You have just implementing a new electronic health records (EHR) system, congratulations!  You probably spent anywhere from $75,000 – $500,000+ on hardware, software, licenses,and implementation labor.
Hopefully you qualify for EHR meaningful use incentive funds to offset some of those expenses. While you are looking to stop spending money and to start recouping some of the expense, I am going to tell you 3 additional products and services that you must consider.

The 3 products and services are:

1. Offsite data backup
2. HIPAA Security
3. Disaster Recovery

I realize those 3 items are not sexy and will not help increase your revenue. I think that is one of the reasons that many medical practices don’t sign up for these services. The 3 services are about protecting your EHR, your data, your patient’s information and protecting your practice.

Offsite Data Backup

“Why do I need offsite data backup when we are backing up to a tape drive?”

I can’t tell you how many times I have had this conversation. Backing up your data nightly to a tape drive is a good practice but unfortunately backup tapes are not completely reliable. Every time we have to restore a file, database or other data from a backup tape, I hold my breath and pray that the data is on the tape and we can retrieve it successfully.

If you are backing up to tape the responsibility to switch tapes on a daily basis is usually assigned to an individual in the practice. From experience we have seen that people forget to switch tapes (trust me this happens more then you can imagine). In addition, tapes are used over and over and eventually they lose their ability to successfully read and write data. Hence the praying comment that when we need the data, the tape will not be at the point where we can not successfully retrieve the data.

Offsite data backup is a very straightforward process and very similar to backing data up to tape. On a nightly basis the data is backed up but instead of being backed up to tape it is backed up to a server in a vendor’s data center. Here is how it works.

1. On the system that you are backing up, there is a backup agent (software program) that starts to backup the data.
2. The backup agent makes a secure encrypted connection via the Internet to a server(s) at a vendor’s data center.
3. The data is copied to the servers and is stored on the vendor’s server is a secure encrypted format.

As you can see it is critical to have an Internet connection in order to perform the offsite backup.  The offsite data backup is scheduled and runs automatically so there is no human intervention required. This eliminates the issue with someone forgetting to change the backup tape.

My recommendation to most practices is to use offsite data backup as a supplemental service in addition to doing nightly tape backups.  If you do both then you have your data in 2 different places and you increase your chances that the data will be available if and when you need it.

On an average, offsite data backup costs around $2/GB.  So if you are backing up your EHR and you have 20GB of data it will cost you around $40/mo. I think that is a very reasonable amount to help ensure that your data is protected. To help convince you that offsite backup is worth the additional expense let’s look at a scenario that I have seen happen multiple times.

There is a really bad storm with heavy rain and lightning. The storm knocks out power to your office and although your EHR server is on a uninterrupted power supply (UPS) the server does not shut down cleanly (immediately loses power) and in the process it corrupts the EHR database. When power is eventually restored and the server comes back online the EHR program generates errors stating that it can not read the EHR database (it is corrupt). Imagine that you have been using the EHR for 1 month and every patient that you have seen is in your EHR (go ahead and imagine you have been using it for over a year and the amount of records would be even scarier). Your IT company comes in to help restore the EHR database from tape and get you back up and running.  When the IT company inserts the backup tape they can not locate the EHR database.   It turns out that the person who was responsible for changing the tape forgot to do it the last 2 evenings. They are able to restore the database from 2 days ago but all the data that was entered for the past 2 days is lost.  Think about having to recreate that data. You are using an EHR so do you have notes on each patient? Probably not. The amount of time and effort you and your staff will have to use to recover from the lost data makes the $40 look cheap.

HIPAA Security

The second service I urge you to consider is HIPAA Security. You are using an EHR and all of your patient information moving forward will be electronically stored. You may also have interfaces with vendors for electronic lab results, digital x-rays, ultrasounds, etc. For each patient there is a lot of electronic information that has to be protected.

Most EHR vendors do not address HIPAA security when they are training employees on the new EHR. If they do it is not in depth and there is a good chance that your employees will not understand what is required by HIPAA to protect patient information.

HIPAA security is about protecting patient data in electronic format. I am recommending you sign up for a HIPAA security service not only to comply with the HIPAA regulations but to ensure that your entire staff is educated on what exactly is required to protect patient data and to understand the best practices for protecting data. More importantly HIPAA security is a defensive measure to help protect your patients and your practice against a data breach. A lost laptop or USB drive with patient information could have serious financial impact on an organization.  Imagine a data breach that costs your practice $1,500,000. If you think that number too high consider the regulatory fines, patient breach notification expenses, lost revenue from patients leaving the practice, IT related expenses to re-mediate the breach, etc.  Even if the expense is half of that at $750,000 it can have a significant impact to an organization. And if you are thinking that your general liability insurance policy will cover most of those expenses you should check your coverage. Most policies do not cover HIPAA related expenses (although there are supplemental insurance policies that do cover HIPAA and cyber expenses).

There are many HIPAA security services on the market but on a whole you should look to accomplish the following:

1. Implement policies and procedures to ensure that patient information is properly protected
2. Perform a risk assessment to understand where you are at risk in protecting patient information and what additional security measures you should implement to better protect the information.
3. Train your entire staff on exactly what is HIPAA security, what they should be doing to protect patient data and what they should not be doing that could put patient data at risk.

HIPAA security will range in costs but for some real numbers this service will cost $1,750 to provide the 3 items above. (Full disclosure, HIPAA Secure Now! is a service of Entegration, Inc.).

As with the justification for offsite data backup, spending $1,750 to help protected you from fines and expenses that could be up to 100 times more expensive seems like a good investment.

Disaster Recovery

The third and final service I will urge you to consider is disaster recovery for your EHR and network.

I will start off by acknowledging that the odds of a disaster are slim but yet we have seen the affects of earthquakes and tornadoes in the past few months. And disasters are not only confined to natural disasters.  Fires and floods occur all the time.  Broken water pipes and sprinkler systems can destroy servers and computing equipment.

What exactly is disaster recovery?  Simply stated it is the ability to continue to utilize your applications in the event that your primary servers, network and applications are either destroyed or made unavailable by some event. Disaster recovery is ensuring that you can run your EHR on another server and access that server in the event of a disaster.

I wrote a detailed blog article on cheap disaster recovery which you should read.  But from a high level view, disaster recovery is:

1. Ensuring that you have another server(s) in another physical location that you can use in the event your primary server is unavailable
2. Data needs to be copied and kept up to date on the server(s) that you will use for disaster recovery
3. A method of accessing the disaster recovery server must be established
4. A detailed procedure must be in place that defines exactly what is needed to utilize the disaster recovery server(s) and what your employees need to do to operate in disaster recovery mode.

If you go back to the blog article that I wrote on cloud based disaster recovery the prices range from around $100/month/server.  So if you need to ensure that have your EHR server and your Domain Controller available in the event of a disaster then it will cost you around $200/mo.

Again let me define a scenario that helps justify the expense.

Let’s assume a water pipe bursts in the office above you and overnight hundreds of gallons of water leak onto your servers, destroying them.  Everything else in your office is wet but usable. After a couple of days of clean up you are ready to see patients but you no longer have functional servers and no functional EHR. You can order new servers from Dell or HP but even with overnight shipping there is a chance you will not receive them for 10-14 days.  Can you go without your EHR for that long? With the cloud based disaster recovery you can be up and running in as little as 4 hours. You can even access the EHR if you need to see patients in another practices’ office while you repair your office. Again I argue that $200/month is worth the expense to provide the safety net and flexibility to recover in the event of a disaster.

Summary

The 3 services that I described will protect your medical practice. Each of the services can be considered a safety net and operational insurance to protect you and to avoid events that can have significant financial impact to your organization. Take a step back and think of how much money you just spent on your EHR. The services that I recommend will cost you under $5,000 the first year (and half of that moving forward) and will help protect your investment in your EHR.

I would love to hear your thoughts and help with any questions you may have. Use the comments section below to give feedback.

Almost like the Earth spinning and no one notices it, there is a major shift in health care IT going on. On the surface you can’t miss the chatter.  Talk of stimulus funds, meaningful use requirements, cloud based EMRs, free EMRs, iPads, smart phones and the list goes on. Hundreds and thousands of medical practices ranging from 1-3 employees up to hundreds of employees are in the process of either evaluating or transitioning to electronic medical records.  And as these organizations continue their transition from paper based records to electronic medical records the impact will be felt for years to come.

It is exciting to be a part of something that will have a lasting impact. But at the same time I think that there will be a lot of fatalities in this process. On the surface the migration to electronic medical records seems pretty straightforward.

1. Select an EMR vendor
2. Purchase equipment
3. Install equipment
4. Train staff
5. Start using new EMR

But the reality is it is far from easy. There are hundreds of EMR vendors; some good, some not so good. EMR implementations fail at a very high rate. The complexity of setting up a network to support an EMR is daunting. Integrating servers, network, tablets, smartphones, lab equipment, etc. can be a challenge at best and a disaster at worst.

And if a practice makes it this far there are the concerns with patient records and HIPAA security. These practices that are new to electronic medical records have not been tasked with protecting electronic assets in the past. This skill set in not easily acquired nor is it cheap. Network and data security is not a part-time job and it should not be added onto to someone’s job responsibility especially if they are not IT savvy.

And will these practices understand the risks of implementing technology to support electronic medical records? Will they implement the appropriate data backup solutions and disaster recovery solutions to ensure that a disaster does not cripple their ability to use and access the electronic medical records? Will they understand that most small businesses never recover from a disaster that impacts IT?  Will they make the appropriate investments to ensure that a disaster does not put them out of business?

It is almost like a herd being led into an ambush, some of these organizations will be among the fatalities.  A failed EMR implementation can cost hundreds of thousands of dollars. Not many smaller medical practices can take that financial impact and still survive.  A data breach or serious HIPAA violation can  have a huge financial impact on an organization. An unplanned for disaster can put an organization out of business.

So as the headlines talk of meaningful use stage 2 and 3, Medicare EHR Incentive Programs, Attestation, the next greatest tablet, mobile health apps, and cloud based EMRs remember that the impact to some health care organizations will be fatal. Can the quest for electronic medical records be similar to a herd being led into an ambush? Will we look back and see that 2011-2013 led to a thinning of the herd? Will these fatalities lead to more hospitals and larger organizations consolidating smaller medical practices? Electronic medical records are needed and provide an enormous opportunity for the entire health care system but without proper guidance and support many medical practices will be causalities in the process.

On April 21, 2011 Amazon’s East Coast data center went down and brought many high profile businesses down with them. Some of the businesses that rely on Amazon to provide their infrastructure include Foursquare, Quora, Hootsuite, SCVNGR, Heroku,  and Reddit.  In addition small or mid-size businesses that relied on Amazon felt the impact as well.

So a day later we take a step back and look at the impact.  Let’s ask some questions:

First question: Will this signal the end of cloud computing?  NO!

Second question:  Will this be the last cloud based provider to experience an outage? NO!

Third question: Will this harm the migration to cloud based providers? YES!

The first two questions are easy.  The outage is not the first and will not be the last. The benefits of cloud computing to startups, small and mid-size businesses are real and this outage will not signal the end of cloud computing. But the high profile outage may harm the migration to cloud computing.

If you are a medical practice and are in the process of purchasing an EMR for your practice, yesterday’s Amazon outage gives you something to think about. Many EMR vendors give multiple options for deploying the EMR including on-site servers that are in the practice’s office and hosted servers or applications that are at the vendor’s data center or some other hosting facility. A day after Amazon’s outage you have to ask yourself; if Amazon can suffer a complete melt down of their data center what is to stop an EMR vendor from having the same experience? You may even conclude that Amazon, one of the leaders in cloud computing, have far more resources to support their data center than an EMR vendor does.  Does this make you think that the likeliness of an EMR vendor having a prolonged outage is even greater than Amazon having one? I would answer yes. And if you do answer yes, the next question you have to ask is; can you afford to be without your EMR for 24 or more hours?

I think Amazon’s outage will impact migration to cloud based computing. It will not stop cloud based computing but it is a wakeup call for businesses that are looking to use or are currently using cloud based computing. My advice remains the same as it has been in the past. Migrate non-core functions and servers to the cloud and keep core functions and servers within your network / office. There are real benefits to utilizing cloud based services but the risk is just as real. Yesterday’s outage makes that perfectly clear.

Image: Jennifer Ellison / FreeDigitalPhotos.net

I spoke with a potential client today and had a conversation that I seem to be having a lot lately. The client gave an overview of their issues and it with something like this….

Potential Client: “Our network is really screwed up. We have been through 5 IT people already. We installed an EMR but it is a bunch of junk. We are getting a new EMR in a few months. We spent $44,000 on the first EMR and even more on the second. We can’t add new laptops, we can’t print. We need help.”

The good news is that the problems he mentioned to me all seem to be very straightforward and fixable. I let him know that the first thing that has to be done is to ensure that the network is operating correctly before any EMR is installed.

As I mentioned this is the same conversation that I have had over and over. It seems that so many medical practices are implementing advanced technologies to support EMRs but operating on networks that are not up to specs or configured correctly. In addition, the EMR software does not perform the way the vendor stated and does not provide the functionality they are looking for.

One of the core functions we do for our clients is to help them with software and hardware selection. A client that is evaluating an EMR needs help to ensure that the EMR will work in their environment. They need technical guidance to ensure the infrastructure can support the new EMR. A lot of EMR vendors try to undersell the hardware requirements to make their products look more affordable. I think this is a huge mistake. It is critical to ensure that the network is properly sized, configured and ready to run an EMR.

Epsilon, the largest email marketing firm, announced that their customer database has been breached. Epsilon has over 2,500 large clients including: Kroger, TiVo, US Bank, JPMorgan Chase, Capital One, Citi, McKinsey & Company, Ritz-Carlton Rewards, Marriott Rewards, New York & Company, Brookstone, Walgreens,  and The College Board. They send over 40 billion emails a year on behalf of their clients.

Epsilon said that the hackers only had access to customer email addresses and first / last names. The affected clients are sending out warning notifications similar to the one from Kroger:

As a result, it is possible you may receive some spam email messages. We apologize for any inconvenience. Kroger wants to remind you not to open emails from senders you do not know. Also, Kroger would never ask you to email personal information such as credit card numbers or social security numbers. If you receive such a request, it did not come from Kroger and should be deleted.

Although no social security numbers or credit card information was accessed, the emails and names could be used in SPAM and Phishing scams.

This massive breach shows the danger of outsourcing functions to other companies.  No matter how good the security was for each of these companies, they had no control over the data at Epsilon. The take away here is that all companies not only have to look at their own security but also the security of business associates and vendors.  When you outsource your customers’ information and trust make sure you fully understand the dangers that are associated with this decision.  Some of the world’s largest companies are now coming to grips with this reality.