An EHR Without Appropriate Technical Infrastructure = Patient Risk

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Home > An EHR Without Appropriate Tec hnic al Infrastruc ture = Patient Risk
An EHR Without Appropriate Technical
Infrastructure = Patient Risk
By Edgar D. Staren, MD, Senior Vice President for Clinical Affairs and Chief Medical Officer, Cancer Treatment Centers of America
and Chad A. Eckes, CIO, Cancer Treatment Centers of America
Created 08/11/2009
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
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2. 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
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3. commonly overlooked locations include stairwells, elevators, and cafeterias.
Continued on next page...
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:
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4. 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?"
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