Practice Review: Goondiwindi Medical Centre
Located centrally, the Goondiwindi Medical Centre is the largest of the two general practices in the town.
The medical centre was established when Dr Ian Thompson joined Dr Rowena Sheppard, Dr Bruce Dixon and Dr Kathryn Mainstone in 1998. Since the co-location of these two practices, the medical centre has grown steadily and now has nine doctors with a tenth scheduled to start in early February.
The medical centre services an area 250km high and 350km wide, with half of the regions 10,000 people living in the town. The practice has 15,000 active patients, which Practice Manager Matt Gilchrist attributes to the towns large number of itinerant workers and the high volume of travellers passing through the area.
The doctors are supported by four full time and one part time administration staff members. The practice currently has two registrars, with four practice nurses working 2.25 FTE also based in the medical centre.
The practice is a teaching practice, taking students from the University of Queensland and the other universities under the John Flynn Scholarship Scheme. In the past 12 months, a total of eighteen students have attended the practice including the winner of the inaugural RDAA Rural Student of the Year Award, Lydia Scott. Hailing from the University of Adelaide, Lydia was presented with this award in November 2006 in recognition of her work in setting up a Q Fever clinic in Mungindi, 170km west of Goondiwindi. Lydia established the clinic with the assistance of the doctors from the practice.
The medical centre switched clinical software packages from Medical Director 2 (MD2) to Best Practice eight months ago. The decision to look for a new solution was made when it became apparent that HCN was scaling back development of MD2 in favor of the products newer sibling, Medical Director 3 (MD3).
While Matt did evaluate MD3, he concluded that it was not suitable for his practice due to the additional underlying licensing requirements that his practice would need to meet. Due to the size of the medical centres database, Microsoft SQL Server would have been required to run MD3. While expensive in its own right, the practice would have actually been required to purchase a second copy of the database software for use on their backup server. To ensure compatibility, an additional copy of Microsoft Windows Server 2003 would have also been required to upgrade this same machine from Windows XP.
After evaluating several other solutions, the medical centre ultimately chose Best Practice. Matt indicated that they were impressed by the products client-server SQL underpinnings, the ability to run the product on a free underlying database system (MSDE), and the fact that the user interface was intuitive and easy for their staff to use.
Matt also pointed to Best Practice's strong documentation and vibrant online user community as important factors in his decision, stating that these resources have allowed him to manage the MD2 transition and ongoing maintenance of Best Practice with little outside assistance.
While Best Practice also has a practice management module, the medical centre has retained HCNs PracSoft for its billing and appointments. Matt indicated that the practice intends to migrate from PracSoft to Best Practice Management when the Medicare Online Claiming functionality is finalised.
The Best Practice database is hosted on a 3-year-old, custom-built machine running Microsoft Windows Server 2003. This server is powered by dual 2.66 GHz Xeon processors and has 3 gigabytes of RAM installed. Storage is provided by an external SCSI drive enclosure containing four high-performance, 72 gigabyte drives spinning at 10,000 rpm. These disks are configured in a RAID 5 arrangement, which provides a good mix of performance and redundancy. While only a fraction of the space is used, the RAID has an effective capacity of around 216 gigabytes.
This machine also acts as a terminal server, accepting both remote and local network connections.
The practice has a computer configured as a replacement server for instances where the primary server is out of service.
Due primarily to the expense (over $1200), this computer doesnt have a SCSI interface to allow it to connect to the primary servers external RAID enclosure. The implications of this limitation were felt recently when the primary servers SCSI interface card failed. Fortunately the card worked intermittently and the data was able to be transferred to temporary storage while a replacement card was sourced.
The practice data is backed up and restored to the backup server on a weekly basis to test both the integrity of the database and the preparedness of the backup server.
Computers are installed in each of the 8 consultation rooms with one also installed in the practices treatment room. There are two computers positioned in the reception area, three in the back office, one in the practice managers office and one in the practices skin clinic. A computer is also installed adjacent to the practice sterilisation facility to allow the nurses to confirm patient demographics and match samples with the treating doctor.
Some of these client computers are configured to use Terminal Services to connect to the practice server, while others are setup as conventional smart clients.
The medical centre uses a Fujitsu 4110C document scanner that has performed reliably since being deployed several years ago. The practice has been paperless for six years and routinely scans up to 60 pages per day.
Scanning is typically performed once a day, with documents imported into Best Practice via the bulk document import feature.
The bulk of the printing in the practice is handled by HP1000 series machines. Other assorted printers including a HP LaserJet 4 that wont die are also utilised in the practice.
The practice network operates at 100 Mbit over standard category-5 Ethernet cabling. A heavily secured wireless network is also available, though rarely used.
The practice connects to the Internet via ADSL running at 8000/384Kbit. This service has only been connected for a short time, however Matt indicated that it didnt perform noticeably faster than the 1500/256Kbit ADSL service it replaced (large downloads from some website being the exception).
The Goondiwindi Medical Centre was the first practice to be granted permission from Queensland Health to make connections from the local hospital back to the clinic. Remote access can also be established from the local nursing home and the doctors homes.
As is now commonplace, the remote access capability is achieved using Microsoft Terminal Services (RDP). While this access is encrypted by default, the practice has changed the default port in an attempt to strengthen the overall security of the system. Policies to enforce non-trivial passwords to both Microsoft Windows and Best Practice are also in place.
Backup and Redundancy
The practice maintains an aggressive backup regime, with copies of the PracSoft data taken ever hour. The Best Practice data and other documents are backed up at least four times a day, with the data copied to multiple practice computers.
Once a week, DVDs are burnt and stored securely offsite. As the amount of data needing to be backed up is over 10 gigabytes, both a dual layer (8.5 Gb) and single layer (4.4 Gb) disk are used.
A large APC Uninterruptible Power Supply (UPS) provides backup power to the practice server, external SCSI enclosure, phone system, network switch and Internet router.
Smaller APC UPS devices are also installed on each client computer, a prevention measure that is being adopted by more practices in line with the falling price of UPS hardware and the increased realisation of the importance of reliable computer access.
Both the server and client UPS devices allow up to 30 minutes of run time. In the event of an extended blackout, a large purpose built diesel generator is started, which can provide enough power to run the entire building.
As mentioned previously, the practice has a room dedicated to skin related medicine. The doctors have a range of photographic tools to choose from, including a Nikon Coolpix 4500, various Heine dermatascopes, and a dermlite which attaches to a 7.2 megapixel Sony DSC -W70. The practice also has several Pentax digital SLR cameras used primarily for macrophotography.
The computer in this room has two monitors (a 17 inch and 20 inch wide screen) to allow for easier photo viewing and manipulation.
After photos have been examined on screen, they are linked to the Best Practice patient record by the practitioner for future reference. Prior to this linking process, Microsoft Office Picture Manager is used to crop photos to ensure the practice database isnt bloated unnecessarily.
Like many modern practices, the Goondiwindi Medical Centre is infested with a plague of pathology and radiology downloading applications including MQLink, Fetch, Medical Objects, Promedicus and Argus.
All results are downloaded in the preferred HL7 format. As a result, the practice was able to join the National Primary Care Collaboratives program with no additional IT setup required.
Despite attempts to leverage the doctor-to-doctor communication capabilities in some of the aforementioned communication products, the vast majority of incoming and outgoing correspondence arrives and leaves on paper.
The practice hosts its own email server behind the practice firewall, which allows communication within the practice to be conducted without encryption (as the unsecured messages arent exposed to the public Internet).
Wildfire, a Jabba instant messaging server has been installed for quicker, less formal communication within the practice.
As a self taught IT systems administrator, Practice Manager Matt Gilchrist demonstrated a good understanding of IT theory and its practical application in a medical centre. From an IT perspective, his practice has many strengths including:
- Excellent power redundancy.
- Robust data redundancy.
- Remote access.
- Innovative internal communication techniques.
- Client-server based practice software.
- Comprehensive digital clinical photography facilities.
As with all medical practices however, a few aspects of the IT system warrant review:
As Matt evidenced first hand during the recent hardware failure, SCSI hardware is not readily available, nor is it cheap. While the technology continues to rein supreme in terms of raw performance, Serial ATA storage technology is a better solution for the vast majority of medical practices. While only fractionally slower than SCSI solutions, Serial ATA disks, cables and interface cards are more readily available and significantly cheaper.
The external SCSI enclosure is a good solution in its own right, however the fact that the backup server doesnt have the ability to connect to it is a cause for concern.
The practice should seek to replace their existing SCSI solution with a modern Serial ATA alternative. It would be cost effective to arrange this when the practice is ready to replace the ageing primary server.
Once this setup is in place, in the event of a hardware failure on the primary server, the new external drive enclosure would simply be plugged into the backup server, allowing the practice to continue unaffected.
Given the large amount of data the practice needs to back up, the fact that DVDs arent burnt daily is understandable. Under the current arrangement however, in the unlikely event of a fire, the practice stands to lose as much as a weeks worth of data.
Deploying one or more external hard drives with either a USB2, Firewire or eSATA interface is a cost effective solution that would allow backups to be transported off-site each day.
With the ever expanding capacity of modern hard drives, as much as 150 daily snapshots of the practices data could be stored on a single external drive unit (though it would be cheaper and provide more flexibility to deploy multiple, smaller-capacity drives). To ensure a permanent archive of the practice data is kept, DVDs should still be burnt at least once a week. While this would involve more DVDs, it would actually be more cost effective if the higher capacity dual layer DVDs were not used (due to their relatively high cost per megabyte).
While Matt has taken extra precautions to secure remote connections to the practice, when examined discretely, these techniques are not infallible. As such, the feasibility of wrapping their Terminal Services connections in either a VPN or SSH Tunnel should be investigated.
Such additional measures can be deployed without additional software cost, and add little or no complexity for the end user when establishing or using the remote connection.
While the likelihood of an unauthorised party penetrating the existing system is highly remote, adding either of these additional security layers would bring the practices remote access system in line with the highest available security standards.
Pulse IT invites medical practices interested in participating in a future practice review to contact the editor.
Posted in Australian eHealth