Executive Update
January 2010

Creating the Infrastructure for EHR Implementation
Michelle Sisson, COT

Many offices already have the computer hardware required for their practice management software, but what else needs to be considered once the decision to implement an electronic health record (EHR) system is made? Are the requirements truly different? Although a comprehensive evaluation of the pros and cons of the many options available are beyond the scope of this article, I hope to provide you with an overview of some of the issues that will need to be considered as you migrate to EHR.

Communication
If you have satellite offices, you must consider how your office will communicate with your network server. There are many networking options on the market, including point-to-point T1, DSL, broadband cable and fiber. In my practice, we began with point-to-point T1 at all locations except one. This can be a pricey solution. We are a comprehensive practice in Pueblo, Colorado, with nine locations and 15 providers. Depending on your locale and the distance to the nearest hub, your cost may range from $350 to $1,500 per month per location.

Because one office was located in a rural area, the costs of T1 in that instance would have been out of proportion to the number of patients seen there, so we opted for DSL in that office. DSL has worked better than expected, although it did affect our ability to scan from that location. As a workaround, we set up remote scanning services to send the data over intermittently in small packets which would not interfere with network performance.

In the past year, we have moved away from point-to-point T1 and set up a fiber loop at our main office; we connect to that loop via DSL and broadband cable. The cost at our main office did go up, but with the much less expensive DSL and broadband hookups we were able to save about $2,000 per month and increase our connectivity speed. Be sure to check out the options available in your area to see what will be the most cost-effective solution for you.

Servers
Once you have your WAN (wide area network) set up, you need to decide what to do about servers. What size should you buy? I would recommend at least 1 terabyte for a practice similar to ours in size. The life of a server is about five years. Make sure that if you are going to be scanning charts that you buy a server large enough to handle your storage needs for several years. Moving data is a large undertaking, so you want to do it as infrequently as possible. Most EHR vendors will have guidelines on how to scan, what type of file format you should use, etc.

Another consideration is your diagnostic equipment. Will you interface your equipment to directly import data into your software, or will these results be scanned in from hard copy? What about external photos, fundus photos, visual fields, A-scans, OCTs and Pentacams? All of these tests are actually images in most programs. Take this into consideration when you are purchasing the server you will store your images on. Three years into EHR, my practice outgrew its image server — the server that holds all of our scanned and imported patient images. We went from 750 gigabytes to 2 terabytes to allow for future growth.

Should you buy more than one server? Should you store your database, images and documents on the same server, or does the EHR vendor recommend keeping them on separate servers? We chose not to put all of our eggs into one basket and opted for multiple servers. In my practice, we have separate servers for data, images, accounting, domain and phone along with eight terminal servers. A terminal server is a way to route connections to the main server so that people are not actually working on the main server.  This does not bog down the server and it prevents damage to the main server in the event someone decides to experiment. Only IT admin staff are allowed access to the main servers directly. We only work directly on them when there is maintenance to do.  (At our nine locations, we have a total of 175 computers and about 70 printers.)

You will also need to decide whether you want to have a redundancy setup. In a disaster, this will protect your data in the case of data loss at your main site. We do nightly backups and take them off site right now and are looking into setting up a redundancy site in addition to this.

Long-Term Storage
Deciding about long-term storage requires thinking into the future. Will you use a SAN (storage area network) or NAS (network attached storage)? Will you back up your data online or use a local data storage facility? There are many options you need to consider. To help with this decision it is extremely important that you have a knowledgeable IT department or outside IT vendor.

Wiring/Access
Next you need to consider rewiring your building if you haven’t done so already. I thought we had done a great job of allowing room for expansion with double drops. But then we grew and needed to add more wiring. If you choose to go wireless, you also need to think about wireless sites. Consider the size of your office and how many wireless routers you will need to provide consistent access: make sure that you have enough coverage to avoid connection loss due to “dead zones.” Encryption is, of course, mandatory, since you will be dealing with patient data. When considering the pros and cons of wireless, take into account that even the best wireless network will drop a connection periodically. Is this something your office can put up with? Your routers also need to be robust enough to handle multiple connections without getting bogged down.

How are you going to connect to your main database? Are you going to use a Citrix type environment or connect with remote desktop? This will drive whether you purchase fat clients (actual computers) or thin clients (terminals that runs off the network). Thin clients are a bit less expensive. You will, however, need to decide if you need to run additional applications on the local machines. If you do, you will need fat clients. Will you need to have peripheral devices attached? Some thin environments can run some peripherals, but most need fat clients. Again, get educated by your IT department or consultant.

Additional Equipment
Is your practice growing? If so, you will want to place printers throughout your office, even where you might not think you’ll need them. Look at office flow and think about where it will be easiest to pick up prescriptions, consents, referrals, etc. that you may want to give your patients. You don’t want to be walking long distances to retrieve your printouts.

Will you be purchasing desktop computers, laptops or tablets? We started with desktops and a couple of laptops. Tablet computers are expensive. Are you more concerned about costs or accessibility? I have spoken with several offices that started out with laptops and tablets — but the machines got dropped and broken or just disappeared — and they have since converted to hard-wired desktops. Small computers also sometimes become less attractive on closer acquaintance: One of my doctors insisted on having a tablet PC, used it for about two months, and then instructed me to give it to someone else.

Software
What types of programs are you going to want all staff to access? The client access licensing (CAL) for Microsoft can be a killer! Cost is determined by the number of users accessing certain programs. For instance we incurred $15,000 in licensing fees on our SQL server so all staff could access our EHR database. Each product is set up differently. Once you purchase the CAL, you can access any portion of that program but many of their programs use CAL pricing. You have to purchase separate licensing for their MS Office and MS SQL server. This is why the price can be so high.  Check on the costs before you start buying programs now that you may want to use later.

IT Support
How do you pick an IT support vendor? This is a tough issue. We went with a large company in a metropolitan area and later found out that they really gouged us on equipment costs. If you do not have an onsite IT person, talk with other practices in your area and ask if they have found a vendor they are happy with who can help guide you through this major undertaking.

Along the same lines, although you may start this project, you need to think about who is going to manage it day to day going forward. We have one full-time and one three-quarter-time person maintaining everything. We also use an outside IT company to help us with whatever comes up that is outside our expertise, as neither myself nor my assistant has a degree in IT. However, we have educated ourselves enough that we purchase only about 100 support hours each year.

Whether you need an onsite IT person depends on the size of your office and the expenses involved. I take care of all template and documents changes and any EHR or practice management system issues. My assistant and I take care of everything else. We maintain all the computers, phones, printers, all peripheral devices, scanner, copiers and multifunction units. All of this keeps us busy. (I also purchase equipment directly to save money. Developing relationships with large vendors will give you access to discount pricing. They usually will give you freebies, too: printers, keyboards, etc.) Weigh the costs of having onsite support versus outsourcing.

When selecting IT support, be sure that the vendor you choose understands the particular needs of health care, including your typical clinic hours. They should be able to respond to your needs even if you call at 7 a.m.

Whew! Your head may be spinning after reading this article, and rightfully so. There is a lot to consider. Use the products and other resources provided by AAOE to help you navigate this territory. Soon enough you will be astounded by your expanded technical vocabulary. Best of luck to you as you venture into the brave new world of EHR.


About the author: Michelle Sisson is a COT working as the IT coordinator with Rocky Mountain Eye Center Inc. in Pueblo, Colorado. She can be reached at michelle@rmecpc.com.