Yay, I work for a small business.

Fast forward a couple years, your neighborhood kid has outgrown the IT position and you are now getting $4000 quotes for a server, licensing, and installation; plus $500 on monthly retainers from the local IT shop.   You expedite things now because the server is on the verge of complete failure and upon reviewing the books at the end of the year you are now aware of $2500 in additional IT costs.  Does this sound vaguely familiar?  It all creates the thought provoking question, when do all the administrative costs end and you can just focus on selling your own products and or services for your own company?

Well administrative costs don’t end but you can at least contain them.  Infrastructure as a service is the solution I’ve been preaching for the past year now.   In its simplest form, think of it as your cable bill with support and additional services that can be added or subtracted throughout the tenure of the agreement.  Basically, your IT equipment or infrastructure is no longer owned and maintained by you.  Frightening thought?  Not really.  You have fortune 500 like services and support but without all the hassle and for less than your generic IT guy is providing in IT services on a monthly basis.

Still not intrigued?  Let’s talk about reducing energy, limiting hardware replacement costs, and containing maintenance below.

Did you know…

• A server cost about $200 to power a year
• A computer cost $45 to power a year multiplied by five computers in the workgroup is $225
• $4000 is required for a new server, license, and labor.  Not to mention the three to five year server lifecycle.
• It costs $1000 for workstation replacements
• A typical monthly IT retainer averages $500 covering five users and one server.

Let’s do some quick math after one year…

Energy: $425
Server Software & Hardware: $4000
Maintenance:$6000

Total: $10425

It is completely plausible that you do you provide some of your own support so you can slice that in half.  That can bring the cost down to $7000 but you can get all the latest hardware and software without all the worries, plus 7 to 7 support, for a fixed price that is significantly less than that monstrous total.  For some it’s a no brainer, others may need to take a step outside the box and look at things differently to appreciate this new setup but with the exponential cost savings it’s definitely worth looking at.

VoIP solutions like high end hardware from Avaya that are very scalable or simple software like Skype, Google Voice, etc. can make super flexible mobility happen.  However, most people think they are still tethered to the office desk because of their software.  Most software these days is offered as SAAS – Software as a Service.  Generally, all is needed is a web browser and the credentials to login.  They can then work from anywhere.  While this tends to be more and more the case, some software requires a complete Window’s installation of some locally installed software.  The software tends to be not as flexible as web browser based apps.  The laptop you were using in the office that was relocated to Starbucks is off the grid unless you have some remote connectivity in place to connect to that lingering local server app back in the office.

laptop on the run...

For the less flexible software, remote Connectivity varies depending on what solution you opt for.  Remote log in tools such as LogMeIn is the best in the business  for connecting to a remote desktop but a lot of people can consider this sometimes to convoluted or delayed.  Other remote connectivity may include site to site VPN that people tend to stay away from because they are simply unaware of the product or for the labor involved of setting it up.  There’s also VPN software that us used to extend the office network virtually anywhere you are located.  This again cannot be a fun solution because it is sometimes a slow and it annoys people if using VPN software.  Certificate based remote connectivity is a no nonsense based solution but not every software has that capability.  I think the best solution these days is to start hosting everything out of your local data center or colo.  All these remote tools still work from VPN to remote desktop but it is housed off-site in a secure location instead of the broom closet at your office.  Popular Data Centers in San Diego include Level3 and AIS.  Level3 is in Sorrento Valley while AIS is a little more centrally locating in Kearney Mesa.  Although, you may want to consider “infrastructure as a service” if you are hosting equipment outside of your office.  Manage Solutions Providers or MSPs offer competitive rates for this service.  The majority of your workstations or “clients” are now downsized to a thin client where no data is stored locally and the server at the colo is actually performing all the work.

Email tools such as Outlook in conjunction with Microsoft Exchange have the ability to jump on with your laptop from Starbucks or any internet connection and immediately connect with a certificate.  No VPN or clumsy OWA.  However, the latest Outlook Web Access is so easy to use that you may think about removing the locally installed software from your machine.  It really comes down to parting ways with locally installed software and embracing SAAS.  SAAS makes things more hardware agnostic.  You can use your iPad, Android, or PC and still get the same feel but it generally comes with a monthly subscription fee.

However, all those remote connectivity tools go out the window when that internet fails.   Companies with a retail presence or some situation where they can never be offline due to immediate lost revenue must consider having a locally based server to collect all data then synchronize when the internet connection resumes but I digress.

For the less demanding workforce, all the basic SAAS tools are fine.  Avaya IP Office allows you to extend your office extension to your laptop and use it as a “softphone”  ala Skype.  Small businesses can quickly outgrow Skype if they have a considerable amount of calls coming into the main line.   Google Voice has its place for businesses reluctant to give their cell or office line.  It’s a great first line of defense against cold calling agencies and annoying people.  The voice to text feature is beautiful for dictating voicemails.  Whatever route you choose, get a crazy consultant guy like me to assess the situation, have him give some great insight and or his seal of approval.

ultrasound equipment Acuson 128 XP

Fortunately, she didn’t rush to judgment and contacted our helpdesk line. We were able to get a $30 part to connect the EHR workstation and stream video of the ultrasound to the computer. I advised her to never by new if the ultrasound finally decides to die. There are refurbished units out there for a fraction of the cost
Once again, all is well in the world and we can all sleep well knowing NA is out there. :p

I’m not suggesting converting to high end MFP with toner but just realize they make their money on ink.  For businesses or doctor practices that are producing a lot print outs and still want something intuitive like a Canon, I suggest Kyocera.  Yes Kyocera, not HP.  HP is great for very high end printers but the SMB market their drivers are atrocious and the product breaks all the time.  Not to mention, it’s not easy to use.

You get what you pay for.

I plugged in the Kyocera CS-5050 into the network and once my clients Controller had at it with her Mac and she absolutely loved it.  They are now looking to replace all the SMB MFP HPs at their other business with the Kyocera MFP.  I think the latest version of Kyocera MFP hardware is called the FS-1135.  I have to deal with it but feel free to look it up.

Anyway, say you want to scan something like 3 pages in the ADF Feeder.   Simply press a button and the device not only scans but sends the attachment straight into your email inbox.  You can program it for additional inboxes as well.

Tired of replacing ink cartridges?  The toner will probably last a year for most businesses.  I formed a partnership with a print/copier company because I liked them so much.  I don’t get much out of it except demo units for my clients that are tired of something that doesn’t scale to their needs.  Seriously, I have one client that have over 50 of those crappy Dell MFP and other Dell toner printers.  This cost the company several thousand in toner replacement each month alone.  Don’t wait, check these printers out!

There are several things to consider.  Knowing that you have patient records scattered everywhere, can you scan the next 3 months of patient records then on a ad hoc basis retrieve records from what is hopefully a storage facility?

This looks more overwhelming than home depot

Yes and no.  As much of you like to purge boxes and boxes of patient charts, HIPPA  forbids you to do so.  The retention rate in California alone is 10 years before you can incinerate those records or delete the digital version if you already converted.   Simply scanning all those records may unfortunately lead to archive data on server hard drives that less than 10 percent may actually be used.  My advice is to retain digitally two years of data or three visits.  The rest can be stored in offsite storage location.

The format varies from EHR provider to EHR provider but Eclinical Works and Allscripts prefers their scans be in a TIF format.  Check with your provider on the best format to scan your records in.

While I don’t recommend doing it in-house because of HIPPA issues if you do proceed please purchase a heavy duty Fujitsu flatbed scanner.   These scanners are robust, fast, and most important they are compatible with all Electronic Health Records Systems.

Oh yeah, regarding compatibility don’t muddle around with patient intake using something that something that adds a significant amount of time for the admin.   There’s hardware now out there that pulls insurance card and driver license information straight off the ID all in one fell swoop.  Seriously, spend more money now your office admin will thank you later.

Controller (Commonly known as a Host Bus Adapter)

• Host Bus Adapter – HBA converts PCIe card slot on a server to one of many interfaces listed below.  The basic form of a HBA is your NIC on your desktop.  High end HBA listed below are manufactured from companies like Qlogic
  • Host Bus Adapters running on the “SCSI Protocol”

-Centronix  i.e Adaptec 2930: The cable that attaches to adapter looks like an old printer (parallel) cable.  Still common in external tape backup drives.

- SAS: This serial cable replaced the old Centronix cable and is currently in use by many high end products today

-Fibre:  A fibre optic cable is commonly used in high end Direct Attached Storage

-Twisted Pair:  Used in iSCSI Storage Area Network and can be run on the same network equipment as the rest of you LAN

• Storage Devices
  • SAS: Expensive, fast, and robust hard drive on the market.  Commonly used in high end servers and data storage devices
  • SCSI: SAS predecessor used a different interface to connect the drive.
  • SATA: Cheap and slower hard drives commonly used in desktops, laptops, and external hard drives.   It also saves money when purchasing archiving equipment such as a SAN to provision your less accessed data on SATA drives.  Note:  SANS are typically $75,000 plus storage devices.  So this extra tidbit of information may not apply to you.
  • IDE: SATA predecessor, used a different interface to connect the drive.
  • Backplane – Used in high end DAS and SAN units with it own controller to operate the disk arrays.  Ie. Disk sub system
    • SAS – SAS bays can handle SATA but not the other way around.
    • SATA
    • IDE
    • SCSI
    • Host Bus Adapter Speeds
      • SAS

-3 GB

-6 GB

-9 GB (not yet available)

• Fibre Channel

-8 GB

• Disk Drive Speeds
  • SAS Drives 3 GB
  • SATA Drives 3 GB
  • Ethernet Speeds
    • iSCSI 1 GB (works fine w most networks)
    • iSCSI 10 GB
    • iSCSI 100 GB

Common RAID product lingo

• On the host side, use fibre to SAS/SATA arrays

Fibre Channel equipment

• Direct Attached Storage and SAN
  • Uses Brocade switches, Qlogic HBA, and Cisco

Common high end RAID

• RAID 6 – it’s like RAID 5 but contains an extra parity disk
• RAID 10

Software Arrays

• Dynamic Disks (Microsoft)
• MD Array (Linux)

iSCSI high end storage allstars (based on popularity, not necessarily best choice)

• Compellant (Now Dell)
• Lefthand (Now HP)

Anyone catch the article on Electronic Medical Records in Businessweek? Check it out…

article on Electronic Medical Records “Silicon Valley Gold Rush” in Businessweek

The first is taking about the great shift to electronic from the dated ”zombie” paper records and who are the major players in this arena. It’s pretty good read. The next is the man behind Obama’s push the adoption of EMR through the 2009 “Stimulus Bill” where part of the bill initiated the “HITECH Act” to help cut or control costs through implementing EHR systems and the government would incentivize doctors through huge subsidies that decrease over time. It may be in a doctors best interest to purchase their Electronic Health Record system now while the government is tossing out tens of thousands of dollars but some are hesitant because some software may be obsolete through acquisitions or not retaining a big enough market share to be compete. Read on…

article on Electronic Medical Records “Digitizing Health Records” in Businessweek

Anyway, we nerd it out with the following equipment:

(In the four post rack)

Dell PowerEdge Servers

DLT and LTO Backup Devices

UPS Power Backup

(two post rack)

Patch Panel

HP Procurve

Cisco 2800 Router connected to Cox High Speed Internet

Sonicwall Firewall

Hardware and Software Requirements:

• Windows Server – The majority of small businesses still run on 2003, 2008 server is preferred.  Servers should be on a 3 year life cycle.  Anything older is considered out of date and will fail.
• The Windows server “database server” or “dedicated server” meaning not shared with any other services or applications like a Domain Controller, DHCP, DNS, VPN, RDP, or RAS host.
• Static private IP should be applied to the server
• Latest windows updates applied to workstations, the exception may be Internet Explorer.  A lot of programs simply won’t run and are an easy target for hackers if not updated with the latest patches and service packs.
• Server Partitions
  -   The C drive on all servers has at least 5 gigs free and a separate Non-OS partition for the D drive
  -   The D drive should have 80 gigs free.  This varies significantly on the growth of your client base.
• A gigabit switch for 20 users or more
• Avoid Celeron processors on the network unless used for the basic task of a fax server
• Windows XP service pack 3 is acceptable or Windows 7 is the preferred workstation format.
• All in one fax printers should be avoided for patient or client intake. Certain scanners like Fujitsu have the integrated protocol that works with CRM applications like eClinicalworks. Others, like Visioneer handle intake processes of ID and medical information incredibly efficiently that obviously saves time.  Inquire with your consultant for hardware specifically design to handle data entry for eClinicalWorks and Waiting Room Solutions.
• Although Google Business Apps is on its heels, the Microsoft office suite still is required for most of these server applications.
• Fujitsu laptops are the de facto standard for doctors and to see the input pen work with eCW is a beautiful thing.
• A dedicated fax server in the form of a Windows XP machine will be required if you are using eClinicalworks. This is used for clearinghouse transmission and prescription transmission throughout all workstations on the network.

Almost all of the above will apply to any application in a local-hosted model basic network setup.  The SAAS model does need the servers information mentioned above

The next purchase item usually comes with additional services.  A “domain controller” for authentication to the network.  This means what use to be a basic login account applied on only one workstation can be used throughout the network.  Basically, your user and password can be entered at every computer on the small business network.  Your permissions are controlled by the domain controller’s Active Directory and is administrated by a Network Administrator or that kid down the street who kinda know what they are doing.

The other service people typically at the same time as the Domain Controller is email.  Exchange is Microsoft’s extremely popular program for email, calendar, and contact collaboration tool.  A hefty backup system is critical when you get this juncture but this may all be a moot point because everyone’s decision maker should be looking at “the cloud” to offer new often cheaper and exciting opportunities.

With that said, here’s a link to a basic EMR or EHR setup…

http://www.networkantics.com/2011/08/09/ehr-hardware-and-software-requirements/

This does not mean that the future may entail more of the same approach but perhaps a hybrid model to network computing with more emphasis on the “cloud” once they feel more comfortable about securely storing data offsite and the convenience of it all.  Today’s likely scenario may be a Microsoft 2003 or 2008 Server located in the closet of your office with workstations attached to it via the Local Area Network.  This usually is a comfortable setup to the owner; they own the server and their data is hopefully secured.  However, this model will diminish as software becomes increasingly complex and the affordability of that software becomes more available for small businesses.

It is best to consult with your IT integration team but below is quick guide to get you thinking on  some basic requirements for a EMR, EHR and CRM server.

General Network Setup:

• Windows Server – The majority of small businesses still run on 2003, 2008 server is preferred.
• The Windows server “database server” or “dedicated server” meaning not shared with any other services or applications like a Domain Controller, DHCP, DNS, VPN, RDP, or RAS host.
• Static private IP should be applied to the server
• Latest windows updates applied to workstations, the exception may be Internet Explorer
• The C drive on all servers has at least 5 gigs free and a separate Non-OS partition for the D drive
• The D drive should have 80 gigs free
• A gigabit switch for 20 users or more
• Avoid Celeron processors on the network unless used for the basic task of fax server
• Windows XP service pack 3 is acceptable or Windows 7 is the preferred workstation format.
• All in one fax printers should be avoided for patient or client intake.  Certain scanners like Fujitsu have the integrated protocol that works with CRM applications like eClinicalworks.  Others, like Visioneer handle intake processes of ID and medical information incredibly efficiently that obviously saves time or inquire with your consultant for hardware specifically design to handle data entry.
• Although Google Apps is on its heels, the Microsoft office suite still is required for most of these server applications.
• Fujitsu laptops are the de facto standard
• A dedicated fax server in the form of a Windows XP machine will be required if you are using eClinicalworks.  This is used for clearinghouse transmission and prescription transmission throughout all workstations on the network.

Almost all of the above will apply to any application in a local-hosted model.

To continue the warm fuzzy approach of today’s generic model, we will provide a best practice that will ensure major EMR, EHR and CRM servers have the generic setup their business needs to thrive.

General Network Setup:

• Windows 2003 Server – The majority of mainstream server applications still run on this platform.
• The Windows 2003 “application server” (a generic term for the server hosting EMR or whatever application unless the application is so resource intensive that it needs a dedicated server specific to that app) or “dedicated server” should not be a Domain Controller, DHCP, DNS, VPN, RDP, or RAS host.
• Static private IP should be applied to the server – You’d think this goes without saying
• IE 6 or above applied to workstations
• The C drive on all servers has at least 5 gigs free and a separate Non-OS partition for the D drive
• The D drive should have 80 gigs free
• A gigabit switch and NICs are mandatory for 20 users or more
• Avoid Celeron processors on the network.  Weak workstations like these should have never been purchased in the first place
• Windows XP service pack 3 is the preferred workstation format but may vary if your application is browser based
• All in one fax printers should be avoided for patient or client intake.  Certain scanners like Fujitsu have the integrated protocol that works with CRM applications like eClinicalworks.  Others, like Visioneer handle intake processes of ID and medical information incredibly efficiently that obviously saves time.
• Although Google Apps is on its heels, the Microsoft office suite still is required for most of these server applications.
• Local administrator login is required for all workstations setups.
• A dedicated fax server in the form of a Windows XP machine will be required if you are using eClinicalworks.  This is used for clearinghouse transmission and prescription transmission throughout all workstations on the network.

Almost all of the above will apply to any application in a local-hosted model.