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Overview of Cloud Electronic Health Record Systems

By Matthew Delisle posted 06-28-2021 08:08


Cloud-based vs Server-based EHRs – Things to consider

Is your institution in the market for a new EHR? Congratulations - there are now more options than ever before. While increased options allow a greater likelihood that you can find precisely the EHR that you need, it also means there are more decisions to make and details to consider. This can make this seem like a daunting task.

Choosing an EHR is an incredibly complex decision. Dozens of variables need to be evaluated to determine which EHR works best for your situation. With this blog post, we wanted to focus on one particular variable – cloud-based versus server-based EHRs– and highlight some key points to consider when comparing the two.


What is a Cloud-based EHR?

Simply put, a cloud-based EHR is an EHR that resides on the cloud. Major players generally provide both cloud-based and server-based options while some companies only provide one or the other. The field is certainly not limited so be sure to explore your options.

The cloud is just another way to say that the EHR lives on someone else’s server (AKA the vendor’s), not yours, and you access it via the internet. This a key difference compared to traditional client-server setups that live locally on an institution’s private network.

Pros vs Cons

There are many pros and cons when comparing a cloud-based setup compared to a traditional server-based setup. Here are three areas to consider when evaluating cloud-based EHRs: 1,2,3


  1. Cost

                When it comes down to it, cost is ultimately the most important variable in all the decisions we make. Don’t limit yourself by just considering the dollars and ignoring the opportunity costs, however. Both play a major factor when it comes to choosing an EHR.

Cloud-based EHRs excel in terms of cost predictability. Because EHRs are primarily software as a service (SaaS), financial costs are agreed upon ahead of time in the contract. Upgrades, maintenance, and expansions can and should be well-defined from the beginning. This makes the accounting aspect fairly straightforward. Predictable doesn’t mean cheaper, though. Because the vendor is responsible for most of the work, cloud-based EHRs can often be more expensive in terms of dollars. This can be especially true if you need to purchase software licenses for a large number of users.

On the other side of the equation are opportunity costs. Maintaining a local, server-based EHR means you need personnel and resources that otherwise aren’t required by cloud-based EHRs. Having your EHR maintained by the vendor frees up personnel resources for other tasks.


  1. IT Infrastructure

                Does your institution have a robust and comprehensive IT department capable of properly maintaining and managing an EHR in-house? Or do you have a smaller IT department that is more limited in scope and may need significant outside help?

Choosing a cloud-based EHR outsources the vast majority of IT work to the vendor. This can be critical for sites lacking IT resources. This isn’t to say that having a powerhouse IT department doesn’t knock cloud-based EHRs out of contention. The vendor can almost certainly maintain and upgrade their own system more efficiently than you can. However, outsourcing means trusting the vendor to complete work to meet your quality and time standards.


  1. Control

                A key factor that cannot be overlooked is control. Employing a cloud-based EHR means trusting your vendor to do what you want. While you could allocate more resources to a particular problem with an in-house system, your vendor may not be able or willing to do the same. A certain trust (and a well written contract) is needed when handing someone else the reins.

                One upside to shared control is shared liability. If a potential data breach should occur on a cloud-based EHR, the vendor should at least share potential costs. This is significant as HIPAA violations can range from thousands to millions of dollars. 4


Examples of Cloud-Based EHRs in Clinical Practice

                The effectiveness of cloud-based EHRs has been documented in multiple clinical settings. Over 45 million patients who were uploaded to the cloud based Explorys from twenty-six integrated US health care systems for the purpose of screening HIV patients. Data extrapolated from this cloud based EHR was then compared to CDC data. Cloud based EHRs may provide objective, daily up to date information on HIV screening daily compared to traditional survey methods.5

Cloud-based clinical decision support (CDS) tools have been adopted and accepted to provide clinical care for patients. Pharmacists could perform therapeutic drug monitoring (TDM) using a model-informed precision dosing (MIPD) cloud based tool for medications such as vancomycin. Over a two-year implementation in the pediatric intensive care unit, 2,148 TDM levels were evaluated using the CDS tool. Greater than 96% of end users agreed in a survey (26 users surveyed) that automatic transmission of patient data to the tool was helpful in being more efficient for completing clinical work.6

Another example of a cloud-based CDS tool helped providers identify patients with sepsis early through implementation of a tool developed across 5 different medical centers. A challenge clinicians encounter is identifying all the symptoms of system inflammatory response syndrome (SIRS) along with the patient’s active disease states. The sepsis CDS tool is cloud-based real time system that identified patients with sepsis based on data captured in the EHR. If a patient’s symptoms align with the sepsis criteria defined in the cloud-based CDS tool, then an alert is triggered to the clinician. Using this cloud-based CDS tool was instrumental to help providers accelerate the time to a sepsis diagnosis with the goal in providing treatment to improve patient outcomes.7


Ultimately, the decision of what EHR to use is an extremely nuanced decision based on the wants and needs of your particular institution, and whether or not to employ the cloud is just part of the equation. The considerations highlighted in this blog post are just a few to consider when evaluating your options. Cloud-based EHRs have been implemented in clinical practice and have demonstrated to assist physicians and pharmacists in providing patient care and may help improve patient outcomes.



Andrea Duong, Pharm.D. PGY2 Pharmacy Informatics Resident. NorthShore University Health System. Evanston, IL.

Matthew Delisle, Pharm.D. Clinical Informatics Pharmacist. University of the Hospital of Pennsylvania. Philadelphia, PA. 

Scott Wade, Pharm.D. Pharmacy Informatics Analyst. West Virginia University Medicine. Morgantown, WV.



  1. Find & Compare EHR Software. Accessed April 15, 2021.
  2. Local or Cloud: Which EHR is Better? Accessed April 15, 2021.
  3. Ahmadi M, Aslani N. Capabilities and Advantages of Cloud Computing in the Implementation of Electronic Health Record. Acta Inform Med. 2018;26(1):24-28. doi:10.5455/aim.2018.26.24-28
  4. HIPAA Violation Cases. Accessed April 15, 2021.
  5. Niforatos JD, Wanta JW, Durbak E, Cavendish J, Yax JA. Assessing the National Prevalence of HIV Screening in the United States using Electronic Health Record Data. Cureus. 2019;11(6):e5043. Published 2019 Jun 30. doi:10.7759/cureus.5043
  6. Frymoyer A, Schwenk HT, Zorn Y, et al. Model-Informed Precision Dosing of Vancomycin in Hospitalized Children: Implementation and Adoption at an Academic Children's Hospital. Front Pharmacol. 2020;11:551. Published 2020 Apr 29. doi:10.3389/fphar.2020.00551
  7. Amland RC, Hahn-Cover KE. Clinical Decision Support for Early Recognition of Sepsis. Am J Med Qual. 2019;34(5):494-501. doi:10.1177/1062860619873225