Local-First vs. Cloud: A Compliance Perspective

Most compliance tools require you to upload patient documentation to vendor infrastructure. The pitch is convenience: "We handle the complexity so you don't have to."

But that convenience comes with a trade-off that rarely gets discussed until something goes wrong.

The custody question

When you upload PHI to a vendor cloud, you're not just sharing data. You're transferring custody. That vendor now holds your patient information on infrastructure you don't control, managed by teams you've never met, governed by policies you didn't write.

Yes, there's a BAA. Yes, they're probably SOC 2 certified. But none of that changes the fundamental reality: your patients' protected health information now lives somewhere you can't see, audit, or directly control.

The uncomfortable question most vendors don't ask:

"If we get breached, are you prepared to notify 10,000 patients and explain why you sent their PHI to our servers?"

Most clinics never think about this until the notification letter arrives. Local-first eliminates the question entirely.

What happens when things go wrong

Vendor breaches happen. In February 2024, Change Healthcare (a major claims processing vendor) was breached, exposing PHI for over 100 million patients. Providers using their cloud services had no advance warning, no control over the response, and limited visibility into which records were compromised.

When your vendor gets breached:

• You're still responsible for notifying affected patients
• Your reputation takes the hit, not theirs
• Regulatory scrutiny falls on you as the covered entity
• You have limited visibility into what actually happened

The BAA shifts some liability, but it doesn't shift accountability. In the eyes of your patients and regulators, you chose to send their data to that vendor.

The local-first alternative

Local-first architecture keeps PHI where it belongs: inside your environment, on your machines, under your control.

This isn't about rejecting technology. It's about applying it in a way that doesn't create new attack surfaces or custody chains. You get the analytical power you need without creating the liability exposure you don't.

What local-first means in practice:

• Software runs on your infrastructure (desktop, local server, or private cloud you control)
• No patient data transmitted to vendor systems
• No external accounts, logins, or cloud dependencies
• Audit logs and outputs stay within your environment

How Data Flows: Cloud vs. Local-First

CLOUD VENDOR MODEL

Your PHI → Vendor servers → Unknown data centers
Data custody: Vendor holds indefinitely
Access: Vendor employees (tier 1, tier 2, engineers)
Breach impact: You notify patients, handle regulatory review
Your control: BAA terms, compliance audits (if allowed)

LOCAL-FIRST MODEL (Assurium)

Your PHI → Your machine → Your local storage
Data custody: You retain at all times
Access: Only your authorized staff
Breach impact: Your infrastructure security controls apply
Your control: Complete visibility and audit capability

The operational benefits

Beyond compliance, local-first architecture has practical advantages:

• No connectivity dependency (works offline or in low-bandwidth environments)
• No per-user cloud costs (software runs locally regardless of team size)
• No vendor lock-in (your data formats remain portable)
• Faster performance (no network latency for data processing)

The trade-off

Local-first isn't free. You're taking on the responsibility of running and maintaining the software in your environment. Updates require local installation. Support may require screen sharing rather than vendor dashboard access.

WHAT YOU GAIN

• Full data custody
• Zero vendor custody risk
• Complete audit trail
• No usage limits

WHAT YOU MANAGE

• Local installation
• Software updates
• Your infrastructure
• Direct troubleshooting

For clinics that prioritize data control, that trade-off is acceptable. For clinics that want someone else to manage everything, cloud tools may still be the right choice—as long as the custody implications are understood.

The decision framework

Ask yourself:

1. Do I fully understand where my PHI goes when I use this tool?
2. Am I comfortable with that vendor holding patient data indefinitely?
3. If that vendor is breached, am I prepared for the consequences?
4. Is the convenience worth the custody transfer?

If any of those answers give you pause, local-first deserves serious consideration.

See what local-first looks like in practice

Assurium brings clinical compliance auditing to your machine. No cloud upload. No vendor custody. No external dependencies.

Your data stays local:

• Audit engine runs entirely on your infrastructure
• PHI never leaves your environment
• No vendor database custody or retention
• You control who accesses what, when

First 10 audits free. No account required.

Download Assurium → — macOS & Windows — SQLite storage

(Want to understand how Vault Mode works? Read our security architecture →)