but someone else signed your paycheck and you made less. Either way the customer company now had a staff that was far less responsive to their needs - or even downright contemptuous of them.

In 2003 or so outsourcing was called "offshoring" and everyone sent everything to India. Most of you have been around at least that long so I shouldn't have to explain how this worked out.

Today, we have cloud computing. Same tactic (e.g. "Give your stuff to us and we'll run it for you!") different name. Before jumping headlong into the cloud, there are some points to consider:

1. Cost. For most of the people I have seen on this forum, you are fed up because IT seems to cost so much. There are three possibilites: First, you have an unrealistic grasp on what IT should cost. Second, your IT support charges to much. And third, you overspent drastically on hardware/software on initial purchase. Will the cloud save you money? Very possible. But on the other hand, wouldn't you be better off to purchase equipment that is more to your needs? A $3,000 Dell server can run AC for a 3 doc practice and 2 dozen employees quite easily. At that point, you may as well get SBS 2011 along with Exchange and have everything. And that $3,000 server should last you 4 - 5 years. What will AC in the cloud cost every month? How much money will this really save? What about your other servers (if you have any)?

2. Leverage. My boss knows how hard I am working to keep his stuff going. If I can't keep our three terminal servers, Exchange 2010 server, domain controller, storage server, sharepoint server, SQL Server, and web server going to our client's expectations then I'm looking down the mouth of unemployement. How much leverage do you have over the cloud company? Most likely, AC will sub-contract out the job of actually hosting the servers to some third-party. If, heaven forbid, something goes wrong, will that cloud provider be able to bring you up right away? If that cloud provider has 4 fortune 500 companies and several little solodocmom's or Bert's, who are they going to bring back up first? What would you do if you were the cloud guy?

3. Service Level Agreement. Will you have a SLA with the cloud guy whereby they guarantee you that you are not down more than x amount of time or they pay you money to help you recover your losses? If you are down for 2 days, for example, can you handle that? Say you are paying the cloud guy $500 a month to host your stuff. If you are down two days in a 31 day month, that means you get refunded $32.25. Will that cover your losses? What about the overtime you'll have to pay to get data entry caught up?

4. Agility. Cloud guys trot agility as their ability to bring more processors/servers online for your needs on-demand then scale them back as needed. The agility I discuss is the agility for you to get on or off the cloud as you need too. If you decide to go with a cloud provider, how much downtime and work is involved in getting your stuff to them? How about the reverse. What if you want your stuff back? Will the cloud provider be accomodating? Will it be as simple as buying a server and the cloud guys sending you your AC database on a DVD? How much downtime is involved to make this transition? Cost?

5. Say you want to leave AC altogether because the company is heading in a direction you simply cannot follow. It could happen - notice how some are just up in arms about the whole PM thing. If your database is sitting in some datacenter 2 - 3 time zones away, how do you get your data back? With AC sitting in your office on your own server, you can always hire someone like me to export your stuff from the SQL Server database for you. However, if your data is on somoene else's server, you are completely at their mercy.

6. Competence. Will the cloud provider have a few awesome people like Indy working for them, or a bunch of n00bs they got on the cheap?

These are all things to think about. For some of you, I am convinced the cloud is the way to go. You can't find good IT support and you can't do it yourself, so you need someone. For those of you who do have good IT support or you have a Bert or Indy on your staff, I'm not so sure the cloud is a good idea.

It's all up to you to decide. But ask the hard questions and be honest about the answers.

As for Jonathan Bertman's post that said this:

Allow me to provide my interpretation:

JamesNT

Great post, James. Very detailed yet easy to read article.

First off, great post, James. Very thorough and well-versed. As long as it remains an option and not a requirement. Some other pointers. When you start using CloudServices, you need a decent ISP. A basic T1 line is ~300-400 dollars.
Some internet plans have data caps like Comcast which means you have a limit to how much you can access AC. Also, this would essentially kill Imported Items as you'd have to upload everything into the cloud, we would have to focus on compression and optimization so a web interface doesn't slow us down. I.e. if you took a picture of a patient and wanted to put it in their chart, you'd have to upload it. I'm fine with this as long as it's not required. You're also right about people not wanting to spend money on the hardware when that's their entire practice sitting on it. I'd never use an off-the-shelf desktop for my server.

James,
Thanks for taking the time to respond thoroughly. The key, for me, is about making this an option rather than a requirement. I simply find it hard to believe that Jon B would reverse the entire trend of his company, and require a cloud-based program. Your final interpretation of what he is saying seems cynical to me; Jon B has known all along that it is a challenge to deal with all of this disparate hardware, cobbled together networks, and relatively IT-challenged docs. Sure, a cloud solution would be far easier for him and for the company, but I don't believe that he will insist on one.
What I want to remind you (and the other technically minded people here) is that the average physician is feeling maximally stressed by the concept of going to an EMR. Despite pretty major incentives, many have held off. Sure, many have done it...and many of those are tremendously unhappy and are looking to change. Most small practice docs don't employee a Bert or Indy...they don't even know of one. Their ideal is to order a product and start using it the next week, with minimal disruption as they continue practicing medicine. To me, just as AC needs a PM to stay competitive, they also need a more effortless solution, and that means one that is cloud-based.
I think the choice MUST involve picking a provider that you can trust. You could work with some faceless corporation that puts you at the bottom of the pecking order and subject to all of the indignities you describe. (Not to mention that they could get rich selling your data a la Practice Fusion). If it were me, I would look for someone I trusted (like Indy) to set this up so that I could feel confident that there was a commitment to ME as a small but important customer. Someone who I could trust to keep an eye on my interests and MY data. Not some faceless, shapeless "cloud", but a person who makes my practice of medicine easier.

I wish JB would clarify if the direction of AC is going cloud-based, or if there will remain option to be networked on-site in future versions of AC.

A potential benefit of AC being cloud based is that it should make upgrades seemless. After reading many of the various upgrade hassles over the past few years, having a more seemless upgrade approach would make it more efficient for us Doc's and AC support.
I do however like my server based network and probably wouldn't change to cloud based unless there was no other option, and then, I would look for another option.

I would definitely look for another option if this became only cloud based. Internet is nearly 100% reliable, but the only time it's ever down is when we NEED it to be up. What about that? What if one doesn't have internet up/download speeds that a good enough to handle the massive data exchange, especially with importing image files and patient photos? What if the host server is down?

I want things to be in my control as much as possible, keeping the variables of things that are out of my control to a minimum. That's why I don't want cloud based EHR.

Agreed. First, it means that you don't have to do a thing; you just log in one day and the latest update is installed.
In addition, there was some discussion of this at the Tahoe meeting during the period where many users were unsure about whether to upgrade to the most current version because there were so many problems with it. Under the right circumstances, you might let the provider "vet" the new version and make the call as to when the upgrade should be undertaken. If your cloud version is maintained by a knowledgeable, trusted provider (again, I use Indy as an example), you might let them decide (not even necessarily AC) when it is appropriate to upgrade.

SaaS sounds interesting for many of the reasons given. In my experience, however, cloud computing isn't mature enough for "mission critical" software services as yet, so I would always want the possibility to cache a portion of the database on my local network to allow me to work at some basic level when SaaS goes down.

There is not only the possibility of an extended interruption of the local internet connection as was mentioned above -- major online providers are regularly down. I have used Google Docs for a few years now, and there are infrequent but often prolonged service interruptions (in spite of Google's massive server redundancy). As many Blackberry users are aware, RIM is reporting yet another BB email failure since yesterday. And as Jon posted recently, the Practice Fusion message boards are full of posts about SaaS outages.

Don't even get me started about security of patient records. According to news reports, the hacker group Anonymous managed to record a confidential internet communication between law enforcement bodies in the US and the UK.

There are a lot of issues to solve.

Good post, John.

I think I and maybe we have always been fascinated by a dual system of a cloud solution downloaded every night to a hardware and networked solution.

I am just going to throw a point out there and see where everyone runs with it. I agree with what JB and I think Jon has posted about how it is difficult for AC to provide support when it may involve AC but many times it involves the network. Anytime a program involves a database which resides on a central computer whether P2P or Client/Server, there are going to be issues. There will be issues with the computer savvy, but there will definitely be issues with those who are not. Permissions and DNS, DNS, DNS are going to play havoc with connection issues of a network database system. And, for those who don't know what DNS is, you have proven my point. And, I don't mean that in a mean way. I have contact the Guardian Angels three times in eight years, two for ePrescribe NewCrop issues and one for a printing issue.

Now throw in as JB says different OS, 32-bit vs 64-bit, Dell vs Gateway, wireless vs wired, Cat5 vs Cat5e vs Cat6, P2P vs server oriented and at least three different versions at the same time. While it isn't always a networking issue, I can recall during the time when things were a bit bleak many users stating it had to be SQL Server or AC, when it was clear that it was not.

How to solve this issue? One way is simply for AC to state when it is not an AC issue. If I call Microsoft because one of my computers keeps blue screening, they will just say to call Lenovo. And, this is a company which charges $259 per incident. Of course some times it is difficult to know when it is AC vs network.

You could charge more for support and have AC cover everything but that doesn't sound doable as how would you know what the issue is.

Many EMR companies (and I know as I looked at many) make in mandatory that you have $10,000 of support and training right up front. That is clearly a money-making ploy.

But one has to wonder, given what someone posted above about docs setting up networks, if AC shouldn't offer a package whereby they come out, set up a network using their hardware and do training for a certain price, which would cover three years of network support. Of course, that would mean more support but, hopefully, they would be covered by those users who opted for this.

I have not had connection issues with AC, and that is due to not having connection issues with the server, but when I do have issues with my network usually due to DNS, one email to my friend who has 20 years of networking experience as a Microsoft Certified Engineer and Networking specialist and it is usually resolved within a day.

But, after all this, it really comes down to hiring an actual IT Microsoft certified specialist to come out and go over your entire system, recommend changes and know your system so they can make changes over the phone or remotely.

The doctor I leased from recently bought five new computers and a server, hired a local company, and they installed the entire thing in less in an afternoon including eMDs without ever having seen it.

I think the issue of upgrades, based on the past, would be extremely difficult. And, I don't know how one and a group of people would know who would want one upgrade. I think to wake up on day to v6 with all of its problems would be an issue. Of course, there would be less since it would be on one server and hopefully tested over and over. I am used to having the choice, but this is because I have never used SaaS programs.

As the CMIO of our hospital, I am kept apprised of the upgrade process, timelines and downtimes.
To say that it is transparent to the end user would be an attempt to sell you a bridge in New York.
We have transitioned from pure SaaS to more control locally, but remain at the mercy of upgrade and downtime schedules that are driven by the corporate vendor. They have to consider other customers needs accross several time zones. .
The are upsides as well as down sides, to this model, so it become an individual decision.
A change from local server to hosted by vendor occured with the hospital dialysis facility. Now that became a real pain in the butt, because we had been able to query the SQL server directly to get QA data, now we have to stand in line and pay for the vendor to get us CSV data files.
Personally, I chose AC in part because it my my network and my server, and avoided the eCW penetration here because the most cost effective offering (but 10x the cost of AC) because it was SaaS type.

Over the years, we have had several experiences with outside entities holding our data, and relying on employees that I did not have the power to hire and fire. Let's just say all these experiences were bad. If AC wants to do what some other companies have done, and give exact specifications as to equipment that is found to work seamlessly and then be willing to support that, that is not an irrational approach. They might even be able to get a package deal from Dell or whomever. Other users that think they know better can do it their own way, and they are on their own. I am personally happier paying for good IT support to customize our system, but I do sympathize with AC when they get a call that AC is not working correctly on a system that the client has built out of seemingly random components, and the client basically says "now, what are you going to do about it?"

What we do, and what I suspect JBS may be referring to, is how we do upgrades for our clients; local or hosted. We notify clients when we have tested an upgrade or beta, and based on how their practice uses AC, their setup, their appetite for "new and shiny", we have a discussion/recommendation on whether it is a good time for them to upgrade, and then we schedule the upgrade for off-hours. It either goes fine [or not], and they either have the new version to run with, or we roll-back off-hours and they have the old version they were running when they left the office. It is their practice, their call; we work to serve that practice well and "Make it so."

We bill services, but ultimately we are in the solutions business; Technology is a tool towards that end. It is as seamless as we can make it once the Doc decides they want the upgrade. They may try it over a weekend, and decide they want to roll-back instead.

Among our clients I think we have almost ever Release and Beta between 5.0.26 and 6.1.2. We have our own internal perspective about their relative merits and blemishes, but our job is to keep the trains running.

Taking a break from something else, so working backwards

It will be available within 60 days. We have been told that we go too far out of our way to not talk about what we do, so let me strike a middle ground and just say that because of a client request, we have come up with a Disaster Recovery/Fault Tolerant solution that allows a practice to have a Hosted/Local AC "server", as well as a Local/Remote backup of the "server" that includes DB and Imported Items/Directory copy. In the event that one goes down, you have the other as of the last backup.

We can even move that install onto different hardware, ship it to the client while they continue to run on their backup system (Local/Remote), then sync once the new hardware is in-place. It is obviously not free, but it is the product of adapting Enterprise technology to what a independent practice needs to operate in the midst of an outage of some sort.

Indy,

Thanks for your time on a Saturday. When you say upgrade a client off hours, what does that entail? Not specifically but in general. I am just envisioning 1,000 clients out of 4500+ wishing to upgrade off hours, then 75 wanting to go back, etc. That sounds like a nightmare.

Less than a year after "going live" with a CPOE/PowerChart system hosted by Cerner, one of our local hospital systems (5 hospitals totaling several thousand beds and dozens of local radiology, therapy and office affiliates) went completely down, no data, no records, nothing for days. Needless to say, it was a mess and no one even pretended that it didn't affect patient care. After it was all over, the hospital IT department and Cerner made a big deal over the fact "no data was lost".

They just don't get it.

Thanks for all the great discussion. First, let me allay any concern that we are migrating Amazing Charts in any way from our good old #1 rated EHR to some cold slow limited browser solution, selling data to the highest bidder. That would be Amazing Charts without its usability and without its soul, and it?s not what we?re about.

There are, however, a growing number of people requiring a hosted version of Amazing Charts. Our software delivered to them over the Internet, without them having to install and maintain anything other than a basic network through which they can access the Internet. Makes sense, and as Indy noted, he and others have already been providing this service to some clients, who have reported to us that its been a life-saver.

During our V6.0 rollout, we quickly became aware than nearly 15% of practices were experiencing performance issues. 15% doesn?t seem like a very big percentage, but try telling that to one of the 15% (aka 750 practices) that experienced slow-downs. (This issue is currently solved in V6.1 Beta.)

Anyway, not something we want to re-experience (which is one reason V7 will be ready when it is ready ? and not before). In any case, the idea of hosting got fast-tracked as we identified one reason for the performance issues: there is wide variability in the way clients have deployed Amazing Charts. While medical practices tend to flow essentially the same way, there is a tremendous variation in the hardware, software, and configurations of various practices. (And yes, as JamesNT points out, we find ourselves spending much time troubleshooting and arguing the merits of these weirdly configured systems with the weirdly configured IT people who designed them.)

The solution? Exactly as Indy, JamesNT, and others here already have done: provide an option to clients wishing for a solution that they can access over the Internet, and not have to worry about how Amazing Charts is set up or configured on local machines.

Yet as JBS noted, Amazing Charts needs to choose a trustworthy and reliable service provider who is capable of providing an always up, redundant, and robust system. Although we found a number of these folks, we could not find any ability within their pricing models to allow for the other requirements of being an Amazing Charts product or service: it needs to be easy to get started, free to try, and affordable to buy ? and without requiring any long-term commitment. This is what Amazing Charts in the Cloud can offer.




Within the next few weeks, we should have a ?sandbox? in which you can experience the Amazing Charts in the Cloud experience.

Pricing
The Amazing Charts in the Cloud hosting service is an additional charge on top of Amazing Charts pricing, and is by user, or seat-based. This design is due to Microsoft licensing requirements (there is a reason Microsoft made $70 Billion last year), as well as our goal to make this as affordable as possible for both solo and groups of various sizes.




More on Amazing Charts in the Cloud coming soon...

In the meantime, please let us know if you would be interested in beta testing Amazing Charts in the Cloud - please specify that this is what you would like to do in the comment section of the submission form.

Jon,
Thanks for the clarification. We knew you wouldn't force us into this, but it is still good to have any concerns nipped in the bud.
I am sure the pricing will be much more fully explained in the future, but I take the seat price to be per month, and per user. So, for example, a doc with 2 staffers = 3 users (could be more people, but only 3 on at a time) and that would be $300/month, right?

Right. In that case, somebody would likely buy a 5 pack for $300/month per practice, and have a few extras.

At this point, I count six people who are on this board instead of (or in addition to) watching the Super Bowl. And some are from New England. Not naming any names.

thank you for clarifying.

Me...I'm multitasking.

Wow, talk about your hijacking, lol.

The concept of a cloud version is appealing to me; I have one question / problem, which relates to very large imported items and how quickly they would load.

Before I started using AC about a year ago, I had my own sort of EMR, which was basically one PDF file per patient, with all notes, reports etc in it, and with bookmarks that allowed for easy navigation.

I have kept the original PDF for each patient in AC, and whenever I scan a report or anything else, I put it into that single PDF (using Acrobat), and maintain the bookmark structure. I do the same for new patients. It makes for very easy navigation, and I end up with just one imported item per patient, the patient PDF file. I much prefer this approach to having a ton of imported files, both because of easy navigation within the file and because it gives me a single file that can be sent if I need to forward the chart to someone.

These PDF files can get very large, often in the 10's of MBs, sometimes 100 MB or more. Opening these big PDF's on my office network has never been a problem, whether they are opened on the main server computer or on another computer on the network. Opening speed has always been fine. But what will happen if these files are on the cloud? Will they be locally cached, somehow, or will the entire file have to be transferred via the Internet each time? If so, there could be major speed issues.

Any thoughts?

Michael Jacobson
New York

I've been testing this, and it seems that imported items actually open faster in the hosted environment. I'll be sure we test larger pdfs too. Thanks.

Thank you!

Michael Jacobson

Just because they open fast, doesn't mean they'll upload fast. Are there going to be any bandwidth caps?

I am still having trouble with Imported Items opening slowly but only on one machine, 64 bit W7. The "fix" that we thought we had in Tahoe did not carry on once I got home. But it may be because of a "wacky" network thing.