As electronic health records have grown more sophisticated, one path of the technology has pushed into cloud-based data management. Time, development, and experience have honed many cloud-based solutions into products that offer therapy clinics a number of solid benefits, but there are vital considerations any practice should evaluate before embracing a cloud solution or changing their cloud-based provider. To help readers understand the current state of cloud-based technologies, and the benefits they offer, Physical Therapy Products asked a panel of industry insiders to highlight the critical characteristics that rehab facility administrators and owners should know about these products.

Participants in this roundtable include the following: John Wallace, PT, chief executive officer, BMS Practice Solutions; Jeremy Cader, vice president of product, IT and engineering, Clinicient; Luke Sands, ReDoc by Net Health; Sharif Zeid, business director, MWTherapy by MerlinWave Inc; Steven Presement, president, Practice Perfect EMR + Management Software; Raintree Inc; Daniel Morrill, PT, MPT, chief executive officer, TheraOffice powered by Hands On Technology; Nelson M. Aviles, PT, sales manager, Therassist Software LLC; and Heidi Jannenga, PT, DPT, ATC/L, chief operating officer, WebPT.

1) How have implementations, updates, and usability improved for current cloud-based systems over earlier generations?

John Wallace: The user experience for typical users of cloud- or browser-based applications has improved in several ways. Access anywhere, use anywhere. Users are able to access the applications and get their work done from virtually any remote location with assurances of security for all data. Software updates on demand. Application vendors are now able to push updates and enhancements to users with the frequency required to support the business’ needs.

Jeremy Cader: Clinicient’s private cloud provides customers with fast access to all of their data in any setting. Also, our standardized implementation methodologies and best practices for using a cloud-based platform decrease the time to adopt and improve the overall results. Lastly, our cloud-based Insight platform features an intuitive user design, which decreases the amount of time needed to train staff on use of applications.

Sharif Zeid: With every version, MWTherapy continues to improve. Updates are installed automatically during off hours to avoid user interruption. MWTherapy has focused on bringing many new features targeting customization, ICD-10, compliance, efficiency, speed, clinical perfection, insightful analytics, as well as maintaining/improving the ease-of-use.

Luke Sands: Generally speaking, software management has improved by leaps and bounds. Implementations are faster to launch because we no longer require an extended wait period while customers procure hardware and licenses or get on the IT team’s schedule for product deployment. Now, we can just fire up a browser and go. Product updates are far simpler because we can deploy them with strategic timing, and there is no need to burden IT departments with testing and rolling out our patches. For example, if we were to find something that needs an update in our software, a fix can go out in a matter of minutes versus the previous 24-hour or 7-day cycle times.

Steven Presement: While updating cloud-based software is certainly easier than locally installed software, since the user really has to do nothing, the proliferation of different browsers and multiple versions within each browser has certainly complicated matters. We have Firebox, Safari, Chrome, Explorer, and Edge, all with multiple versions. Then we have desktop versus mobile apps. While the delivery of updates is substantially simpler, development has become more complicated.

Raintree: Cloud-based systems have really improved implementations, updates, and usability. This is simply because you don’t have to worry as much about hardware issues. Cloud-based systems have excellent up-time, security, and redundancies, so it makes it easier for our implementation and support teams to increase the level of service to clients without also having to support that client’s hardware.

Daniel Morrill: At Hands on Technology we have been watching the progression of cloud services over the last few years. Microsoft, Google, and Apple have invested an enormous amount of money in cloud infrastructure and the development of “Apps.” Today, developers can bring highly configurable user interfaces that work across multiple platforms and deliver an amazing user experience. Updates are very fast
(20 seconds) and, with more reliable Internet connections and speed, allow developers to push the envelope of delivery of information to end users. The age of big data in healthcare is here, and believe me, there is lots of storage in the cloud.

Nelson Aviles: Accessibility and portability are the two biggest changes over time. Users have seen significant changes in bandwidth, hardware, and Internet access that makes using cloud-based systems increasingly reliable, commonplace, and irreplaceable. These changes make an online solution affordable, simple, and robust for companies of all sizes. For example, it used to be that a company would look to invest in tablets for all employees. Now, almost every employee comes in already equipped with an Internet-ready device (their smartphone).

Heidi Jannenga: A big driver in improving implementations, updates, and usability is the trend toward SaaS—software as a service—models, which puts the focus on quickly and consistently addressing customer needs. Previously, getting up and running with an EMR meant going through a strict, inflexible implementation process. While some EMRs on the market today still require all clinics—no matter how tech-savvy or eager they are—to jump through tons of hoops just to get started, many have changed their implementation processes so customers can start using the software after a short setup period that involves configuring settings and/or importing data. The process of updating cloud-based systems also has greatly improved. Now, updates can be as frequent as multiple times a day. Moreover, changes are made more incrementally, which minimizes disruption to users and makes it easier for them to learn and adapt as the software evolves.

2) How is cloud-based security keeping up with what seems to be growing sophistication among hackers, and an increase in their attempts to access data?

John Wallace: The sophistication of cloud-based security continues to increase on several fronts. Hardware-based security: Firewalls, switches, servers, all hosting facility hardware keeps increasing security protections. Software security: Virus scanning-type solutions have increased significantly in sophistication. Data Encryption: The last line of defense for security, even if data is breached, is data encryption. This is where data is coded in a way that is extremely difficult to read. You need the correct “key” to decipher the data. The algorithms for data encryption continue to grow more sophisticated.

Jeremy Cader: Clinicient built its own private cloud environment which is collocated in a HIPAA-compliant Tier 3 datacenter. We also encrypt data that is being transferred between the client and the datacenter and maintain an IP filtering and blocking regime. We understand the value of corporate and patient data. Therefore, Clinicient appointed a certified security specialist as our corporate information security officer, who maintains the security posture of the organization and stays abreast of current and emerging threats.

Sharif Zeid: As with all systems, security is essential. MWTherapy is always assessing and implementing new security techniques when and where necessary. The important part of a cloud-based system is that security updates can be pushed without clinic intervention or involvement. While there is growing sophistication, it’s important not to lose sight of the basics including strong passwords and physical security.

Luke Sands: Security is always going to be a risk whether your software and data is on premise or hosted by someone else. The majority of attacks over the past couple years have been against on-premises systems (though the ones against cloud-based systems usually receive more media attention). Luckily, for the same reason that updates are much easier to apply to cloud-based systems, the same is true when it comes to ensuring systems are patched and hardened. If any vulnerabilities were to become known in our infrastructure, we could deploy a patch within hours or minutes.

Steven Presement: Let’s face it; we’ve been lucky. Fortunately, Ashley Madison does not fall under HIPAA. If companies worth billions of dollars are being hacked, how can smaller companies, even large versions of smaller companies, be immune? The truth is, they aren’t. Its not a matter of “if”; its a matter of “when”—that’s the reality. Everything is secure until it’s not. A patch is issued, and things are safe again—until the next loophole is found. HIPAA violations range from $100 to $50,000 per record, depending upon the level of negligence and steps taken to correct the issue. Imagine, you have 5,000 patient records, and your database—completely under the control of some other entity—is hacked. Even in the best-case scenario, that’s a $500,000 fine. All it takes is one employee with access to open the gates.

Raintree: Raintree uses cloud-based providers that meet the highest standard for security. Since we are in healthcare, there is an increased need for security due to HIPAA regulations and privacy laws. Cloud-based providers have done a very good job in keeping up with regulations, and many providers specialize in solutions specific to the healthcare market.

Daniel Morrill: The sophistication of attacks, and the increased volume of hacking attempts, tell us that healthcare IT is a major target for illegal activity. The IT security industry is always trying to stay current with technology to help avoid large-scale attacks. However, they also need end users to follow security best practices. We can develop software and security features into our platform, but if a therapist shares a password with an unauthorized user, or downloads a virus from an Internet sharing site and does not have basic protection, security can be compromised. We believe that best Data Security comes from a partnership between our security technology and the end user’s security practices.

Nelson Aviles: While it’s rarely mentioned, security as a service is one of the most important aspects of having your vendor host your data. Insofar as your clinic and patient data are concerned, protecting your data is part of what we do, and it doesn’t require any on-premises hardware or software distribution, like anti-virus software that needs to be installed on every single computer on your network. Biometric security measures, redundancies throughout the server farm, and off-site data storage are just a few measures taken to protect vital client data.

Heidi Jannenga: Web-based software providers built their systems from scratch with the Internet in mind. Top-notch cloud-based EMR systems, for example, have bank-level security encryption (256-bit Secure Socket Layer), automatic data backups with multiple replication processes, an audit trail (ie, user activity tracking), and specialized staff who are well-versed in online security measures and at the ready to provide you with their expertise. Plus, cloud-based EMR systems use data centers to house all their—and thus, your—data. To ensure HIPAA compliance, these data centers must possess bank-level security and supreme encryption methods that render data unreadable—even if hackers somehow get to it.

3) How well does cloud-based hosting work for practices in small towns and rural areas compared to metropolitan areas that have robust Internet access?

John Wallace: This has continued to improve year over year. Technologies for Internet service by satellite and mobile phone have contributed to better Internet access for rural areas.

Jeremy Cader: Clinicient’s cloud-based Insight platform works seamlessly in areas that have robust Internet access, in rural areas and small towns. This is because we provide customers with technical specifications that make it easy for them to quickly run our platform efficiently. We also work with our customers to test their technical environment and proactively discover any hidden connectivity issues.

Sharif Zeid: Reliable Internet connectivity is key to utilizing a cloud-based system. MWTherapy is made to be very efficient and can operate well on modest-speed connections. Fortunately, many smaller towns and rural areas are slowly receiving access to better-quality Internet connection options, which is making it easier than ever to utilize a cloud-based system.

Luke Sands: Using a cloud-based system does require a connection to the Internet with effective bandwidth for data transfer, though the definition of “effective” can be subjective based on needs of the facility. Because broadband Internet access is constantly expanding nationally, more geographic locations are gaining access to it.

Steven Presement: This certainly has been an issue in the past, but Internet access, even in rural areas, is getting much better. Of course, if a practice has spotty Internet access, then choosing an online application is probably not their best option.

Raintree: In locations where there is robust Internet access, there are obviously very few problems. In rural areas it can be challenging simply due to data speeds. Raintree’s EMR and Practice Management solution can easily work with low data speeds, but when reliability is an issue, we may recommend a locally hosted solution. Choosing a cloud solution is a strategic decision for any practice, and in some cases it may not be the best choice compared to a locally hosted solution.

Daniel Morrill: Internet speed and reliability is still the ultimate test for whether or not a cloud-based software solution will be effective at a facility. Simple ping tests and speed tests at multiple times during the day will give a clinic a good idea of the speed and reliability of their network. Software companies should be able to provide you with recommended requirements for bandwidth to help you make a final decision.

Nelson Aviles: Probably the best determinant of successful hosting is bandwidth (rate of data transfer). The good news is that there are ever-increasing options for even rural areas to get online, and with the advent of smartphones, cost-effective solutions for staff that go into remote areas. Certainly, metropolitan areas will benefit from competitive pricing and services, but even they have dead spots. From the perspective of managing your network, cloud-based hosting is a boon for remote clinics. If you are in a place where resources are limited, you are better off having online services because that gives you the best option for managing and maintaining a stable company EMR without the costs and difficulty of getting someone to come out to you physically to provide network assistance.

Heidi Jannenga: Less-than-robust Internet access doesn’t have to hold clinics back from using a cloud-based EMR. One solution to weak Internet access is using wireless routers to find an alternative connection. Also, clinics should consider purchasing a mobile hotspot router. Available through cellphone providers, these small routers can provide 3G or 4G LTE Internet service. PTP