Keep your practice alive when the computer goes dead

Tips for keeping your practice alive when the billing and records system suddenly fails.

By Robert Lowes
Midwest Editor

Washington, DC, internist Peter Basch loves his paperless office. A team of professional wrestlers couldn't drag him back to the era of hard-copy patient charts and ledgers.

But now and then, his computer system faints. "There's no piece of technology that doesn't go down," admits Basch.

His four-doctor practice once lost access to its electronic medical record system for two hours when a staffer forgot to turn off her workstation during a software upgrade. Nobody could review patients' medical histories during the hiatus. Another time, the hard drive on the system's server—its central computer—ran out of room to store data, triggering a 20-minute lull. And power failures paralyze the system from time to time.

As doctors increasingly convert to EMR systems, the problem of computer downtime promises to be more nettlesome. If practice management software is out of commission, nobody panics; doctors generally don't miss a step seeing patients, and staffers can catch up on data entry later. "But when an EMR system is down, the impact is huge," says Syracuse computer consultant Rosemarie Nelson. "The chart isn't available for the patient visit."

Don't construe this alarm bell about downtime as a knock against computerization. By all accounts, electronic blackouts in doctors' offices are infrequent, and the technology's becoming more reliable. Paper systems, say Nelson and others, breed more inefficiency than imperfect cyber systems. Still, who wants to stare at a frozen screen?

Fortunately, you can reduce the risk of downtime by investing in extra-dependable hardware. And if the system goes on the fritz, don't despair. With a little planning, you'll recover in minutes rather than hours.

For the most reliable system, think redundancy

Minimizing downtime starts with the right computer network. Roughly 20 percent of small practices connect their computers in a daisy chain called a peer-to-peer network. The transcriptionist stores dictation on her machine, the billing clerk stores accounts-receivable reports on hers, and either staffer can tap into the other's files. Such networks are simple to set up, says Nelson, but they're not as stable as client-server networks. In this hub-and-spoke configuration, the server computer houses data files, as well as application software like a practice management program. Client computers tap into the server.

Obviously, a lot is riding on the server in the client-server network. What if the server's hard drive—a stack of spinning, magnetized disks—breaks down? Solution: Equip your server with at least one backup hard drive that stores every bit of information written to the primary hard drive. If that drive crashes, the "mirrored" drive automatically kicks in. You're still up and running.

Dual hard drives represent a simple form of what computerfolk call "system redundancy." You can outfit a server with four, eight, a dozen hard drives or more, storing application programs on some, data files on others, and relying on still other drives as backups. Large group practices go a step further and use dual servers, sometimes installing one off-site so a power outage won't disable both.

EMR vendors such as MedicaLogic, now a part of Hillsboro, OR-based Medscape, advise doctors to invest in some measure of hard-drive or server redundancy. Consultants say Amen. "You can buy an extra drive for under $500," says computer consultant Jim Geidl in Suwanee, GA. "If you can't afford this, you shouldn't be in business."

Most doctors, however, don't use electronic charts as yet. Their computerization consists merely of practice management software. For them, a second server would be overkill. Do they need multiple hard drives on their sole server? Probably not. "We install them if our customers want to go this route, but we don't think they're a requirement for practice management software," says David Ward, a vice president with Tampa-based Medical Manager Health Systems (which merged with WebMD last year). In the end, it's a matter of comfort level. How safe do you want to feel?

System redundancy extends to other components, and no matter what application software you're using, some options are worth considering. There's a thingamajig inside the computer called the power supply (not to be confused with a UPS—more on that later) that frequently fails. You can install a backup power supply for several hundred dollars. Double up on processors and network cards, too.

Even if you don't pack your computer with extra components, it's a good idea to stockpile hard drives, power supplies, and the like for the sake of quick repairs. Don't forget simple things like computer cables. "I got called in the middle of the night by a client who needed a $4 cable because a floor polisher broke the one he had," recalls Jim Geidl.

Follow these house rules to keep on computin'

Even the most fail-safe system needs tender loving care if it's going to hum along day in and day out. As you might expect, the almighty server warrants the most pampering.

Rosemarie Nelson reminds doctors to run standard programs—typically included in the computer's operating system—that keep the server's hard drive in top shape. One program, called "defrag"—or, more formally, Disk Defragmenter—organizes files so they can be retrieved faster. A program called "ScanDisk" detects and fixes errors on the drive. "I've seen practices get slack about using these programs," says Nelson. Additional caveats:

• Don't be a hard-drive pack rat—erase obsolete programs and data files that consume precious storage capacity. Max out your hard-drive storage, and your computer may freeze up.

• Ban games on your practice's computers; they can mess up other programs and bring a system to its knees, says Jim Geidl. "Businesses ought to warn employees they'll be fired if they install a game."

• A virus can shut you down, so install antivirus software and update it regularly to guard against the latest plague. Doctors will need virus protection more and more as practices go online.

• Instruct staffers to report any error or fault message that flashes on the screen—it may herald an imminent crisis. The same goes for odd noises, odors, and screen flickers. "A hard drive that's dying will make a whining sound," says Geidl. "If you catch this early, you can gracefully shut down the machine, install a new drive, and restore your data from a backup tape. You shouldn't be down more than an hour."

To soften your next crash, take these precautions

You can do your utmost to keep the computers humming, but perfect control is beyond your grasp. So build a system that can handle an occasional failure.

Take acts of God. A tornado knocks down a power line. You don't want a computer to suddenly lose its juice. Not only would you lose unsaved data, but an abrupt shutdown may corrupt existing data files. That's why your server needs an external uninterruptible power supply (UPS). In the event of a power outage, a UPS provides enough battery power for 20 or 30 minutes so you can save your latest batch of data and shut down the machine by the rules. A UPS designed for a server will cost between $500 and $700, says Guy Gillespie of Access Associates, computer consultants in Oxford, MS.

To play it safe, install a less expensive UPS on each workstation as well. That way, staffers can wrap up tasks at hand—such as billing—and print documents needed during an outage. Printers and other peripherals require power, too, so equip them with UPS units.

Another critical precaution: Always back up your data on tape. This is especially important if your server has just one hard drive. Should your worst nightmare materialize—a virus wipes out your hard drive—you'll still have a copy of your programs and data files. Back up daily, advises health care computer consultant Ron Sterling in Silver Spring, MD, and store the tapes off-site in case of fire. ENT specialist Michael Parker in Raleigh, NC, keeps his tapes in a safe deposit box.

You can't be too careful. "Tapes wear out and become useless, so you'll need to replace them every few months," adds Sterling. "Otherwise, you might think you're backing up when you're really not." Perform a test-run of restoring data from the backup tape to the hard drive, advises Jim Geidl. "It's harder than it looks. You may end up restoring your data, say, but not your operating system."

The computer's down, but you don't have to be

With preparation and pluck, your practice can cope with occasional computer standstills.

Always have a hard copy of your appointment schedule in case you can't view it on the computer screen. At Michael Parker's six-doctor ENT group, daily schedules are printed out the night before, along with patient phone numbers. "If we have to close the practice due to a lengthy power failure, we can call patients and cancel," says Parker. If the practice is still open—maybe the downtime's due to a software glitch—staffers can shepherd patients into exam rooms as usual.

Where the schedule really matters is in making appointments. If you only have a printout of today's schedule, how can you book someone for next week? The standard solution is to take the patient's name and number and call back when the computer's up and running again. Ask the patient for a preferred time slot, suggests Tracie Jones, practice administrator for three general surgeons in Maitland, FL. "Often you can plug patients into those slots once the computer is back. So when you call the patient, it's just a matter of confirming the time that she requested."

Some doctors have been known to print out a two-week appointment schedule every day to expedite booking patients during downtime. Consider storing the schedule on a floppy disk and, when the need arises, printing it out on a functioning computer. Or e-mail it to a safe haven as an attachment.

You and your staffers no doubt need other pieces of paper—superbills and patient summary sheets, for example—to treat patients on a computerless day. If the computer's unusable because your power went poof, a system supported by UPS units can print out the forms before you shut down. Otherwise, just rely on blank forms. Of course, you could print them out the night before, but you have to decide how much obsessive-compulsiveness you can stand.

Don't underestimate patients' capacity to roll with the punches when information like lab results is locked inside an uncooperative computer. "Patients are used to occasional glitches," says Peter Basch. "Everybody has gone to the bank and found the ATM kaput."

Doctors and medical assistants may be productive during downtime, but what about back-office staff? At Esse Health, a 70-doctor group in St. Louis, they turn to tasks that don't require a keyboard. "They take a hard copy of our A/R report and call patients who owe money," says Esse information systems manager Kim Carey. If there's not enough work to keep everyone busy, simply send employees home. In a best-case scenario, they can return on a Saturday morning to resume data entry—assuming the system's up—and they won't log overtime in the process.

Getting back up: Easy does it

When computers collapse, it's natural to want to fix the problem yourself. But do you have the know-how? Large group practices like Esse Health are fortunate; they can afford to put computer experts on the payroll. Kim Carey commands three pros who staff a help desk, as well two others who specialize in hardware. But such in-house talent is beyond the reach of the average practice.

Given this reality, doctors should exercise caution when it comes to do-it-yourself solutions. "I worry about doctors who know just enough about computers to be dangerous," says consultant Guy Gillespie. He has heard of doctors changing perfectly sound hard drives or tinkering with esoteric software settings. "If you don't know what you're doing, you could corrupt your data," says Gillespie.

Cyber-savvy doctors and staffers certainly can try to identify easily solved problems. To learn how to troubleshoot, pick up a basic computer text such as Networking for Dummies by Doug Lowe. Is your computer plugged in and turned on? Are cable connections secure? Is the problem network-wide or confined to one computer? Will the problem go away if you restart the network?

At the very least, this sleuthing helps you explain problems to the company that sold you the system. Your relationship with the vendor will play a big part in reviving a fallen network.

Consultant Rosemarie Nelson says you'll get better service if you buy hardware and software from the same source. Otherwise, get used to hearing "It's a hardware problem" from the software vendor, and "It's a software problem" from the hardware guy.

Vendors offer various levels of technical support, which essentially translate into how fast the technician will show up at your door. The quicker the response, the more it costs. "If you have an EMR system, spend a little extra for same-day service within four hours," says Nelson. "But if all you have is a practice management program, you can get by with a 24-hour response."

And while you're waiting for your computer to rise from the dead, just remember—you have downtime in the paper office, too. And more of it, Basch says.

"It's estimated that 15 to 25 percent of paper medical records aren't available on any given day because they're misplaced," he explains. "If you choose the right vendor and build a redundant system, computer downtime should be minimal, even negligible.

"I don't regret making the switch."

How do you reduce downtime when you use Web-based software?

Programs that you access online from an application service provider (ASP) are the cutting edge in medical software. There's no need to install a practice management or EMR program on a server in your office. Instead, the software resides in the server of the ASP. That's where you also store data files.

Such cyber-architecture affects your game plan to minimize downtime. You're less concerned with building redundancy into your office system—buying a server with two or more drives, or buying two servers. These are smart moves if you have an EMR program in-house, but with Web-based software, the ASP worries about redundancy. So pick the vendor best prepared for disaster.

"Good ASPs have multidrive servers, they field servers in different states, and they rely on redundant data lines," says computer consultant Guy Gillespie.

Take a tip from ASPs and invest in reliable data highways. You'll probably experience less downtime if you connect to the Internet with a T1, DSL, or cable line than an ordinary dial-up phone line, says computer consultant Rosemarie Nelson. These lines cost more, but move data faster. For added peace of mind, you can even install two lines, says Nelson. If one line goes bad, you can still call up Mrs. Jones' medical chart using the other.

 

Robert Lowes. Keep your practice alive when the computer goes dead. Medical Economics 2001;7:30.