August 2019 ■ Journal of Dental Education 895 Use of Technology in Dental Education Cost Comparison of an On-Premise IT Solution with a Cloud-Based Solution for Electronic Health Records in a Dental School Clinic Lynn Johnson, Cassandra Callaghan, Madhan Balasubramanian, Haris Haq, Heiko Spallek Abstract: Electronic health records (EHRs) are increasingly moving towards cloud-based web environments. While cloud-based EHRs claim substantial beneits at reduced cost, little cost-beneit research exists for dental schools. The aim of this study was to examine the cost-beneits of a cloud-based EHR compared to an on-premise client-server EHR in the University of Michigan School of Dentistry (U-M Dent). Data were collected in 2016 from the U-M Dent cost-beneit comparison of tangible and intan- gible factors associated with implementing a new EHR, using the Total Cost of Ownership (TCO) framework from EDUCAUSE. The TCO framework assessed three factors: foundational (overarching aspects: three items), qualitative (intangibles: 56 items), and quantitative (actual costs). Stakeholders performed factor grading, and relative assessment scores were derived for each item as well as the overall factor. The cloud-based EHR solution received higher foundational and qualitative factor summary scores. The overall cost of an on-premise solution over a two-year period was approximately $2,000,000 higher than a cloud-based solu- tion. Cloud solutions did not carry any hidden costs, while such costs accounted for 8% (~$540,000) of the overall costs of the on-premise solution. Across the two-year period, both one-time and ongoing costs were higher for the on-premise solution than the cloud-based solution (by 40.5% and 20.5%, respectively). This study found that a cloud-based EHR system in the U-M Dent ofered signiicant cost savings and unique beneits that were not available with the on-premise EHR solution. Based on cost, the U-M Dent has made a case for cloud-based EHR systems. Lynn Johnson is Professor and Associate Dean, University of Michigan School of Dentistry; Cassandra Callaghan is Director of Dental Informatics, University of Michigan School of Dentistry; Madhan Balasubramanian is Sidney Sax National Health and Medical Research Council Research Fellow, University of Sydney, Australia and King’s College London, United Kingdom; Haris Haq is a Consultant, Collaboration for Health IT; and Heiko Spallek is Professor, Head of School, and Dean, The University of Sydney School of Dentistry, Sydney, New South Wales, Australia. Direct correspondence to Dr. Lynn Johnson, University of Michigan School of Dentistry, 1011 North Michigan, Room 1216, Ann Arbor, MI 48130-1078; lynjohns@umich.edu. Keywords: dental education, dental schools, dental school clinic, clinic management, electronic health records, cost-beneit analysis, organizational innovation Submitted for publication 7/15/18; accepted 1/29/19; irst published online 4/22/19 doi: 10.21815/JDE.019.089 H ealth care’s most important informa- tion systems—electronic health records (EHRs)—are moving towards functioning in a cloud-based environment. To date, there is con- siderable evidence to suggest that cloud-based EHR systems ofer substantial beneits when compared to on-premise client-server EHR systems that are more commonly used. 1 The speed and lexibility of cloud resources can shorten the time for implementation, decrease burden on resources required for upgrades, and allow practitioners and patients to focus on a patient’s health versus the technology, while concur- rently allowing for improved cost beneits. 2 As data for a cloud-based EHR are stored using external servers, they can be accessed through any device using an Internet connection. Cloud-based EHR systems provide better interoperability, scalability, maintainability, and accessibility and all at reduced costs when compared to on-premise solutions. 3 Portability is vastly enhanced, as cloud systems en- able easier movement of applications and data from one environment to another. These advantages are signiicant, and a cloud-computing framework can make patients’ EHR sharing easier and allow health professionals to communicate better, as well as help lessen issues associated with on-premise systems such as network security and data storage. 3,4 While there exist numerous and varied considerations in