Friday, January 18, 2008

Planning my new office

Thinking about my new office presents challenges. I may have to change some of my technology (phone, fax), and rethink some of my practice processes (again).

For example, should I consider VOIP (internet-based phone)? What about Internet faxing? A fax line costs $50 per month; Internet fax costs about $10 per month, there is no need for a fax machine, and it is always on (without the need to leave the computer attached to my fax on). Long distance is free. My secretaries are already faxing directly from the computer more and more often. We can use the scanner to fax things that are paper-based. On the other hand, I don't know if Internet fax is secure, and I have not seen how it works. I really don't know anything about VOIP.

We will have many physicians and allied health workers in the new office; there will be 5 practices, each with 3 to 6 physicians. Our Allied Health Professionals will have their central offices there. The FHT administrative offices will be there as well. All of us will be on the same EMR system, and the plan is that physicians will be able to access it remotely for booking. EMR training for our AHPs has just taken place. We will need significant Internet bandwidth to take care of all this, and probably someone on-site to manage the IT. It is exciting, but also more than a little scary to me; it feels just like before we embarked on the EMR project, with many more questions than answers.

My group is now starting to think about what to do when our EMR contract expires, in 2009. We can choose to remain on the hospital-based server, or go to ASP. Our provincial subsidy ends after three years, so we no longer have to comply with the provincial stipulations (use SSHA's internet lines, use a Certified EMR etc). Many of my colleagues in Ontario are going to be in the same boat.

The benefits of staying with our current server are that it is a known quantity. However, it will need to be upgraded (we are taking on new physicians, and the amount of data going in is increasing).

The benefits of going with the SSHA ASP is that provincial healthcare data is going there, so there is a better chance of linking with the rest of the system. Hospitals and Home Care are sending data there. However, much of this is still theory, not fact. The drawbacks are that we have to continue to deal with SSHA; this has not been a physician-friendly (or even customer-friendly) organization in the past.

The benefits of going with the company's ASP (which is not Certified, we could not do this under the terms of our current contract) is that we can access over regular internet (faster than SSHA). This is much simpler and easier.

I am leaning towards the SSHA ASP. I know the problems with SSHA; however, I do think this type of structure gives the best chance of having the data follow the patients. As well, we need to have our data professionally managed and backed up; I was speaking with someone who had been at at physician's office, and saw a sign asking people for patience, as they had lost two months of data. I worry about the small servers in solo or small family practices; not all of us are good at backing up our data. Data loss happens, not everyone is careful; while there are risks in large data centres, I think the cumulative risks in many small, unsupervised practices are likely greater.

I was looking at CanadianEMR, and saw that the results of the 2007 National Physician Survey are now available. It looks like 19% of family physicians are now using a combination of paper and EMR records; that may well represent people currently transitioning to EMR. 12% of us are using EMR only; that must be those who have completed the transition. The total for EMR (full or partial) is 31% of family physicians; for all physicians under age 35, it is 45%. These are much higher rates of adoption than previously reported, and the numbers may mean that we are now in the "early majority" phase of EMR adoption.



Art_Vandelay said...

VoIP is definitely tempting to businesses as the costs are relatively low for the initial equipment (you probably have most of it) and the ongoing service costs are very low in comparison. VoIP systems typically allow easier integration with the computer (i.e., dial directly from your online address book, take information from the computer and combine it with information captured via the telephone). The drawbacks come with a network outage (i.e., local issue where your router goes down - you would be without phone and your EMR), an Internet outage (same as a local outage), or a major power outage (cell phone towers, your router and ISPs sometimes lose power if there is an extended outage). Also you need to consider how the phones are powered (i.e., have their own power source from the wall, use Power over Ethernet, built-in to the PC). If you elect to go VoIP, I'd be sure your UPS supporting your router/server has enough power for a period of time you determine, your critical PCs also have a UPS and you still have an emergency "POTS" (plain old telephone system) line. The phone companies power most phones via the phone line and have more than adequate power back-ups in case of a disaster.

Michelle Greiver said...

Thank you. It sounds very Fiddly still, when compared to a regular phone. I had a look at Vonage business, and it is $69.99 per month. That is not different from a Bell business line. Most physicians do not use long distance much, nor do we use most of the extra features. I am not convinced that VOIP has a place in small practices for now.


Anonymous said...

Thank you for taking the time to inform the rest of us on EHR's and EMR's.

altadel said...

Dr. Greiver:

Do you see a market (admittedly small) for an IT consultant with some years of experience supporting small clinics in EMR installation and maintenance working with architects on how to design clinics for 21st-century medicine? The clinics I've helped switch to EMR from paper were designed in the paper days, and in some cases "going electronic" in the exam rooms, not to mention offices, lab rooms, and reception desks is made more difficult and work flow is inhibited by layout issues.

Michelle Greiver said...

I do not know. That may depend on the size of the clinic and the size of the consultant's fee.

It seems to me that the field of EMR consultancy is evolving. I do not know whether consultants have an effect on individual practices; I think they are more important in policy and system planning at the moment. Effect on small practices may depend on the consultant's knowledge of local conditions and physician's own processes; that will affect the quality of the advice. Generic advice is widely available, you do require specific advice. It may also depend on the willingness of the physician to follow the advice; that will depend on the amount of trust in the consultant.

It would be interesting to compare EMR implementation with and without external consultant input. In my group, we did not have consultants.

I have designed my new office layout with a professional office planner. I think adding a consultant for EMR specific space planning may work for some practices that are moving to a new office specifically to transfer to EMR. I don't think most practices transferring to EMR will renovate at the same time. We'll likely do the minimum required to accommodate the computers, as there is already too much turbulence.


Ashkan said...

Hi Michelle,

I use Single Number Reach (SNR) system from bell for my faxes. Its $12/month and you can convert your current phone number into a SNR number and recieve faxes online. So when you recieve junk fax you can view and delete it online and save the environment. For sending fax you can always use your computer or scanner.

Hope this helps,