Monday, September 15, 2008

Our future: deciding on ASP vs local

We are coming to the end of the three year initial period; our EMR contract runs out early in 2009. My group now has to decide whether to stay on our local server (located at the hospital), or to move to the provincial ASP server.

We are not the only group deciding on this. There are now three approved EMRs on the ASP server; many of my colleagues, especially the ones in larger, distributed groups, have started considering this issue.

For those getting lost in this jargon, "local" means a server that you own and manage. The machine does not have to be in your office; it can be located elsewhere, for example, at the hospital (all physicians access remotely), or in a physician's office, with colleagues in other offices accessing remotely.

ASP, or "Application Service Provider", means the server and all the software sits in a large server elsewhere, and you just rent space. You don't own the server or the software, only the data; everything that sits outside of your office is managed for you. No worries about upgrading the server, about operating systems becoming obsolete, etc.

Google, gmail, google docs could all be considered as ASP. Your copy of MS Word that sits on your computer is "local".

Seems like ASP is an obvious solution, since who wants to manage a server and all its hardware and software. However, like everything else in life, it is much more complicated than this.

First of all, the ASP server is hosted by SSHA; we have not had an ideal relationship with them. SSHA has had many growing pains, see the 2006 Operational report by Deloitte and Touche. They supply our internet connection with the server, and speed continues to be an issue. Moving to ASP means more of a relationship with SSHA, and we are worried about this. Rightly or wrongly, we do not have much confidence that the server will be well managed.

Second, the SSHA ASP model for the EMR we use is new; like most groups considering this, we don't want to be the first. We simply do not know what issues will arise through the data transfer.

Our local server will soon be three years old. We now have additional physicians on it, new Allied Health Professionals, family medicine residents and medical students, locum physicians, and more administrative staff, all adding data. For example, we now have 70 registered users just for my FHN of 14 physicians. The other FHN on our server likely has a similar number of users, and our Family Health Team is still actively recruiting Allied Health Professionals.

Our IT guy manages the server, but I wonder if this is enough for an enterprise of this size. While we continue to think of ourselves as small businesses, I think we are now at least a middle-sized company (but we do not function as one). I worry about whether we can continue to manage a server without a formal IT department. We now have an IT committee, consisting of two physicians from each FHN (I am on that committee), but I am not sure we have the needed expertise. One of the physicians has been putting in an extraordinary amount of time troubleshooting issues that come up.

Our government funding will be coming to an end in early 2009; to my knowledge, there is no more funding forthcoming, unlike our colleagues in Alberta (they get ongoing funding). There may well be considerable costs for managing our server and the rest of our IT, and I am definitely worried about what will happen when we start to talk about costs with my FHN colleagues who are still sitting on the fence with regards to EMR.

I still favour ASP (cautiously), but there is a lot of uncertainty in our IT committee. The uncertainty is certainly justified; we simply don't feel that we have the information we need to make a decision as of yet.

I am also looking at moving to the new FHT office in 2009; our main lease was finally signed, and we can start the renovations in the next few months. We will have 5 practices, with 3 to 6 physians in each practice, all moving to the same floor of a building, but maintaining their own practices. We will have the main office of the FHT, with our Allied Health Professionals located there. This comes to about 21,000 sq feet, and includes a lab. I have the layout of my new office (I am moving with my current two partners). I now have to think about what to do with my IT (wired access points, where to put the wireless etc). The plan is to have the entire FHT office on EMR.

Despite all this uncertainly, things are generally good at my office. The programs we have implemented for preventive services are working well. My staff told me that several patients came in to the office to pick up FOB kits after the reminder mailing, and all of our FHN secretaries knew to include a requisition when the kits were being picked up. We are now on our 5th or 6th cycle of mailings for paps and mammos, and everyone knows to expect phone calls with questions or to book a pap after mailings.

I have now moved to three days a week, since the beginning of September, with very little disruption; my schedule looks reasonable, and I can see several open spots for next week. I can see that I do not need to reduce the size of my practice for now, as I can manage 1300 patients with the EMR and the additional Allied Health from the FHT. We even have a new resident on block time (more or less full time with us) this month, and are functioning well. My desk continues to be clear of paper.

My staff are now scanning everything that comes in for both of my partners; the volume of scans is increasingly problematic. We still do not have any electronic transmission from the hospitals, from Diagnostic Imaging facilities, or from specialist. Nothing.

I think I am managing well within the walls of my office. The rest of the system continues to present problems; solving those is out of the hands of family physicians like myself, and we continue to wait (and hope) for leadership in the IT front at the local and provincial level.



Ben Quirk said...

Dr. Greiver, your success is really remarkable. You're seeing a measurable impact to clinic care, maintaining your patient load, logging in from outside the practice, and are pretty much paperless!
I usually recommend ASP for medium and large practices. Your local IT guy might be great, but as your site grows you will need greater confidence in your up-time, back ups, and disaster recovery than your IT guy can provide. You just need to ensure that the ASP is extremely experienced and easy to reach (you won't be able to just walk over to you IT guy's office anymore).
Here in the states, I have had a lot of success with Tellurian Networks (which I am in no way affiliated with).

kevin said...

I recommend ASP for medium and large practices too. A reliable system is what we need.

TBD within 2 weeks