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Pros and Cons of Thin Clients with an EMR

Posted on August 13, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This is the second guest post by Bill Horvath II describing the pros and cons of thin clients with an EMR.  Also, take a look at his first entry discussing the pros and cons of laptops with an EMR.

Thin Clients

Overview

An office which chooses this approach will typically have one thin client terminal in each exam room, as well as in each physician’s office, and at stations occupied by non-mobile staff who need access to computerized records.  The terminals are typically managed or ‘driven’ by a server, which provides applications, data storage, and administrative control over the whole system.  Remote access to charts is usually provided via application server software.

Pros

  • Easy To Use – Thin clients don’t have to be carried or pushed from room to room, and don’t require recharging.  Some manufacturers also use smartcards or other technologies to offer location-independent desktop sessions, whereby the desktop session virtually ‘follows’ the doctor from room to room, eliminating the hassle of logging out and logging in at each station, or of figuring out how the last person to use the computer left it.  Many thin clients can go from off to fully ready to use in 15 seconds or less, and because they have no moving parts, they are silent when operating.  And because data storage is centralized, a complete backup strategy is straightforward.
  • Inexpensive – A fully-furnished thin client (with monitor, mouse, keyboard, and cabling) can be purchased at a price starting around $650, depending on the makes and models of the components.  Spare parts are inexpensive to keep in inventory, and individual parts can be replaced in the event of failure.  Because they are highly reliable (and their capabilities are usually determined by the central server which administers the network), they can remain functional for 7 years or longer.
  • Reliable – Modern thin clients have no moving parts, making them exceptionally resistant to normal wear-and-tear.  Since they aren’t typically moved by the doctor, they’re less likely to be broken through an accidental drop or collision.
  • Trivial to Replace – Since thin clients are usually controlled and configured by am administrative server, it’s trivially easy to replace one in the unlikely event of a failure.  In such cases, replacement of the device is simply a matter of unplugging cables from the old unit and plugging them into the new one.
  • Energy Efficient – Because they have no moving parts, thin clients use very little electrical power.  Around 5-15 watts or less is common, even when operating at full capacity.
  • Highly Secure – Thin clients, by definition, have no local data storage, meaning it’s impossible to lose data by way of theft or equipment failure, and a bad actor can’t use a stolen device to extort money or expose private or embarrassing information.  Some thin client manufacturers also provide two-factor authentication built into their products, which precludes access to the system entirely without an alternate means of identification, such as a smart card.  Under these circumstances, the thin client won’t even present a password request (or other user interface) without the required token.  It is also easy to physically lock a thin client in place to prevent theft.
  • Unlimited Scalability and Upgrade Capabilities – The capabilities of some manufacturers’ thin clients are completely determined by the managing servers, which means the maximum number and processing power of the thin clients in any particular installation are limited only by the capabilities of the controlling server.  To allow for more simultaneous users or more complex applications, only the servers need to be upgraded or replaced; the thin clients can remain unchanged.
  • Automatic Firmware Updates – Many thin client manufacturers provide software in their thin client server package which automatically keeps the firmware of the thin clients up-to-date.

Cons

  • Expensive Back End – A thin client installation with an administrative server will almost always be more expensive at the point of purchase than a set of laptops, especially if the laptops are deployed without an administrative server.
  • Single Point of Failure – If the server which provides administrative control to the thin clients fails, all of the thin clients may be down until the server is brought back up.  Exposure to this risk can be mitigated by using redundant servers, which themselves feature redundant systems (power supplies, memory, processors, etc.), however it can’t be entirely eliminated.
  • Everyone is Subject to Each Others’ Usage Patterns – The performance of thin client’s desktop sessions can be adversely affected by what other users on the system are doing.  Someone watching online videos, for example, may occupy significant processing power and bandwidth, which can drag down the performance of other user’s sessions.  This problem can be alleviated by upgrading the administrative server, but doing so engenders additional costs.
  • Limited Peripheral Support – Thin clients may have limited support for attachable peripherals, such as USB storage or printers.  (This will mostly depend on the operating system of the administrative server.)
  • Geographically Grounded – Because they aren’t mobile, a thin client terminal is needed for each location in the office at which a computer is desirable.  Power and network access are needed at each such location, which may require the installation of additional wiring.
  • Limited OS Options – Most thin clients come with a Linux desktop as a default option, as this doesn’t force any additional licensing costs.  Presenting a Windows-based desktop to thin client users currently requires Windows Server, Windows Client Access Licenses, and Windows Terminal Services licenses, each of which costs extra.  Furthermore, Apple does not currently offer a suitably efficient protocol for serving an OSX desktop to a thin client.
  • Server Requires Physical Security – The administrative server must be physically secured from theft, accidental damage, and power loss.  In addition, such servers are typically noisy, meaning placement in a closet, mechanical room, or soundproof rack is usually highly desirable, but may require additional wiring or other expenses.

Bill Horvath II is the CXO of DoX Systems, a company which offers medical office productivity solutions to physicians in private practice. Their flagship product is DoxCIS, an electronic medical records system.

Pros and Cons of Laptops with an EMR

Posted on August 12, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

In the comments of my previous post about Tablets vs. Convertibles vs. Laptop and EMR, we started an interesting discussion about “thin clients” in addition to laptops and desktops in the healthcare environment.  From that discussion I invited Bill to do a guest post about the various advantages and challenges of laptops and thin clients with an EMR.  Bill did such a detailed job I decided it was worthy of 2 posts.  The following is Bill Horvath II’s description of the pros and cons of laptops with an EMR.

Because doctors who have an EMR system need access to patient histories at the point of care, they need a computer in the exam room.  Traditional desktop computers have been used for this purpose in the past, however, more cost-effective laptops and thin clients are becoming much more common in clinical settings.  This post examines some of the pros and cons of laptops.

Laptops

Overview

An office which chooses this approach will typically have one laptop per physician, and possibly one for each of the other staff members who move between exam rooms, such as nurses.  In this scenario, traditional desktop PCs are usually used at the stations occupied by non-mobile staff, such as the receptionist.

Pros

  • Mobility – The doctor can take a laptop wherever he or she goes, including out of the office.  Remote access to charts is usually accomplished via a VPN.
  • Local Data Storage – The doctor can easily store files on the hard drive of the laptop, meaning those files are accessible wherever the laptop is, and regardless of whether it’s connected to a network or the Internet.
  • Many OS Options – Laptops are available for virtually all of the major operating systems (Windows, Apple, Linux, Unix, Solaris, BSD, Chrome).
  • Broad Peripheral Support – Laptops usually have built-in drivers for dealing with a wide variety of peripheral attachments, such as USB mass storage devices, cameras, printers, and scanners.
  • Flexible Performance – With a few minor exceptions, the performance of a laptop computer is determined solely by the capabilities of the computer itself, and how it’s used by the person sitting in front of it.

Cons

  • Require Recharging – When configured for mobile use, laptops run off battery power, which means they must be plugged in periodically to recharge, or the doctor must switch to a freshly charged battery when the available charge runs low.  Most laptops will provide two to four hours of continuous use on one battery charge.  Laptop battery capacity also typically declines approximately 20% per year, which adversely affects performance over time.
  • Expensive – Good quality, business-class laptops start at around $1000, and can range into $3000+ for more advanced units.  Necessary accessories (docking station, supplemental monitor, extra batteries, carrying case, etc.) can add significantly to the cost.  Support contracts for the laptop can be pricey as well, as the components are tightly integrated and difficult to replace.
  • Fragile – Most laptops have moving parts (typically fans, optical drives, and hard drives; also mechanisms such as the connection between the lid and the monitor) which will wear down, and which don’t respond well to being dropped.
  • Difficult to Repair – It is often not possible for the doctor or her staff to repair or replace the components of a laptop (such as the screen or keyboard) if they fail. Laptops often need to be shipped to the manufacturer to be fixed.
  • Hard to Replace on Short Notice – Even if a ‘hot spare’ laptop is kept in the office for emergencies, synchronizing applications, settings, and files between a (possibly broken) machine and the spare may not be trivial, nor is updating the operating system.  This effect is amplified when each doctor has their own particular configuration, and if there is no centralized management server (e.g., Apple Workgroup Manager, Windows Server Domain) in place.
  • Complicated to Secure – Because they are mobile, laptops are subject to theft.  This problem can be mitigated by encrypting the hard drive, but doing so creates challenges around encryption key management, especially in multi-laptop environments, and as laptops and hard drives are replaced over time.  In addition, laptops accidentally left in exam rooms with patients are particularly subject to a variety of security risks, such as accidental damage, malicious hacking, etc., especially if the laptop lacks a two-factor authentication system.
  • Limited Upgrade Potential – Most laptops are limited in how they can be upgraded over time (Typically RAM and the hard drive are the only user-upgradable components.)  This can become an issue in keeping current with software and operating systems, as new programs often have more stringent system requirements.
  • Noisy – The fans, hard drive, or optical drive on a laptop can spin up at inopportune times, creating a distraction, and making soft sounds harder to detect.
  • More Complicated Backups – Because a laptop’s data is stored locally on the hard drive, the laptop must be backed up on a regular basis to protect against data losses due to breakage or theft.  This typically requires action on the doctor’s part (connecting a cable, triggering the backup function, taking the backup medium off-site), though some systems come with an automated backup system which can function wirelessly.   However, changes to the laptop’s files which occur between backups may be irretrievably lost if the machine is compromised.
  • Require Individual Updates – Laptops which aren’t managed by an administrative server require individual patching to stay current with operating system and application updates.  Furthermore, since laptops aren’t typically on for automatic updating late at night, the update process which takes place during the day may interrupt the doctor’s workflow by forcing reboots at inconvenient times.  Laptop firmware also usually requires manual updating, a process which may not be especially ‘user friendly.’

Bill Horvath II is the CXO of DoX Systems, a company which offers medical office productivity solutions to physicians in private practice.  Their flagship product is DoxCIS, an electronic medical records system.