Edgar D. Staren, MD, Senior Vice President for Clinical Affairs and Chief Medical Officer, Cancer Treatment Centers of America
Chad A. Eckes, CIO, Cancer Treatment Centers of America
An EHR Without Appropriate Technical Infrastructure = Patient Risk
August 11, 2009
An often times overlooked aspect to implementing an electronic health record (EHR) is the need for a solid technical infrastructure.
Unfortunately, most organizations in healthcare do not have a technical infrastructure that is fully prepared to handle the needs of an EHR safely.
The typical "as is" state of infrastructure in healthcare includes: spotty wireless coverage, networking with inadequate bandwidth, under capacity data centers, and a severe lack of redundancy. Implementing an EHR on top of the typical infrastructure can lead to significant issues and failures with a direct impact on patient care.
If one thinks through the root cause of why this is the case, you come to an understanding that the technical infrastructures are in the current state because there wasn't a need for them to be more robust. In paper-based or hybrid paper/electronic environments, clinical operations easily continue when the systems are unavailable. Even in a hybrid environment, clinicians can care for their patients and complete the documentation on paper. This is not possible with a full EHR environment.
This situation becomes especially concerning when you consider the American Recovery and Reinvestment Act of 2009 (ARRA). ARRA provides substantial financial incentives to help organizations implement healthcare information technology (HIT) systems, especially EHR. The goal of course is to prompt healthcare organizations to aggressively begin implementing EHR solutions.
Although these organizations may be receiving incentive funds for implementing approved EHR's, they are not receiving incentive funds for upgrading their technical infrastructure; the latter can cost as much or more than the investment in an EHR. The result is that organizations may endure significant cost with no associated financial incentive to support upgrading their technical infrastructure or they may attempt to implement the EHR while maintaining an inadequate infrastructural status quo.
Unfortunately, many organizations have and continue to opt for the latter resulting in significant risk to their systems reliability and therefore, to patient care.
We have chosen four common scenarios of inadequate technical infrastructure to explore with recommended approaches to mitigate such risk. Whereas each institution will have their own unique threats, one or more of these four tend to be present in most organizations.
Spotty Wireless Coverage -- Most EHRs are designed to rely upon a consistent wireless network connectivity so as to bring the EHR to the point of care.
However, the fact is that EHRs do not handle network "blips" gracefully.
Moreover, most wireless infrastructures are full of network "blips" including clumsy migration across access points, insufficient coverage for saturation of users, low coverage areas, and inappropriate mixes of protocols impacting performance.
Recommended mitigation: Complete a full wireless survey of the facility which covers every location. The most commonly overlooked locations include stairwells, elevators, and cafeterias.
Continued on next page...
Showing 2 Comments
Dan Draper say: Don't forget about power and cooling
August 13, 2009 | 09:05 AM GMT
I couldn’t agree more about the necessity of evaluating the IT infrastructure when implementing EHR and other HIT applications. Another area that should be addressed is the necessity of uninterruptible power and precision cooling. A utility outage, voltage sag or brownout will cause servers and routers to lose connection and reboot, resulting in the loss of any patient data that was in transit. A power surge could also damage the expensive IT hardware purchased by the facility.
Also, with all this new hardware, there will be a huge increase in heat density. I constantly see hospital network access rooms with overheating routers because the building’s comfort AC isn’t enough to properly cool the equipment. This is especially true in ambulatory facilities where AC is turned off in the evenings.
pcharland say: System redundany and clustering
Another challenge is, depending on the size of the hospital or practice faced with these decisions, the lack of IT expertise or staff that's sophisticated enough to deal with many of these complexities. Even in larger facilities, there should be consideration given to how much complexity - along with risk - can be tolerated. Many EHR deployments fail to consider uptime options due to perceived complexity and cost. There are alternatives to clustering for example which are software based, easier to implement and lower in costs, yet offer reliability greater than a clustered server option. All EHR implementation plans should understand the options for increasing availability based on the technical options, operational complexity and costs - compared against the risk and impact of downtime. In most if not all cases, even the smallest of deployments can incorporate solutions that increase system uptime within their budgets and operational capabilities.