Imagine you receive a grant which enables you to purchase an Electronic Health Record (EHR) system. Now you own it and everyone is telling you how much better your operations and clinical outcomes will be once you start using it. You already use a Practice Management (PM) system and you picked your EHR system because it supposedly shares data with your PM system. Obviously, you won’t get any advantage out of these systems from just buying them. Your people must be able to use them effectively. Your EHR vendor has just told you that the reliability and robustness of your software systems (PM and EHR) are dependent on your technology infrastructure. The vendor fires several questions at you:

• Do you have adequate server power, at least 20 Gigaherz with 20-30 Gigabytes of RAM?
• What about T1 connectivity? Do you have at least half a terabyte of available storage and uninterruptible power?
• What workstations do your people use?
• What software do you expect to use?
• What is your disaster recovery plan?

The largest barrier to the effective adoption and use of technology in CHCs is the lack of appropriate infrastructure. This is a result, in part, of a culture that does not emphasize technology. It is also due to a lack of information from technology suppliers about requirements for use and support of their software and hardware. A HRSA1 study found planning and specific focus on IT and IT infrastructure was generally emphasized by larger health centers; that most IT decisions were made on an ‘ad-hoc’ basis; and that approximately 2-5 percent of their budget was typically allocated to IT (although this figure is closer to 15-20 percent in industries that make more effective use of IT). Understanding the elements of the IT decision-making process and increasing your emphasis on HIT can help create an environment that improves both your operational and your clinical results.

Let’s consider the vendor’s questions:

Do you have adequate server power? What workstations do your people use? Do you have half a terabyte of storage capacity?
These questions have to do with hardware infrastructure. Infrastructure includes computers that act as servers – that is, machines that provide common capabilities, like database and document storage or performance monitoring, throughout the health center. It also includes the computers we use at our desks. It may also comprise specialized computers that only provide large amounts of data storage, or are connected to specific clinical devices. Finally, it includes the devices (specialized computers) that run the network like routers. The terms “Gigaherz” and “Gigabytes” refer to the processing power and memory capacity of the server machines. These have to be matched to the amount of work and the specific programs that a health center needs. This is true even of the machines that people use at their desks. Some of this hardware (mainly the servers) can be located and owned by a third party and leased by a health center, or a health center can own and manage all of it. All of this hardware has maintenance and upgrade requirements, as well as power, cooling, back-up and a host of other issues that need to be addressed in order to have an effective hardware component of the infrastructure.

A subset of hardware that is important to think about is data and information storage. Many mistakenly consider this a low priority. If it is addressed at all, it’s done minimally. Consequently, a leftover machine and any available storage media are assigned to this absolutely critical task. It is essential that a health center know what its data storage needs are and provide more than adequate hardware (and software) to cover those needs. It is common for an entire data center – and indeed a facility’s entire HIT operation – to be brought down by a machine being used as a database server that continually reboots itself because it has insufficient processing and storage capacity.

Do you have T1 capacity?
This refers to the amount of information that your voice and data telecommunications (telephone and internet) lines can carry. T1 is a telecommunications switch that provides approximately 1.5 million bits/second. This is usually adequate for health center needs, although there are higher capacity services. The network connects your computers both internally (intranet) and externally (internet), but may also provide the phone system (voice-over-IP or VOIP) and internet-based conferencing and collaboration capabilities. The internet we currently use is based on a physical layer that includes wires, satellite links, optical cable and different types of switches. The type of links and switches that a health center uses is important because they determine the bandwidth (i.e. how much data can be transmitted at a given time) or speed the network supports. Optical and satellite links are faster than old-style wiring and T1 switches are faster than DSL or cable-type support. Some types of physical layers, like ‘dial-up’ or DSL, may not be fast enough to support a health center, but they may be the only connectivity available, especially in rural areas. The rest of the network is hardware and software that runs on top of this physical layer – the two most important layers are the internet layer (Internet Protocol) and transport layer (Transport Control Protocol), or TCP/IP, our current Internet.

What software do you expect to use?
The software that a health center uses will be a mix between shared enabling programs, such as database management systems and integration engines, and specific end-user applications, like practice management and EHR systems. Each of these programs will have requirements that must be met by the infrastructure. These requirements will change as the size and geographical scope of the user population changes. The hardware and network infrastructure, as well as the infrastructure management policies, must change as these requirements change.

What is your disaster recovery plan?
Just as important as the network, hardware and software are the policies put in place to manage this infrastructure. These policies cover everything from what happens if the infrastructure is damaged or corrupted, to how our databases are managed and optimized. The development and operation of these policies are perhaps the most critical factors in the successful use of infrastructure.

I said at the beginning of this column that infrastructure is the network, hardware and software that provide the environment in which we do our work. As our work environment changes, our infrastructure must change to effectively support us and we must actively plan and budget for these adaptations.

David Hartzband, D.Sc. is the director of technology research at the RCHN Community Health Foundation.