Internet Brownout Exposes Risk of Cloud-Based EHRs

August 22, 2014

The Internet cracked a bit under its own burgeoning weight last week, and as a result, internist Erik Ilyayev, MD, in Flushing, New York, could not access his cloud-based electronic health record (EHR) system for an entire day.

"Why can't I log in?" Dr. Ilyayev wrote in an angry post on the Facebook page of Practice Fusion, his EHR vendor. "What do I tell the patients who are in the office now?"

Other Practice Fusion customers experiencing downtime asked the same questions. The answers are not comforting for physicians who increasingly use Web-based software for patient care, as well as billing and collection. Abetted by the proliferation of smartphones and other mobile devices, the complexity of the Internet's network map, technically known as a routing table, exceeded the capacity of older routers used by some data centers and Internet Service Providers (ISPs) to deliver bits and bytes to their destination.

The result was a global Internet "brownout" that prevented many computer users from logging onto Web sites such as eBay and Amazon, as well as Practice Fusion. Reports of log-in problems started to pop up on the vendor's Facebook page on the morning of August 12. Early that afternoon, the company blamed the snafu on a "third-party provider" that, together with Practice Fusion, was "working urgently to solve the problem." Some medical practices that day reported they were finally able to access their patient records, but log-in difficulties persisted for other customers through August 13.

Cries of distress piled up on the vendor's Facebook page. "I am still unable to log in!!" wrote one customer. "I have patients coming in today and I have no idea who, what time, or what their co-pay is!!!"

Dr. Ilyayev told Medscape Medical News that the loss of his Practice Fusion charts on August 12 forced him to cancel an entire day's worth of patient visits. "It was a financial loss to the practice," he said. However, he credits the EHR vendor with solving the problem as fast as it did. "The outage is understandable," he said.

Practice Fusion executives declined to be interviewed by Medscape Medical News, but a company spokeswoman did issue a statement. Practice Fusion, she said, traced its laggard log-ins to QTS, its third-party data center provider. Networking equipment problems at QTS, she said, "meant that our customers were unable to connect to our EHR and related Internet Service Providers." Hardware upgrades at QTS finally gave physicians access to their patient charts again.

"We believe the larger Internet brown-out issues have not been fully felt nor resolved," the spokeswoman said. "We are monitoring the situation closely with QTS to address any other issues that may arise."

Another company spokesperson told the Wall Street Journal that roughly 1 in 3 users of Practice Fusion experienced difficulty logging in.

The Advantages of Redundant Systems

The log-in problems happened to an EHR vendor normally accustomed to happy customers. One reason for smiles has been a free product: Practice Fusion does not charge physicians anything because it makes its money off advertising.

However, Practice Fusion is admired not just by cheapskates. Its program tied with Amazing Charts for second place among the top-rated EHRs in a Medscape Business of Medicine survey of more than 19,000 physicians this year, posting a 3.7 on a scale of 1 to 5. It ranked second in terms of ease of use (3.9) and, significantly, reliability (4.0). Practice Fusion also tied with Amazing Charts for first (3.8) in the category of continuing customer service.

Although last week's Internet brownout might have dented Practice Fusion's reputation, Athenahealth, another cloud-based EHR vendor, said its physician customers were able to log in as usual. The company reported an average uptime rate of 99.996% in 2013.

Athenahealth spokesperson Jillian Palash told Medscape Medical News that her company was not vulnerable to the brownout because it owns and operates its network infrastructure, including state-of-the-art routers. System redundancies, Palash said, play an important role in keeping the network up. Athenahealth uses multiple, top-tier ISPs, so if one goes down, "we would still have other paths to our clients." It also operates 3 geographically dispersed data centers.

Get an Uptime Promise in Writing, Consultant Says

Cloud-based EHR programs such as Athenahealth and Practice Fusion appeal to physicians who do not want to bother with systems that reside on an office-based server. The practice must not only regularly update the software but also manage the server, a daunting task for the average physician or office manager. Cloud-based vendors have a price advantage, too, at least in the short term: They typically charge customers a monthly subscription fee, cutting down on upfront costs that for other EHRs can easily top $10,000.

In light of the vulnerability of cloud-based programs to Internet brownouts, however, physicians must choose carefully, said healthcare information technology consultant Mark Anderson in an interview with Medscape Medical News.

"Part of it gets down to how much a company is willing to spend on redundancy," said Anderson, chief executive officer of the AC Group in Montgomery, Texas. In addition, vendors may sacrifice quality for price in terms of the data centers and ISPs they use.

A company selling a cloud-based EHR may blithely say that downtime has never been a problem, but physicians should get their reassurances in writing, said Anderson. That means a clause in the sales contract that promises an average uptime percentage of at least 95%, or else the vendor pays a penalty. This clause typically does not appear in the contract proffered by the vendor, Anderson said, so physicians need to negotiate its insertion.

The best cloud-based EHR vendors, Anderson added, give their customers advance notice about impending Internet brownouts. "A proactive company will say, 'We think we're going to have problems today,' " he said. That gives the practice time to print out chart summaries for the patients scheduled to come in.

Anderson predicts that the growing pains of the Internet will continue to threaten users of cloud-based EHRs and other software services with downtime. Such mishaps, he said, will make some physicians think about switching to another program, perhaps one residing on an office server instead of floating in the cloud. Having patient data in hand is that critical.

"If they're down 20 minutes, they start screaming," he said. "After a day, they say, 'You've killed my practice.' "

An EHR program on an office server, Anderson noted, is also susceptible to downtime. There's no getting around the screaming.

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