Sunday, April 27, 2008

Taking care of our server

Our server is getting full. This is both a good and a bad thing. We thought we bought plenty of capacity when we first started; however, we are running out of space, after a little over two years.

This reflects the fact that the EMR transition is going fairly well; pretty much everyone is scanning everything in. We are increasingly giving up on paper-based processes. All labs are coming in electronically.

As well, we are now adding five more physicians to our group. Information Technology changes at such a rapid pace that what was considered pretty good two and a half years ago, when we bought our server, is now barely adequate. We now have to add extra capacity, and are working with our EMR company to do so.

When I switched to EMR, I ditched my old computer, which dated from 1996. EMR applications are far more demanding, and you use them constantly. It is a good idea to maintain and update both hardware and software. Some peripherals, like printers will last longer; the computers' hardware and software will likely need upgrading sooner. You also have to think about replacing parts.

For example, a label maker broke recently and we had to replace it. I just ordered a second scanner; I will have to buy a PC to go with it. I bought a new battery for my Tablet, after a year and a half. We broke three shredders when we first started (buy shredders with a replacement warranty).

However, the server is at the heart of your practice. It will need to be upgraded, and eventually replaced. Plan for this, and budget for it; a server that does not meet your needs is dangerous: it will slow you down, and it will eventually fail.

The IT committee for my group is functioning well, and we are meeting regularly; we also talk frequently by email. We have met with OntarioMD and with SSHA, as well as with the head of our hospital's IT department. We are still weighing the risks and benefits of a move to ASP; in Ontario, there are now three large EMR companies on ASP (1 previously approved, and two approvals are pending). We see the finite lifespan of a server happening in front of us, and what server maintenance for a mid-sized group of 23 physicians entails. Going to ASP means renting space on a very large, continuously updated server (not that this is without problems either); doing this would mean completely outsourcing server maintenance and upgrading.

In Ontario, government subsidies for EMRs end after three years. We will be at that mark in 2009. I can see that there are on-going costs; in Alberta, the government has decided to continue to subsidize and support EMRs. Perhaps this is something that Ontario should consider as well.

I have joined the IT committee of the Ontario College of Family Physicians. We are reviewing the key issues impeding the transition to EMR; failure of the system to connect continues to be right at the top of the list. I am increasingly reluctant to forward any proprietary forms. We have a new tri-hospital initiative to expedite colonoscopy after a positive fecal occult blood test; however, the first thing that the program did is send us copies of their proprietary referral form. We discussed this at my hospital's recent family medicine business meeting; programs have to realize that this approach is no longer acceptable. I had a patient with a positive Fecal Occult Blood last week; my first referral was generated in the EMR, with a note requesting a waiver from the form (Je Refuse).

I am now generating public health requisitions within the EMR; the req contains the same information as the proprietary form. I have staplers in every room, and I staple a blank proprietary form behind the real form with four staples so it is strongly attached. There is a Six Sigma Method for improving quality; I call this method the Four Staples Method for patient safety.



Ian Furst said...

If it's not too personal due you mind sharing the appx cost of renting the space for the ASP on the server?

Michelle Greiver said...

Hi Ian

I don't know yet what it will cost, as we haven't been told. From what I understand, the cost is fixed by SSHA (I am not sure about this). When we looked at ASP three years ago, it was about $400 per physician per month, which included the cost of the server, EMR software and support (both server and EMR software). There was no up-front EMR licence cost for the ASP model at that time, just the monthly cost. The internet link is provided free by SSHA. This is actually less than what it costs to buy and maintain a local server, but there are economies of scale for ASP.


Ian Furst said...

Even if a T1 is included $400 x 20 x 12 sounds steep for the year but I've never priced it out myself before. Thanks for the insight. Ian.