Tuesday, September 08, 2009

Internet speed and quality of care

I have a fast connection to the Internet in my new office. The reason for this is that we have several practices on our floor, with a lot of physicians, staff and Allied Health Providers. eHealth Ontario has provided us with a bigger connection, because we are now a medium sized business rather than a single small office.

At my previous office, I had a “regular” internet connection, similar to what most of us have at home. There was some security overlay on this connection, through eHO’s central circuits, which reduced speed. Security is important (these are medical records we are talking about), but there is an effect on speed. As well, the security overlay failed at times, which affected multiple practices across Ontario. My access speed at home, via VPN, was always much greater than at the office. The single office internet access line was shared between all of us at my office, and the net speed per PC varied, depending on how many people were using our computers: number of physicians present, front staff, residents, medical students, “special projects” (such as our preventive services audits). As well, we found fluctuations during the day: it was slower when everyone logged on together at 9 am, or when there was heavy system internet use, such as 4 pm (probably kids coming home from school and logging in).

Our server at the hospital also had an older access line, and an older firewall. This limited speed of access at times, even if Internet speed was good. The lines coming into the hospital were unstable at times, and we had several outages.

eHealth Ontario has been working collaboratively with our IT manager to solve these issues. It does not seem like a simple problem to me; there is a cost/benefit ratio to providing faster lines, and I know that funding is not unlimited. There are many factors influencing speed. However, slow or unstable lines do have an impact on patient care.

The three months before my move were more difficult than usual, with more frequent slowdowns and outages; when the system slows, we call our IT manager, and he tells us whether to switch to our backup internet line, which we buy privately. Our IT manager is allowed to handle this for our group, as it works better than having each office call eHO individually. Switching to backup means that all office computers access the EMR via VPN (Virtual Private Network); we only have a limited number of VPN passwords, so the number of computers in use is restricted. Some networked printers don’t work. VPN at the office is unstable, and logs us off periodically. Using the backup internet line does not work well for more than a few hours, but does allow us to continue using the system. Once our IT manager tells us that the eHO lines are working again, then we switch back; we have to log off, stop the VPN, wait for 10 minutes for the eHO Internet connection to come back, change some computer settings, and then reboot all the computers. Because of all the work, it is impractical to do this while seeing patients; we stay on backup and switch at lunch or after last patient is seen in the afternoon.

During the slowdowns, I often could not look at my flowsheets, and I did not print information for my patients to the same extent that I normally do—no labs, no CPPs, fewer handouts. Printing just took too long and was too frustrating. I limited the amount of information entered in the chart to essentials, and less information was coded, because that took too long. I finished charts at home. If it was really too slow, I wrote prescriptions on a paper prescription pad. Sometimes patients would ask me about results, and I just couldn’t look them up; one of my patients commented that I had problems for two of her last three visits. In addition to being unable to look at and input information, I was very distracted and upset, which made it more difficult to give my patients the care they deserve.

eHO has now upgraded our hospital line, as well as the firewall at the hospital server. Access from home is noticeably faster. However, the biggest difference is access from the office, via the new lines— we are no longer on “normal slow”: my secretaries are not frustrated with information coming in at eyedropper speed, and I can look at records without thinking about what I can or can’t do. This just feels right.

A colleague in Markham on another EMR system told me that they had two sites: one with a local server, and a second with remote access to a hospital-based server. The second site eventually switched to local because of the same issues we had (access line speed and stability). His comment: “an absolute requirement is fast, stable access to servers”. We just don’t tolerate slow access speeds while using EMR.

Despite the difficulties, I still believe that ASP (one large server for multiple small practices, remotely managed) is ultimately the way to go. We could not have done our preventive services project, our diabetes reminders and common flowsheets, or the data quality improvement summer projects if we had individual, isolated servers in each office. I believe that Quality Improvement initiatives should start and be tested within individual practices, then be spread to the group if successful. Spreading QI is much easier if you have a common server—you can have similar data entry for several practices from a single location once you all agree on what to do. However, a prerequisite for this is IT stability and speed.

We have been talking with eHO, and I think there is a good understanding and appreciation of the importance of this issue with respect to the quality of care we provide to patients. I am now seeing sure signs of progress at the front line. eHO is upgrading the Small Office Firewall Appliance (SOFA) in our offices to a more modern firewall and router system in a month, as part of a provincial initiative. The move to my new office involved a complex IT installation; however, we were up and running from day 1, due to collaborative efforts between our IT manager, our FHT’s IT manager, and eHO’s staff. My husband’s large business moved last year, and he commented that one of the most difficult aspects of the move was making sure that the IT transfer was seamless. eHO has been criticized heavily in the press for their consultants’ billing practices; it is harder to talk about what goes well, and I can say that the job was done right in this instance.

In my practice, we are now posting monthly graphs for quality in our staff room’s bulletin board (for example, percentage of diabetics reaching targets for blood pressure, cholesterol, blood sugar control); you can’t improve what you don’t measure. Perhaps we should think about having reports of system access uptimes and access speeds for practices using EMRs posted online. I think that this may give a more genuine indication of progress at eHO.



Unknown said...

physician practicing in Toronto nice information in ur blog thanks for sharing
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kashif ali said...

The future of health
innovative thinkers in health care to predict the future of care delivery
By Sara Michael

The year is 2025. Do you know what your profession seems?

Try to imagine how the practice of medicine will transform in the next 10-20 years - not an easy task taking into account recent efforts to reform the health system and the scientific discoveries that even after six months in crystal ball a little cloudy.

Will high-tech full scans of the body, an IPAD in the hands of every practitioner, and the hologram version of himself to be picked up at the homes of their patients?

It is unlikely, but rising costs and growing demand in the health care system certainly requires a transformation in the physician's role today. Rather than the universal adoption of EHR or the use of smart phones, the practice of the future is likely to reinvent the model of care delivery, reimbursement to rethink, redesign and technology.

Here, some innovative thinkers and practitioners of medicine aims to re-imagine the doctor in the future, as pointed out by some of the innovations taking root today. .