Previously, I described some of the benefits gained from having an office computer network, even if you haven’t yet implemented an electronic medical records system. At our practice, even as we prepared for EMR, we began to see unexpected benefits. At that time, the thought that a computer network could help improve overall efficiency in the practice was met with skepticism from staff, especially some of the doctors. Over a year later, I was pleasantly surprised at the variety of ways that the office network makes our practice work smarter.

Emailing Documents Instead of Printing

Any forms that have to be distributed throughout the practice are ‘printed’ as PDF files and emailed, instead of printing memos and physically handing them out. This also allows the sender to keep a record of what has been sent. I have also used this to scan and email important documents to myself, which can then be shredded, so I don’t have to drag paperwork home from the office.

Document Repository

The redundancy and security of our servers makes them ideal to store private (for an individual’s use only) and public (for use by all staff members) documents. Some of the doctors use these to backup important personal or financial information. Large documents that are frequently updated, like employee manuals, can be accessed electronically without the need for wasting massive amounts of paper at the slightest change. It can also be used for important timely documents such as a practice-wide Influenza Pandemic plan.

‘All Hands’ Alerts

Previously, someone would have to call the satellite offices to try to locate a missing chart or document. Now an alert is sent to everyone in the practice via the network. This has significantly cut down on hours spent on this process.

Security Issues

Prior to setting up our practice-wide network, we had a rag-tag collection of PCs which were unsupervised. Any employee could send email or access the Internet with impunity. Now that the amount of bandwidth needed for our EPM and EMR is critical, unauthorized use of this resource is a problem. Our administrator can access email or Internet usage and determine its appropriateness. It is important to note that employees should be instructed that use of practice computers is not considered personal and is subject to scrutiny.

Batch Scanning of Paper Documents

Temporary workers help handle the load of documents which need to be scanned into the EMR system – these include laboratory data, personal documents, or medical records from other physicians. The batches are then processed by clinical techs, from whatever location they may be at, and placed in the appropriate patient files.

Public Outlook Folders

Our executive secretary posts the doctors’ social schedule, meeting schedule, and on-call schedules. The clinical supervisor posts announcements, memos, and meeting minutes. The doctors have also posted any articles of interest to others for viewing. Our marketing director posts ad tracking data, as well as advertising proofs for review. Our EMR committee has a shared task-list folder for sharing progress on template changes or other projects.

Confidential Documents

Our bookkeeper and business office personnel can send certain critical documents electronically with password-protection.

Computerized HVAC Control

We installed this system at our ambulatory surgery center. It tracks temperature and humidity throughout the building and plots these on a graph. Our nurse administrator can optimize the system depending on the use of the facility, and can even remotely monitor the system from home if there is a problem at night or over the weekend. We have been able to run the building much more efficiently, recouping half of the system cost already from energy savings.

Networked Devices

Expensive peripheral devices such as color laser printers can be shared among employees, making them more cost-effective. Newer diagnostic equipment is frequently network-ready, so reports can be accessed from anywhere in the practice without having to print and fax, saving paper costs on both ends. Cameras are also networked so images can also be seen electronically instead of using expensive photo paper.

Employee Intranet Portal

This is basically an internal website for staff members only. What started out as a simple way of communicating within the practice has grown into a myriad of tools, from critical ones to fun ones:

• Practice Wiki – from the Hawaiian word wiki meaning ‘fast’, a wiki is a simple website that can be easily edited by many different users. We use this to post manuals and how-to’s for every kind of task or project.
• Employee blog – this is a website managed by our marketing director and keeps the staff up to date on practice news. Employees can also post news of interest to their colleagues which makes it a great morale booster.
• Security cameras – these networked cameras can be accessed by physicians and supervisors. Buildings can be checked on remotely during off-hours or during periods of bad weather. They can also be used for theft deterrence.
• Doctor scheduler tool – supervisors can check all the doctors’ schedules at a glance to determine optimal staff scheduling.
• Work order system – our staff utilizes an online work order system for department-specific issues. Examples include printer cartridges needed at a particular location, a leaky faucet at a satellite office, or a new employee who needs orientation, security codes, or time card access. These ‘orders’ would then be distributed to the appropriate department (physical plant, clinical supervisor, IT staff, HR staff, etc.). In the past, this required phone calls or paper messages which would invariably get lost.
• EMR Bug Tracker – this is a tool used to post problems or ‘bugs’ with the EMR system. These can range from misspelled words to a template that crashes to a wish list item. Our IT department can prioritize these on the fly.
• Various auditor tools – these are used by different supervisors to monitor things such as schedule changes, use of the EMR medication module, coding audits, or triage workflow, to name a few.

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Regardless of whether or not you use an EMR system, you may already have computerized billing and scheduling. And if you have multiple computers at your practice, most likely these computers operate on some sort of network. Even if you are not the ‘technical’ person in your practice, you should understand the designs and capabilities of computer networks, especially when a complex, multi-user EMR system is finally put into place.

Below are some basic principles of computer network design you should be familiar with:

Networking Basics (WAN, LAN, or MAN?)

Certain network hardware and system software may be incompatible with some EMR and EPM systems. Obviously, you should know this in advance. If you plan on adding users to your network at a later time, it’s often better to buy multi-user licenses rather than individual retail software packages. You can connect computers and printers in a practice on a Local-Area Network, or LAN. The LAN can link up with other local area networks via wireless connectivity. But be sure to check with the vendor of the EMR software to insure that it can operate on a wireless network.

A Wide-Area Network (WAN) can connect other smaller LANs, or Metro-Area Networks (MANs). Large practices can use these WANs to connect multiple satellite offices over a wide geographic area, for example.

The most recognized WAN is the Internet. The Internet can also create the possibility of an Intranet, or a private Internet, on which employees can communicate and collaborate with each other, regardless of where they are located. For such a system to function well between dispersed offices, a hi-bandwidth connection is a must in order to maintain smooth operations. We use an Intranet for such things as employee manuals, a practice Wiki, staff newsletters, photo sharing, and educational materials.

Bandwidth and Topology

Data capacity, or network Bandwidth, is often measured in bits-per-second (bps). In most cases connection rates range from 56kbps to millions of bits per second. Even so, the rates achievable may be limited by the hardware or sometimes even the software used. Overall speed on the network can be drastically reduced when many users are trying to use the system at the same time. If network speeds are slow because the hardware is underpowered or the network design is bad, ‘fast’ connection speed rates promised by the internet service provider won’t really mean much.

Network Topology is also important. Topology is the ‘shape’ of the network, as in the wiring between a series of computers. This topology should have a clean, intelligent design and not simply daisy-chaining PCs in a random, haphazard way. Optimal topography may mean more wires, but this can contribute to overall system resilience from failure due to a weak spot. Otherwise, if one part of the network fails, the entire network could collapse as a result. Proper topography protects against this sort of situation with redundancies. A network consultant should recommend a good balance between expandability and redundancy.

Wiring

In most cases, a practice running an EMR system will employ hard-wired computers connected to a server. However,  some physicians may prefer to input data via a wireless device, as this can be carried throughout the areas in a practice. However, wireless networks present some new points to address:

Signal

Wireless devices have less-than-expected ranges when functioning in an office with many walls. Many consumer-level devices may be inadequate for the needs of a medical practice network. And they may suffer from interference due to common appliances such as microwave ovens or cordless telephones.

Bandwidth

The useful speed on your local network can be limited by the speed of your wireless connection, even if your LAN has good bandwidth rates.

Wireless Security

A hacker can destroy your network if it isn’t protected. Even simple wireless access points need to have built-in security. This is especially important in the age of HIPAA compliance.

Firewall

And speaking of security, you can protect yourself further by having what is know as a firewall. These are software programs, either stand-alone or as part of a hardware device, which protect private networks against intrusion from the outside world. These have become relatively inexpensive for the small business, especially compared to the cost of a successful network attack.

Fat or Thin Clients?

Should you employ laptops (fat clients) that directly run software and connect to your network via a wireless connection? Or, should you run the software virtually with a network appliance (thin client) via a remote connection? With wireless networks, disconnects are an unavoidable reality. In this case, the thin client lets the software continue to run, and you can later pick up where you left off. A broken connection on a fat client may cause a software crash. On the other hand, the latter has certain other capabilities such as running video programs.

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There are many benefits associated with having a computer office network, regardless of whether you are ready to implement electronic medical records (EMR) or not. For example, what may begin as a helpful suggestion from an employee can blossom into a practice-wide tool which can improve overall productivity.

ProtoQue is a program which was developed in response to a problem we were having with our phone triage: we noticed that many patients were not called back in a timely fashion. This program, which is web-based, lets operators register calls automatically. The patient is then subsequently passed off from there to either medical records or a medical assistant. This program manages the ‘chain of custody’ so that the patient doesn’t slip through the cracks. The issue remains open until the problem is resolved. Every time a patient receives a return phone call, a time stamp is created, so our attempts to contact them are documented. The supervisors can use this application to monitor information flow, delegating calls to additional staff if the team falls behind, regardless of where they are located. We no longer have patients waiting until the next day to have their concerns addressed by our staff. Even though our EMR system, like most, has a messaging feature, we still find this program to be more robust and have continued to use it for over three years.

In addition to the phone triage program, we have designed some in-house programs that help us manage specific tasks, and which would not be possible without our computer network:

• The first helps calculate our eyeglass prescription capture rate, which is broken down by location and individual doctor.
• We also have an optical lab tracker program, which tracks jobs in real time, so an optician can tell a patient precisely when their order will be ready.
• Another custom application completes work-orders, and is located on a network that is accessible by IT, Human Resources, and Facilities. If supplies are needed, or a piece of equipment is damaged, an employee can complete a work-order and send it on to the right person. This facilitates full accountability while the chain of custody among the departments is being managed.
• Our Human Resources staff is working on an application that will let new employees enroll using our own electronic interface.
• A new PQRI Tools program which resulted in a significant federal incentive bonus. It attaches to the practice management system and identifies missed reporting before billing.

If you have any comments, please post them here. You can also post any questions you might have about some of our software tools.

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