EHR Implementation: What you need to know to have a successful project: Part 2. Bruce Kleaveland President Kleaveland Consulting, Inc.

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1 EHR Implementation: What you need to know to have a successful project: Part 2. Bruce Kleaveland President Kleaveland Consulting, Inc.

2 Learning Objectives: Recognize key EHR hardware & network components Give examples of hardware & software accessories Introduction to interfaces & database conversions Review training strategies for physicians & staff 2

3 A simple network drawing 3

4 Networking terms & components LAN (local area network) Connects workstations within a single location WAN (wide area network) Connects workstations across multiple locations Point to Point T-1 and fractional T-1 Dedicated broadband lines that connect locations in a WAN VPN: virtual private network A way of securely accessing a specific network over the internet Firewall Software/hardware that prevents unauthorized access to network Monitors network traffic, may include VPN, virus scanning 4

5 Networking terms & components Thin Client Workstations function as terminals to server Thick Client Workstations do primary application processing Citrix or Microsoft terminal services Software used to support a thin client network Access Points Ceiling mounted transceivers used in wireless networks Switches/HUBs Hardware used to connect workstations/printers to network/server CAT 5 or CAT 6 Type of cable used for wiring networks 5

6 Network & hardware services Typically not provided by the EHR vendor Tasks include: Hardware procurement & wiring of office Set-up the server & install EHR software Set IP scheme (numbering nomenclature to ID devices) Set-up Terminal Services for remote access Configure & test printers on the network Install scanners and test Set-up router including web access Install power back-up (UPS) Install and configure firewall to protect the network Antivirus software installed and configured 6

7 Selecting a network services vendor Get recommendations from selected EMR vendor Assess local availability Assess size and current commitments of the organization How many staff? How many current projects? References from like organizations Credentials & certifications (i.e. Microsoft Certified System Administrator or MCSA) 7

8 Hardware: Servers A simple definition: a computer that serves other computers on a network. May also refer to software (i.e. fax server) Types of servers: Application server: computer on which the EMR/PM application resides Database server: computer on which the database software resides Citrix or terminal server: computer that supports thin client network Application, database, and terminal services may reside on the same computer for small installations (less than 10 users) 8

9 Server Criteria Brand (i.e. Dell vs. white box ) Operating system (i.e. Windows 2003) Processors (i.e. 2.4 Hz Xeon) RAM (i.e. 1 GB) Hard drive configuration (i.e. RAID 5) Network Card (i.e. 1 GB per second) Requires: monitor, keyboard, CD/DVD drive, UPS (un-interrupted power supply) 9

10 Server Data Storage & Backup Storage requirements dependent on EHR/PM application, volume of scanned documents Rule of Thumb: 5 GB/per year/per provider (check with your EHR vendor) Disaster Recovery=Restoration of data after complete data loss Disaster Recovery Strategies Daily automated backup, rotating tapes, offsite storage using tape backup (LTO, DLT, DAT), and restoration testing Hot backup: automated switch to backup server (requires special database tools) 10

11 Workstations Desktops: designed for fixed locations Nurse s station, registration, billing, triage, exam room Price: $500-$700/workstation Laptop: designed for portability, mobility, space conservation Physicians & other providers Price: $900-$1500/workstation Tablet: designed by portability, mobility, space conservation, form factor Physicians & other providers Price: $1400-$2200+/workstation 11

12 Example of slate tablet 12

13 Example of convertible tablet 13

14 Example of hybrid tablet 14

15 Examples of tablets with docking station 15

16 Laptops vs. Tablets Laptops: Pros: Mobility, portability, versatility, price Cons: Not optimal for pen or handwriting recognition Tablets Pros: Superior mobility, optimized for pen & handwriting recognition Cons: Less versatile, use is dependent on EHR application, more expensive 16

17 Workstations in the exam room? Advantages Eliminates the need for providers to carry laptop/tablet Utilizes reliable, high performance hard-wired network Disadvantages Requires the purchase/support of addition workstations Requires cabling and configuration of exam rooms 17

18 Printers Prescription printers Networked (vs. local) Requires consideration of location to support workflow Report/Specialized printers Used for dedicated or special tasks (HCFA forms, practice management reports) 18

19 Scanners & document management Scanners capture image of paper document Defined by speed (pages per minute), resolution (dpi), capacity of automated document feeder Document management system files digitized document into appropriate chart Image storage vs. OCR (optical character recognition) Image storage: picture of document stored Fast process, but requires significant hard drive storage OCR: extracts and stores text from image Requires additional manual process, uses very little storage 19

20 Example of scanner 20

21 Fax server Sends print file directly to destination fax machine eliminating paper based faxing processes Receives incoming faxes electronically Used for sending Rx to pharmacies, responding to requests for chart information by third parties and electronic management of incoming faxes Requires: Fax server software Dedicated analog line May require dedicated workstation and/or additional computer board 21

22 Other hardware accessories Card scanner Used at registration desk to capture driver s license or insurance card Image is stored in the patient s chart Electronic signature pad Used at registration desk to capture signature for HIPAA, financial consent and other forms Signature is attached to form and stored in patient s chart 22

23 Conversions One time batch transfer of electronic data from one computer system to another Example: Transfer of patient demographics from existing PM system to new EHR/PM Requirements: Definition of data to be transferred Receipt & loading of formatted file from source system to receiving system (and associated project management) Service fee from both sending and receiving vendors Issues: Data quality, specifications, 3 rd party vendor cooperation 23

24 An ASCII demographics file in Excel 24

25 Interfaces Batch or real-time transfer of electronic data from one computer system to another Types: inbound & outbound Example: Transfer of laboratory data from clinical reference lab to EHR (inbound) Requirements: Agreement on specifications (defining what is sent, how it will be sent, and how it will be received) Service fee from both sending and receiving vendors May require a dedicated PC with full administrative rights 25

26 A sample HL7 message 26

27 Types of interfaces Demographics Medications Problems Allergies Documents--including radiology reports, progress notes, discharge summaries and other text reports Laboratory Billing and coding information Scheduling information 27

28 Training Rank & file training is last major event before go-live Requirements: Assessment & pre-training on basic computer skills Development of job/project specific curriculum/manuals Providers vs. administrative staff Big Bang training vs. incremental Internal staff trainer and/or super users Training facility & computers Allocation of uninterrupted training time Lightening of patient schedule during go-live Staff support during go-live 28

29 Major EHR content categories Log-on and patient look up Provider desktop & PIM Chart navigation and patient history retrieval Progress note creation E-prescribing Messaging Electronic review bin 29

30 Training realities Not everyone is going to like the EHR Learning occurs by doing & in stages Standardizing physician use is hard Baseline computer skills (including typing) are variable First 90 to 120 days are the most difficult 30

31 Role of the EHR Vendor Strengths: Consultant to help define objectives & content Staff resource to lead/assist with on-site training Subject matter & methodology expert Source for training documentation Limitations: Expensive (fees are either hourly or daily) Availability (vendor staff typically have multiple, geographically disperse obligations) 31

32 Training Infrastructure (after go-live) Required for: New personnel New versions of the software Questions from existing users New initiatives (expansion of EHR functions) Consists of: People Facilities Equipment Communication protocols (i.e. help desk) 32

33 Example of training infrastructure 33

34 Photographs from active sites 34

35 Firewall, internet, cables & switches 35

36 Cabling through the ceiling 36

37 Network ports 37

38 Server Room 38

39 Tape backup 39

40 Uninterrupted power supply 40

41 Physician station configuration 1 41

42 Physician station configuration 2 42

43 Nursing station 43

44 Exam Room configuration 44

45 Scanner & fax server 45

46 Document management system 46

47 Card scanner 47

48 Signature pad 48

49 Questions? Bruce Kleaveland Kleaveland Consulting

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