An EHR Without Appropriate Technical Infrastructure = Patient Risk

By Edgar D. Staren, MD
03:19 PM

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.

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Network Bandwidth -- Unless you have a single site, the odds are you are relying upon metropolitan or wide-area networking to connect at least some of the users to the EHR.  An EHR will greatly increase the amount of bandwidth utilized, especially if picture archiving and communication system (PACS) access is being centralized through the EHR.

Recommended mitigation:  Work with your EHR vendor to model the needed network bandwidth and then double it to account for growth as well as margin for error.

Network Equipment Redundancy - No matter how much is spent to purchase the the highest quality equipment, how old the equipment is, or how great the warranty is, equipment will invariably fail at one point or another. The challenge for IT is to ensure that the end user retains access to the EHR despite the even rare occurrence of an equipment failure.

Recommended mitigation: Ensure redundancy which obviates single points of network failure between any individual user and the EHR application. As a best practice, we recommend meshing the network access for each department across multiple network switches. We also recommend surplus "hot" routers.

Application Redundancy -- In the paper world, redundancy was easy.  The paper chart existed in Medical Records and a backup probably existed on microfiche.  Hybrid environments typically utilize tape backups for redundancy of data.  In the fully electronic world, the concept of application redundancy is not so simple.  Here's a simple guarantee, it's a matter of "when" not "if" the EHR experiences a problem causing the system to be unavailable.

Recommended mitigation:  Implement multiple levels of system redundancy.  We utilize and highly recommend 5 layers of redundancy including the following:

Cluster all production environments allowing for one cluster to be "down" without affecting the other cluster.

Mirror all data real time to a second "hot" data center running a duplicate instance of the production environment for the sole purpose of disaster recovery.  We recommend a "Return to Operation" target of 2 hours for a complete data center outage.

Complete data backups to a disk library.  We recommend 7 days of backup on disk.

Complete data backups to tape and store the tape offsite.  We recommend 6 months of backup on disk.

Finally, implement a distributed "read only" copy of the medical record.  Every 4 hours, we download all patient medical record information in a .PDF file to a server at each location.  In a worst case scenario downtime, processes exist to print and distribute the data to clinicians so as to maintain appropriate care of the patients.

Our departing recommendation is to not underestimate the required technical infrastructure.  In preparation for an EHR implementation, analyze every aspect of the technical infrastructure and create a mitigation plan for ensuring a stable and highly redundant environment. As we remind our team constantly, the burden of proof as to whether you're technical infrastructure is ready for an EHR is if you can answer in the affirmative to the question, "would  you feel comfortable having your Mother, Father, Brother, or Sister treated in this organization?"