Long resisted by many physicians, computers are now an accepted part of medical practice. Most doctors have a computer in the office for their own use, even if they don’t have an EHR. Front-desk and billing staff use practice management software on desktop PCs. Even in offices that employ billing services, it is now common to see staff sharing billing and scheduling software with billing service personnel via the Internet. And in offices that have an EHR, everyone has access to a computer.
The number and kind of computers required vary a great deal from one practice to another, depending on what the devices are being used for. In a practice that just has a PM system or shares software with a billing service, generally only the business side of the operation is computerized (aside from the PC in the doctor’s personal office). When an office implements an EHR, clinical staff need computers as well. With each choice, another presents itself in the form of servers, routers, PCs, laptops, and the like.
With so many options and considerations with regard to computer equipment, how do you purchase wisely? We asked consultants for their advice on what you should consider when choosing a computer system for your practice. Then we talked to physicians about what they’re using and why. Here’s what we found out.
Servers and access
The majority of practice management software is designed for in-office computers, and many practices still prefer to keep their financial data in-house as well, says Rosemarie Nelson, an MGMA consultant based in Syracuse, N.Y. Yet it is becoming increasingly common for billing services to host the program and the data on a remote server, she notes. When the billing program is hosted remotely, the PM software is available on the computers in the practice, where the staff uses the scheduling application and enters demographic data and charges in the billing system. There are many advantages to this approach, including lower service charges, more accurate data entry, and the ability to answer patients’ billing questions quickly, Nelson notes.
Another advantage of remote hosting — known variously as an “ASP-model” or “cloud-sourced” system — is that you don’t need to buy or maintain a computer server, which can be quite expensive. This is a more important consideration if you have an EHR, as we’ll see later. For larger practices, networking computers and storing data on an in-house server may make sense for backup and recovery purposes.
Practices also might want to network their PCs to give everyone access to shared files, says Sarah Wiskerchen, a practice management consultant with Karen Zupko & Associates in Chicago. Staff could share frequently-used forms online, as well as lists of contracted plans. In an office that doesn’t have an EHR, a shared network allows clinicians and billing staff to view transcribed notes even when the paper chart is unavailable, Wiskerchen points out.
The most important use of computers, other than for billing and scheduling, is to give everyone in the practice Internet access, Wiskerchen says. “That gives staff access to payer Web sites for checking eligibility and benefits for insurance plans. Some of the plans also allow access for doing precertification online.” If you have an EHR or just electronic prescribing capability, Web access is also essential for referrals and pharmacy communications.
If your practice acquires an EHR, you may need computer devices other than PCs, such as laptops or tablets for clinicians; because these are wireless devices, the practice also will need to install a wireless network that includes routers and transmitters. To scan in paper documents, you will need high-speed scanners. Insurance card scanners are helpful to check eligibility. A fax server is essential for sending computer-generated faxes and bringing incoming faxes directly into your EHR.
While everyone in a practice with an EHR needs access to a computer, you don’t necessarily have to buy a machine for every staff member. For example, a 12-provider family practice in Lebanon, Va., has about 40 FTE support staff. There are only 25 desktop PCs in the practice’s two locations, but not everyone works at the same time, so they all have access. (The providers use laptops.) On the other hand, you should make sure that every physician and midlevel has his or her own computer so that the machines are available at all times. Also, providers are more likely to have their own personal programs and data on their computers, so they will want to have a device of their own.
“Thin” and “fat” clients
If your computers are networked through either a remote or an onsite server, you may decide to use “dumb terminals” rather than fully loaded computers. This means that your PM or EHR programs and data reside solely on the server, reducing the speed, data storage, and random access memory (RAM) requirements of the individual PCs and laptops. The leading vendors of applications for accessing software via a thin-client network are Citrix and Microsoft, both of which charge per-user fees.
A practice can use cheaper low-end computers or even older PCs as dumb terminals. These types of devices usually do not have the performance required to run up-to-date applications for medical offices, but they might function fine in a thin-client network. Family physician David Boles, the leader of a 10-provider practice in Nashville, Tenn., says his practice is using Microsoft Terminal Services in a thin-client setup with its EHR/PM system. The practice uses rebuilt desktops that cost only $300 apiece and rebuilt laptops that cost about $500 each.
The thin-client approach has also made the system faster. Boles’ practice used to have “fat clients” — fully loaded PCs — on its network, which connects the server to three satellite offices via T-1 lines. “Before we put in the terminal server, the EHR was not terrifically fast,” he says. “After we switched, the speed improved dramatically.”
But the thin-client approach has some drawbacks, especially if you’re using it with a remote server. As Nelson notes, staff may want to use Word or Excel, but it’s not installed on their computers. Or they may want to send a computer-generated fax, which may require an onsite fax server. Scanners often must be connected to a fully loaded PC, which makes it easier to manipulate and upload documents, she says. And some outboard devices, such as ECGs and spirometry machines, may not be supported by a thin-client server, Nelson points out.
How much money can you save by using dumb terminals? Susan Jones, an IT consultant and author based in Lebanon, Ind., estimates that a desktop suitable for thin-client use costs about $300 less than a business-grade PC. But you have to buy a more expensive server to handle the data processing with a thin-client system. Because you’re paying the vendor on a per-seat basis, “you have to get to eight to 10 devices before it becomes cost-effective,” she says. “If you’re using a remote server, it might be cost-effective right off the bat.” That’s why she thinks a small practice should have a thin-client network hosted remotely.
