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?

The Medical Group Management Association (MGMA) has an interesting study on the benefits of electronic registration.  In January, 2009 the MGMA launched an initiative call SwipeIT.

Project SwipeIT is an industry wide initiative launched by the Medical Group Management Association (MGMA) in January 2009 to advance the adoption of standardized patient health-insurance identification (ID) cards containing machine-readable information.

The concept is that the insurance providers will issue patient health-insurance ID cards that contain patient information including demographics, health plan information, co-pays, etc.  The cards will act and function like a credit card.  Each medical practice, hospital, clinic will need to have a card reader that can process the information on the card.  The card reader can then be linked to a practice’s EMR or practice management system which will populate the patient demographic and insurance fields automatically.  The whole process is referred to as electronic registration.

The MGMA study takes a look at the costs of non-electronic registration and calculates the savings that can be realized by implementing electronic registration.  There are enough numbers and calculations in the study to make your head spin but I will highlight a few statistics that are eye opening.

Model Assumptions and Raw Inputs	Values
Number of claims per year for physician professional services	1,160,542,000
Hours saved per year during registration process by implementing electronic registration	95,280,498
Dollars saved per year during registration process by implementing electronic registration	$1,931,753,287
Number of claims per year that must be resubmitted due to payer denial due to incorrect patient demographics from non-electronic registration	57,168,299
Hours per year to resubmit claims denied due to payer denial due to incorrect patient demographics from non‐electronic registration	14,292,075
Dollars saved per year by not having to resubmit claims denied due to payer denial due to incorrect patient demographics from non-electronic registration	$289,762,993
Total savings due to implementing electronic registration (dollars per year)	$2,221,516,280

The MGMA estimates that $2.2 billion per year can be saved by implementing electronic registration.  It should be noted that the study does not estimate the cost to implement the electronic registration including the cost to insurance providers to issue the card, practices and hospitals to purchase and install card readers, EMR and practice management vendors to modify their software to interface with the card readers, etc.  I suspect that a good part of the initial $2.2 billion in savings would go to the implementation costs.  The savings on-going would still be significant.

The MGMA also studied the impact on a typical 6 FTE physician practiced and published their results.  They took conservative and non-conservative estimates on the impact of electronic registration.  The difference in the estimates are described as:

A conservative estimate where only 10% of patients have their insurance cards copied, presumably because of changes in their information.

The non-conservative estimate is where:

(a practice) copies the patient’s insurance card on each visit. This practice may also have a much larger proportion of patients whose information needs updating.

The highlights of the study are listed below:

Conservative estimate	Time
Time saved by Swipe card	7 h/ day	1820 h/ year
Non-conservative estimate
Time saved by Swipe card	23h45m/day	6175h/year

If these numbers are accurate, the need for front desk personnel could be reduced and savings could be realized at a practice.

Electronic registration is an industry wide initiative.  All stakeholders including insurance providers, EMR vendors, medical practices and hospitals would all need to be involved and implement the appropriate technologies.  Until then, the savings highlighted in these studies are only theoretical.

Econo-Keys makes a washable keyboard that is very well suited for exam rooms, operating rooms, etc. 

Econo-Keys states the following about their keyboards:

Econo-Keys specializes in economical keyboards that are sealed and completely washable to withstand daily scrubdowns with anti-bacterial agents, enabling them to meet and exceed any hygienic protocol and reduce the spread of infectious bacteria such as MRSA, E. Coli and Hepatitis C.

The company says it protects against:

Splashing, hose-directed and submerged water

Bleach, alcohol and hospital-grade disinfectants

Corrosive, abrasive, acidic and alkaline substances

Dirt, dust, sand and other airborne debris

Extreme temperatures

John Lynn over at EMR and HIPAA has a video of the product from the Healthcare Information and Management Systems Society (HIMSS) exhibit floor of the Econo-Keys keyboard in action.