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Server-based software allows my technology-integrated practice to thrive

Our computerized paperless practice has utilized server-based practice management software (PMS) since the mid 1980s, and we implemented server-based electronic medical records (EMR) in 1991. We’ve chosen to continue using server-based software as opposed to web-based software for four reasons:
• Speed of access. Speed of database access is perhaps the most critical day-to-day issue with EMR. Nothing is more frustrating than waiting for a screen to appear with your patient’s exam data and/or images. Unfortunately, I have found that this can be the case with web-based software, as it often doesn’t provide the consistent high-speed access that our practice requires for our critical tasks. I require data to flow at Fast Ethernet speeds (100Megabits per second[Mbps]) or higher to retrieve EMR and retinal or ocular coherence tomography (OCT) images. When data slow down to Wireless Ethernet (50Mbps) or slower, waiting for images and/or data can impede patient flow. (See “Approximate Speeds of Computer Connections,” page 58.) I’ve found that most high-speed web connections run from satellite rates of 0.4Mbps to T3 connections at 45Mbps. T3 connections are used at such places as banks. They support data transfer rates of 44Mbps. T4 connections are very fast and can cost several thousands of dollars per month. T1 through T4 connections have the same downstream and upstream speeds, and reliability is guaranteed. In other words, the speed doesn’t vary depending on factors such as the number of people using your Internet line. T lines are dedicated lines that don’t vary in speed depending on outside influences. I’ve found that most digital subscriber lines (DSL)/cable connections have much slower up- stream speeds compared with downstream, and the DSL/cable companies can’t guarantee speed. Fiber optics connections promise even higher speeds than DSL in the future and are currently installed in some major metropolitan areas. They may provide re- liability and speed to make web-based EMR feasible for smaller businesses in the future. Something else to note: Tablet PCs run at Wireless Ethernet speeds (50Mbps). This speed is frustrating in exam rooms because it takes too long to bring larger data files to the screen, such as a patient chart that has many exams or retinal and/or spatial skiascopy wavefront aberrometer images. However, I’ve found that small EMR patient files or simple PMS tasks work just fine on tablets.
• Reliability. I use both highspeed cable and DSL connections in my practice for some webbased tasks, such as insurance verification, but I don’t use these connections for mission critical applications, such as PMS/EMR. Why? Because web-based applications are totally dependent on the Internet connection and host server. Therefore, for me to consider using a web-based PMS/EMR, I would require a 100% reliable host server as well as a fast, constant high-speed Internet connection. Currently, web-based PMS/EMR cannot meet these requirements. Through our 20 years in using server-based PMS/EMR applications, we’ve experienced software failure only twice — the first time due to a lightning strike and the second due to a database corruption. Both times, however, the practice was back and running within one day. Computer hardware improvements and online web-based back-up have made database loss a thing of the past. (We back-up our data every night through a web-based company. The Web just doesn’t work for us in terms of PMS/EMR software.) To evaluate the speed and reliability of web-based applications, ask yourself if you’re satisfied with your online banking or insurance company Web sites and Internet services in general. If you have constant high speeds and near 100% reliable connections, web-based applications may work for your practice. My experience however, has proven they’re not ready for my technology- integrated practice.
• Connectivity. Diagnostic equipment interface with our EMR is very important to the workflow in our practice, as it saves us time from printing data or seeking data from the diagnostic instrument itself. Interfaced equipment allows us to review everything in the EMR at the workstation computer. We can interface all our instruments into our EMR directly or indirectly because we have a Local Area Network (LAN) line. Webbased applications cannot interface all diagnostic equipment. You can interface diagnostic equipment into the EMR in one of three ways in a LAN environment. The first way is directly through an interface provided by the EMR vendor. This allows you to access the data while in the patient chart without having to exit the EMR and go to the instrument software. For instance, we can access retinal or visual field images for a patient while in the EMR with only one click. The second way to interface diagnostic equipment is through an indirect interface via Microsoft Windows. We can access Windows-based diagnostic instruments through the instrument’s workstation review software or via remote desktop or terminal services provided in the Windows XP/Server. This allows access to diagnostic data with only a few more clicks. The specific software we use (ExamWriter, from OfficeMate) allows a third way to interface equipment: It enables us to scan documents and link them directly to one exam or multiple exams. This allows us to print results from a non-interfaced instrument, such as A-Scans and specular microscopy and link them to the exam for viewing with a couple of clicks. Web-based EMRs may have problems interfacing with advanced diagnostic imaging without the use of a LAN due to the lower data transfer speeds. But, simple diagnostic equipment, such as autorefractors and lensmeters, should work fine for the web-based EMR due to the small amount of data transferred.
• Cost. I’ve found that yearly licensing fees and T1 upgrades make web-based PMS/EMR applications cost more than serverbased software. T1 is the minimum speed necessary for reliable, guaranteed access for my practice, and it’s still significantly slower than my current serverbased system. Interestingly, I had the cost of T3 data lines quoted at $5,000 per month. T3 provides 43Mbps (about the same speed as wireless networks). Increased Internet reliability, higher speeds and lower costs may allow web-based PMS/EMR applications to become mainstream in the future. For this veteran however, server-based PMS/EMR solutions currently provide the best speed, reliability and connectivity for our technology- integrated practice.