In this article I discussed the network costs of an EMR implementation.  I would like to drill down further to discuss the broadband and wide area network (WAN) costs of a network for midsize and large medical practices.  The definition of midsize and large medical practices is vague but for illustration let’s assume a midsize medical practice has 4 or more physicians and 2 or more locations (offices).  For a large practice, let’s assume 10 or more physicians and 4 or more locations.

A typical EMR implementation in a practice with multiple locations has the EMR Server(s) in a central location in one of the offices.  The other offices access the EMR across the WAN.  For those that are not familiar with the terminology for WAN, it is simply the network that ties together each of the offices and make all the offices appear like they are on the same network.  Most carriers (Verizon, AT&T, Qwest, etc.) will implement a WAN with an MPLS network.  For simplicity lets say a MPLS network is a private network that no one else but the practice can access and allows 2 or more offices to communicate with each other.  The advantage of an MPLS network is that a 3^rd office can be added and then all 3 offices can communicate with each other.

In a minimal MPLS network implementation with 2 offices, both offices are connected to each other with 1.5 Mbps of bandwidth (the speed of a T-1).  For redundancy, each site has a DSL circuit that functions as a backup in case the primary MPLS circuit goes down.  Let’s take a rough look at the cost for this implementation.  I am only going to discuss the reoccurring monthly costs and not address the setup or equipment costs.

1.5 Mbps MPLS at office #1 (central office with the EMR) – $500-$600/mo

1.5 Mbps MPLS at office #2 – $500-$600/mo

1.5 Mbps DSL at office #1 – $75/mo

1.5 Mbps DSL at office #2  – $75/mo

All together, a practice is looking at approximately $1,250 per month ($15,000 annually) just for the network connectivity between the offices.

Before we move on to the cost of a large practice, let’s take the above example and add a 3^rd office to the practice.  When you add a 3^rd office you add not only another connection to the MPLS network but you add additional traffic on the MPLS network from the 3^rd site.  So now you have 2 offices that are accessing the EMR over the MPLS network.  When I say accessing the EMR I am also referring to scanning images (insurance cards, paper referrals, driver’s licenses, etc.), printing, sending electronic faxes (if implemented), etc.  In this case the requirements for the network start to increase.  A typical implementation would put more bandwidth at the central office with the EMR to accommodate the increased network traffic created by the 3^rd office.

3.0 Mbps MPLS at office #1 (central office with the EMR) – $1,000/mo

1.5 Mbps MPLS at office #2 – $500-$600/mo

1.5 Mbps MPLS at office #3 – $500-$600/mo

1.5 Mbps DSL at office #1 – $75/mo

1.5 Mbps DSL at office #2  – $75/mo

1.5 Mbps DSL at office #3  – $75/mo

The monthly cost is now approximately $2,150 per month ($25,800 per year).  Again, this doesn’t include any equipment or setup costs.

For the costs of a large practice let’s make the following assumptions: we have 4 offices and we need 6.0 Mbps at the central office with the EMR and 3.0Mbps at each of the other offices.

6.0 Mbps MPLS at office #1 (central office with the EMR) – $3,000/mo

3.0 Mbps MPLS at office #2 – $1,000/mo

3.0 Mbps MPLS at office #3 – $1,000/mo

3.0 Mbps MPLS at office #4 – $1,000/mo

1.5 Mbps DSL at office #1 – $75/mo

1.5 Mbps DSL at office #2  – $75/mo

1.5 Mbps DSL at office #3  – $75/mo

1.5 Mbps DSL at office #3  – $75/mo

The total monthly cost is $6,300/month ($75,600/year).

The network communications costs to tie each of the offices together for an EMR implementation can add up quickly.  I want to clarify this article by saying that what was discussed is only one way of implementing the network.  There are many other ways and if you discuss these with the carriers you will hear terminology such as point to point T1’s, site to site VPN, etc.  The backup circuits could be DSL, Cable Modem, T1, 3G wireless, etc.  The bandwidth and associated costs are estimates as well.  Additionally, it should be noted that different EMR systems may have different bandwidth requirements. 

For a multi-office practice, WAN costs can be the first financial hurdle a practice will encounter when planning an EMR implementation.  The WAN is the foundation of every multi-office computer network.   Costs can be substantial, but practices should not take the WAN planning lightly or attempt to cut corners.  A poorly implemented WAN, can lead to a failed EMR implementation.  Would you build your home on top of a cracked foundation and expect it to stand the test of time?

There are literally hundreds of Electronic Medical Records (EMR) systems for sale.  Some have similar feature sets while other differ in their offerings.  There are many articles, blogs, and whitepapers on picking and implementing the best EMR for a practice.  Most of these seem to focus on the software selection, the workflow process, the implementation process and ongoing support of the EMR.  What seems to be missing is the focus on the actual network and computer system that the EMR will be running on.

As a practice goes from paper charts to a full blown EMR implementation, there will be a need to grow the practice’s computer network dramatically.   With the old paper chart model, there may be a couple of computers at the front desk for patient sign in and insurance information collection.  There may also be a few computers for billing and administration.  On the whole, a practice may have a very small or limited computer network. 

On the other hand, once a practice moves toward an EMR implementation the amount of technology required increases dramatically.  The front desk will may need scanners to scan insurance cards, driver’s licenses, etc.    Additionally the front desk may check on insurance coverage which may require Internet connectivity.    Physicians will need tablet computers to enter patient information during a visit.  If a practice decides not to purchase tablet computers then perhaps each exam room will need a computer, laptop or terminal to access the EMR system.  The billing department will need access to the EMR system as well as Internet connectivity to submit insurance claims.  Workgroup or network scanners may be needed to scan old patient records into the EMR or to scan patient’s new paper information i.e. letters, referrals, etc.  Electronic fax servers may be required to send information out of an EMR to another physician’s office or the fax server may be used to receive electronic faxes and attach them to patient records within the EMR. 

In addition to the equipment mentioned above, there is the EMR itself.  The EMR may require a database server and database software such as Microsoft SQL Server.  There may be a need for a network domain controller which stores the user names and network credentials for a practice’s employees.  The EMR database may be backed up to a tape backup unit or by a remote backup service that backs up the data securely over the Internet.  The reliance on the Internet become essential and requires a dependable and fast Internet connection.  These connections can be a T1 from a phone carrier (i.e. Verizon, AT&T, Qwest, etc.), DSL or a Cable Modem.  The Internet connection should be secured via a Firewall which protects a practice’s network.

Once all of the above technology is purchased and deployed a practice may want to roll out Email for both internal and external communication.  Email with patients may require additional email encryption technology.  With all the new computers and employees that now have access to the Internet, the potential for abuse may arise.  Technology to limit employee’s access to the Internet may need to be implemented.  Additional technology to provide Disaster Recovery of the EMR or network may also need to be purchased and implemented.  Remote Access to the EMR may be required which may require additional network technology.

As you can see, a practice may go from a handful of computers to a full blow computer network with a lot of advanced technology.  The network will need to be maintained which may include verifying data backups, security patch deployment, software upgrades, preventative maintenance, etc.  In addition, the HIPAA Security Rule and HITECH Act requires that a network be secure, audited and access to patient information must be available.  These requirements bring along the need for additional technology and network maintenance processes.

We will go into detail about a lot of these technologies in future updates.  A final thought to think about when a practice is evaluating EMRs – Don’t forget about the computer network!