Sunday, March 30, 2008

Uncertainty principle

We will be coming to the end of our EMR contract in early 2009. Most contracts in Ontario are signed for three years, because that is how long the subsidy lasts.

Now we have to decide what to do next. Our main options are to stay Local (server at the hospital), or to go ASP (server hosted at the big SSHA box). It is a difficult decision.

We were one of the first large local installations, with 18 physicians at multiple sites, all managed from a single server at the hospital; we own the server. This freed us from having to deal with lab downloads, backup issues, upgrade installation, and all the other server management problems. On the other hand, our server went down recently, and it was not clear who needed to reboot it (the hospital's IT department? The EMR company?) This led to a delay in rebooting the machine, and a loss of service; remote hosting is not without its problems. We are now growing, with additional physicians joining our FHN, as well as all the new Allied Health Professionals. While our server is still adequate to meet our needs, we don't know how long that will last.

Going to ASP (Application Service Provider) would mean moving our data to a fully managed server; the company owns the server, and we just rent space on it. There would be many more physicians also using the same server, so all upgrades happen at once to everyone, and problems are dealt with (or not dealt with) for many of us. We do not know if we can move our data safely to this new server. As well, it may be better for our FHT if all of us were in one large application, so we can share templates and information; I do not know if that is possible.

Because the problem is complicated, we have formed a committee to look into it. Committees are sometimes good: they spread the work (and the blame if needed) around. We'll be looking at the pros and cons of each alternative; just like when choosing EMR software, there are no perfect solutions.

After two years, I think my group has done pretty well. There are now 10 of us in my FHN (and my partner is about to start). We are now at 50% paperless, 40% partial (both paper and EMR), and 10% never started. It is very difficult to come by figures for the "average" implementation; it seems to me that partial implementation is the norm. The National Physician survey shows more family physicians on both paper and EMR (19.4%) than physicians who are paperless (12.3%). It seems to me that about 25% fail to implement, 50% have partial implementation, and 25% are paperless; that is the sense that I am getting from what I have read.

One thing that worries me is what happens when funding stops. For those who never implemented, this is not an issue, they will simply drop the EMR and only pay for billing/scheduling. The physicians who are paperless will not go back to paper. It is those in the middle, who are progressing more slowly, who are at risk; if there is no funding, I think some will abandon the EMR. It seems to me that this may still be a majority of physicians once funding stops.

More uncertainty for us; I thought we were finished with that once we bought the software, but it was just the beginning.



Ian Furst said...

Michelle -- we are similiar size (with 4 locations and the associated headache's) and have gone to an on-site servicer. Obviously there's increased cost but also increased control and integration. Absolutely worth it. Feel free to come by some time to see what's been set up or give me a call if you'd like the name of our IT person. We went with an HP server solution under terminal server. Very stable.
ian underscore furst at yahoo dot com

Anonymous said...


If you want to email me I can relate to you my experience with the ASP solution. Ours is managed by our provincial government.

Michelle Greiver said...

Hi Ian

Switching the server from the hospital to one of our offices is one of the several possibilities at the end of our contract. This is an unlikely one, however. We do not have an office that would be able (or willing) to manage this, nor would it be fair to put the onus on one of us. I certainly do not want to have the server in my office, and be responsible for all of us.

We now have 21 physicians, all our support staff, and an increasing number of allied health professionals. This is distributed amongst 9 practice locations, ranging from a six physician office to solo physicians. As well, there is now the central FHT office where some of our Allied Health are. That may be a place for the server, but they have enough to manage just with FHT start-up right now.

OntarioMD has names for all these different server setups. Configuration 1 is where each office has its own server, and information sharing is pretty minimal. Configuration 2 is where one office has the server, and everyone else accesses it remotely. Configuration 3 is where the server is not in any office, but is located and managed at a hospital, and we all access remotely. ASP is where the server is at a big provincial server, and we basically rent space on it. We are currently a configuration 3 group. I do not think we can function well as either a config 1 or 2, it is enough for us just to manage our internal IT, like printers and local PCs, Tablets and network.

I do not think any of these set-ups are perfect, they all have problems. Config 1 (server in your office) is probably ok for a larger group of physicians all practicing in one location. Config 2 is ok for 1 main location, with a couple of satellite offices, where the setup is not too big and the office can handle it. Config 3 is ok for a bunch of distributed offices.

ASP is likely the way of the future for most us, as there are many many problems with physicians managing servers individually, but it depends on connectivity and how well the set-up is run (and sometimes it is not run well). For larger groups, or for solo/small office physicians who are not IT savvy, it may be the least evil solution (sometimes).

None of these are perfect, they all have their pros and cons. I think that the Uncertainty principle certainly applies.

Thank you for the invitation to visit; I may just take you up on it!


Ian Furst said...

just read the response Michelle -- I can see that if you're doing it for purely EMR the ASP would work well and be stable/"simple" (although I'd love to see how the printer/peripheral issue sort out).

I think you loose flexability with the ASP and I'm in favour of the Config 2 solution. To drive practice efficiency you need to go way beyond the EMR which is tough in an ASP enviornment (I think -- haven't actually used it but we've also debated this ad nauseum so take all of this with a grain of salt). We use it with the connections through terminal services. It increases integration with email, schedule, etc... and let's you play more.

I suspect the bandwidth costs increase but the maintenance is about 2FTE staff to administer. If you're a larger group I think you'd make it up quickly because of improved efficiencies from having the ultimate in data management. Thanks Ian.

Ian Furst said...

michelle 3 quick questions
which EMR solution are you using (vendor?).
how do you monitor wait times?
how are files transferred to other clinicians (.txt? - that's how we get ours from the hospital).

thanks. Ian.

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