Home Forums What is your dream network for the small medical practice

To the techies on the ACUB (and anyone else with an opinion): if you were going to design a brand new network for a small family medicine office with one or two physicians and four to six staff, what would you design?

Be as specific as you wish, including brand and specs of computers, brand and specs of server, OS's, network switches/routers, and peripherals.

thanks for sharing!

Apple Server, Macbook Pros, Apple Airport Express, an iMac for my receptionist, Apple OS X Lion, Fujitsu SnapScan. But then again, this ain't a perfect world and PC's are not my dream, but reality for AC!

I might go in the opposite direction. While I love Apple products, Linux has less viruses and is FREE. Thus it would require a port of AC to operate on that.

Since this is a redesigned NETWORK and not redesigned AC, the network would depend on the level of sophistication of the user/administrator. And I am not considering price as a significant deterrent, but I will try to keep it reasonable because if there were that much money I would spend it on other things.

Workstations: Either AMD Quad Cores or Intel i5s with 8 GB of memory, Windows Pro or Ultimate (so that I could use Bitlocker technology) Hard drive size relatively unimportant, since most of the heavy work will be done centrally. Number of workstations would depend on number of rooms, I would say 1 per room, 2 at the front desk and possibly one in the triage/vital/lab areas.

Server: Windows Small Business Server (this is where the level of the administrator becomes important) Either regular or Essentials. AMD OctaCore or Intel i7 with 16-24 GB memory. 3 x 1 TB drives in RAID 5 external NAS with RAID 10 as backup. You could have 2 servers with one as a backup in case of difficulty.

GigaBit network with Cat 5e or 6 hard wired cabling, I like Netgear gigabit routers, I'm sure there are better out there but I am very happy with them, they have a good firewall and are reliable. Others may be able to chime in here.

All hardware with APS Uninteruped Power Supplies of 750-1000 (450-550 would do but now you have me dreaming.)

23 inch Monitors, I'm not picky as to brand, most are reliable.

Brands are less important to me than the quality of the build. I have done it both ways. I like the flexibility of custom but the ease of Name Brand (Dell or HP)

Did I miss anything?

Actually Bert's set up is probably better than this

Wow! It sounds like this dream network has an unlimited budget! I am that solo family doc w/ 4 staff. It is more cost effective for the nurse and I to have laptops. I would go crazy if I had to keep logging in to workstations in each exam room. Plus those laptops are my weight training program!

Ah, but this is a dream system. My actual system does have desktops in every room, dual cores I picked up for $100 each. I have upgraded one office to HPs all in ones with 20 inch monitors they are a low energy AMD dual core for $300. But I CAN dream!

Hey, I know my intellectual limits.

Step 1: Call Indy.

Step 2: Wait for the equipment to arrive.

My idea of a dream network is cost efficiency.

Server:

One Dell T210 with a single quad core proc, 12G RAM, x2 300G 10,000rpm SAS drives in a RAID 1, SBS 2011 as the OS.

Workstations:
6 Optiplex with 4G RAM, smallest 7200rpm SATA drives available, Windows 7 Pro, Office 2010 Home and Business, 19 inch monitors, onboard graphics card.

Estimated cost approx. $8000.

JamesNT

EPIC LOL!

Missed this - I'll have to come back to this later this week; my vision might be different than some.

So with desktops in each room, are you logging in and out all day?

Server: Hardware - id shoot for 12 core system with a minimum of 32Gb of ram, multiple SAS drives in raid array.
Primary OS: VMware ESXi server for server virtualization
Virtual OS 1: Windows SBS 2011 premium as host OS for AC
Virtual OS 2: a cloned copy of the above to prevent downtime and to test updates before full deployment
Virtual OS 3: Ubuntu server for website hosting etc

Workstations
HP ms6200 windows Multipoint server 2011 x2 with t200 zero clients in each room connected via cat5e (allow for 10 workstations per server running virtual copies of windows 7 pro - although each server can support upto 20 simultaneous connections I prefer more redundancy 2 servers offers)

I'm huge on virtualization for redundancy and minimal downtime. I can completely test an update without even worrying if my system will really crash. I like the idea behind the Multipoint Server from a cost standpoint (you can outfit 10 rooms for ~$3500including 19" lcds which is far less than traditional desktops). Also you can steal my t200 and monitor and you still won't have my server with all the data safely stored in the locked server room.

We haven't deployed this yet but I'm hoping to soon (we are expanding from 2 docs to 4 and will be running ~16 rooms total).

I love all the replies thus far. I hope others chime in. These are some kickass systems you all have in mind!

When I walk out of the room I hit (windows button) and L and lock the screen.

When I come back, I hit control alt delete and type my password (name comes up automatically.)

This takes about 3-4 seconds. My MA's log into their computer to log vitals and chief complaint.

I just log in the desktop and stay logged in. The MA's access my desktop directly in the room. Patients could also access my computer, but I'm trusting that they don't. They wouldn't know how to use AC anyway. There is nothing on the computer otherwise that they could harm, so I don't mind leaving the computers open. It's rare that we are running behind, so the opportunity is rarely present for a patient to snoop around on a computer. In 6.5 years of solo practice, I've never walked into a room to find someone on the computer. Yes a security risk, I know, but with my patient demographic there is little about which I need to worry when it comes to this issue.

I do the same, Adam. The room computers stay logged in under my name. This also allows my MAs to eprecribe or fax scripts with my signature from the rooms. I could give them eprescribing privileges in the Administrator section but then that does not allow them to import items without my AC signature (documents are signed by me in Paperport). To me the ability to do that is more important. I have gone into a room to find a patient sitting on my stool watching the screen saver on the laptops. They then usually ask me where I plan to travel next and why I have not yet added any pictures from Lake Tahoe or Yosemite

Same here. Exam room computers are logged in as me. The patients encounter is up and the MA enters vital signs and complaints and clears fields for the current encounter. Inactivity will lock the screen so no one can mess with the note without a password. I have actually had a patient try to alter his note while in the room with the computer when I left to take a phone call. He thought he was funny. I am sometimes working on three or four encounters at once. I don't know how one could function efficiently without multiple computers

We are a cavelier lot eh? You all make me feel better about the security issues I worry about, too simple passwords, etc.

We like simple things. Give me an EMR that just works right. Give me a car that simply starts every morning. A house that just keeps me warm. A password everyone can remember, ah yes the password is.......password. I think password is a great password. You can get fancy with it so that it meets criteria for complexity too.
Pass12word, pass12Word, pass12worD, P12assword, and countless other permutations.

If I do not lock the computers, the kids will log on and either play on the internet or bang on the keyboard and introduce gibberish into a note. Thus, I do lock the screen when I leave. Takes 1 second to lock, maybe 3 seconds to unlock. Our passwords were very simple but we have introduced straightforward but technically strong passwords.

Sorry to play devil's advocate (oops there's that words again), but I completely, wholeheartedly agree with Wendell. And, the kids playing with it is the last thing I worry about. I would even download Angry Birds for them.

First, how do you know they are not getting on the computer? But, the main reason is this: It's not that patient A will go on the computer and look at patient B. It's that patient A will look at the unlocked, fully accessible computer and think, "Wow, patient B has complete access to my chart.

It's just like the parent in the waiting room who overhears a staff member hang up the phone and call the caller a b.... or something. The parent in the waiting room isn't offended. But, he/she is thinking, wow, what do they say about me?

that devil word gets people in trouble...

To design a brand new network for a small family medicine office with one or to physicians and four to six staff,needs a good integrated plan.As it needs to get registered and to get patents and copyrights.
I think the more important task is to get business copyrights.

I like the idea of no downtime. I have a physical backup server for my SBS 2008, and just did a bare metal restore to see if it works. But that does not achieve prevention of downtime.

How do you keep the copies of AC or entire SBS synced? Once a day backup and restore? (Takes too long). Decompress AC backup only? (Still takes time).

Thanks.

If you are going free/easy, I prefer CENTOS. it addresses your issue of how you run the VMs and provide other functionality.

In this case you run sftp services and copy up backups (DB and imported items) to the host server.

In the event that you need to swap/test/tinker, you can do that side-by-side, even running them at the same time and isolated using the host server.

N.B. you are going to need a certain level of comfort using CLI to do certain things.

I love to tinker, and I love technology. However, time and resource limits dictate that I get something that works with minimal investment. Thus, I have unfortunately not had time to play with virtualization since it has become popular.

My thought on cloning SBS to a backup server was that I did not have to set up all the services and keep data synced (Exchange Server, users, etc). I guess the intermediate solution is to just get any old computer to serve up AC if the main server goes down, copying daily backups of AC across the network. I can then restore the entire SBS at leisure to an identical server. That would really be still a daily process, with some data loss and not real time. If I then work in the backup AC, I would have to re-restore AC to the real server when it is up, making any data loss permanent.

I have tried database synchronization programs in the past, such as dbconvert, but never got it working right. Even on an hourly schedule, it would tie up AC database for minutes at a time.

If any IT genius on the board can work out a real-time switch-over AC backup scheme with no data loss, I am sure many would pay for it.

Yes, this is my dilemma as well. I have a Windows Home Server Virtual Machine on Emergency/Standby mode. In the event of a main server failure, I can quickly restore an AC backup to the Emergency server and point the workstations to the new server (maybe 15 minutes of real downtime), but we're still looking at losing 1/2 day's worth of data.

This has already been done. You can keep two live servers, it's called failover clustering. If one goes down, the other node kicks in and users don't notice a thing. You can also do things like a live migration. MS made this affordable for small businesses by offering Hyper V Replica even on their standard line (Server 2012) of OS's.

However, the configuration can be confusing and is best left to the Pros like Indy or James. If you need an in house solution, it's best advised to contact someone who is familiar with the setup. I'm working on a way to make local servers easy to setup with little to no input required from the end user. What you mentioned above was also another thing I was working on.

To use this Replica technology, do I have to migrate from SBS2008? SBS2011? Standard or higher 2012 server only?

I will await the announcement of your project's success.

You don't have to migrate to the newer OS. You can keep your existing setup and convert it to a virtual machine. We just need the Hyper V Roles on Server 2012.

I read up on Replica. Fascinating. However, is there no solution that does not launch into virtualization?

Without detracting from all the advantages, virtualization adds a layer of complexity to our thinly resourced practices and requires a major investment in time to learn, or money to hire an expert. As usual, while I may seek help from an expert, I like to know my technology to at least an intermediate level.

Virtualization not that daunting. I picked up most of the concepts on this board in about a week from kind strangers like Sandeep. Most of the computers nowadays have the muscle it takes to host Virtual Machines. Do what I did when I was learning:

- Install Windows 7 Pro x64 on some kind of multi-core machine with maybe 16GB RAM.
- Buy and install VMWare Workstation (or get the freebie version).
- Build VM's to your heart's content.

Here's a recent thread that covers much of it:

VM

Not cost effectively.

I have worked on or delivered redundant, live-failover systems such as you seek for over 20 years. The price was measured in portions of a million, and has come down over the years, but I would ball-park the cost to still be in the 20-50k for what you are seeking. Many skilled shops won't entertain a project of that scope for less than 50K to start.

Virtualization allows you to reduce the entry cost, at the cost of true hardware redundancy.

Virtualization also allows organizations to more cost effectively implement hardware redundancy as well as location redundancy, but that is still rather pricey as well.

Virtualization is the most cost effective way to deploy these types of systems. Especially for small business who can't afford to heavy duty servers. It has to one of the best things for SMB since you can move between different hardware with relative easy whereas with physical servers, they have to be exactly identical. If not and you try restoring to the other non identical server, you will be plagued by incessant blue screens.

Thanks for all your input, especially Sandeep and Indy. It looks like virtualization is the way to go if I want a loss-less failover solution. I think I will start a new thread for this project and stop hijacking this thread, as it is no longer really about a generic "dream network". GoBruins, since you pointed out the VM thread and yet still expressed the dilemma of instant failover, were you going to experiment with Replica as well?

Yes - that would be the end goal for me: zero downtime.

I would say that zero downtime is the goal of any network.

The problem is all the ones who insist on having a wine taste on a beer budget.

JamesNT

I take a weekend away from the board, and I almost missed one of James' pearls.

From the title that included "Dream" and "Small", I inferred a level of compromise; that balance is going to vary widely.

You are spot on.

I am all for failover clustering and no downtime, but this isn't NASA. What is so bad about one day's downtime. I don't mean one day's data loss, which even that would not in and of itself be a castastrophe. But, restoring and then entering the data back to AC.

The problem is that any work lost is probably lost forever. There is no paper trail to re-enter. For AC, I cannot recall any specific encounter well enough to re-create the note. For accounting, there is no way anyone would have remembered details (copays, posted payments, etc). I guess it would be different if AC has a transaction logger that resides elsewhere than the crashed server, one that we can play back into the restored backup.

If you love technology
If you love to tinker, virtualization will put you in heaven. VMWare and Virtualbox (Citrix) have free versions along with Free MS hyper-V, which is built into Windows 8 (limited number of machines on 8 but not servers).

I too have been reading up on hyper-V replica, sounds like it could create the perfect solution for a fallover. The cost would be that of another machine.

I think it could be doable on Windows Home Server 2011 (which can still be obtained for $50) then a hex or oct core AMD machine with 16 gigs for another $4-500 (or less.) This might be my project for 2013 (I have already picked up a couple of WHS licenses.)