08 - Installation and Maintenance of Health IT Systems - Unit 8 - Troubleshooting Maintenance and Upgrades Interaction With Vendors, Developers, and Users - Lecture B

Installation and Maintenance of
Health IT Systems
Lecture b
This material Comp8_Unit 8b was developed by Duke University, funded by the Department of Health and Human Services,
Office of the National Coordinator for Health Information Technology under Award Number IU24OC000024.
Troubleshooting; Maintenance and
Upgrades; Interaction with Vendors,
Developers, and Users

Learning Objectives
1. Identify and implement an effective troubleshooting procedure for
reporting, evaluating, fixing, deploying, and follow-up of errors,
problems, or limitations for the system (lectures a & b)

2. Integrate downtime schedule for OS, network, database, and client
application maintenance and updates (lecture b).

3. Develop a process for communicating requirements and supplying
updates between vendors/developer and users (lecture b).

4. Create a baseline for system performance measurement and
comparison for troubleshooting (lecture b).
2
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Installation and Maintenance of Health IT Systems
Troubleshooting, Maintenance & Upgrades & Interaction with Vendors, Developers and Users
Lecture b
Troubleshooting:
Diagnosing Complex EHR
Infrastructure Issues
Identify the problem

Determine the scope of the issue

Start Simple

Seek Additional help during an Outage

Remember to communicate

(Halamka)

3
Lecture b
Troubleshooting:
Diagnosing Complex EHR
Infrastructure Issues
Use the logs
Develop a timeline
Stick to the PlanSet deadlines for escalation
Stay focused on resolving the problem.
Dont be too quick to declare a problem resolved.

(Halamka; AHRQ, 2011)

4
Lecture b
Troubleshooting: An Example
User contacts the EHR Helpdesk about
slow EHR
Start with the local machine
Recent Updates or Patches
System and Application Logs
Wireless/ Ethernet Connectivity
5
Lecture b
Troubleshooting: An Example
If the issue is more widespread
Network or ISP Issues
Misconfigured switch, router, ISP Connectivity
Erroneous OS Upgrade/ Misconfigured Server
Server Hardware Error/ Upgrade Needed
Application Upgrade Error
EHR Design
EHR Software Code

6
Lecture b
Performance Baseline
Generated after completion of
performance baseline testing.
Shows normal operating parameters of
your system under normal load conditions.
Used to gauge overall system health &
assist with isolating performance
problems.

(Wunder)
7
Lecture b
Performance Baseline: Testing
Benchmark testing
Compare performance of new server/system against
standard (e.g., existing measurements or software
specs).
Test at regular intervals, when problem-free:
System resources (server & hardware)
Network architecture
Operating system
Database applications
Client applications

(Sqlserver, 2009)

8
Lecture b
Performance Baseline:
Utilities Available
Work with vendor to determine
best method for your EHR.
Many third-party utilities
available.
Windows built-in utilities:
System Monitor (collect & view
real-time data on usage of
memory, disk, processor)
Performance logs & alerts
Task Manager
Event Tracing for Windows
(ETW; trace & log events
raised by user-mode
applications & kernel-mode
drivers; export most SQL
Server events.)
(Microsoft, 2011; Technical, 2005)

Databases often require special
utilities.
SQL Server built-in utilities:
SQL Trace
SQL Server Profiler
SQL Server Management
Studio Activity Monitor
SQL Server Management
Studio Graphical Showplan
Stored procedures
Database Console Commands
(DBCC)
Built-in functions
Trace flags
9
Lecture b
Performance Baseline:
Measurements & Next Steps
Measurements
Peak vs. off-peak hours
Production-query, batch-command response times
Database backup and restore completion times
Next steps
Compare baseline statistics to current server/system
performance.
Investigate if numbers far above or below baseline.

(Wunder)

10
Lecture b
EHR Maintenance & Upgrades
Upgrades crucial for extending EHR
functionality & overall system lifespan.
Improperly planned/managed upgrade
procedures can severely damage system,
reducing performance.
Use highly structured approach in
upgrading any major, critical production
system.

11
Lecture b
EHR Maintenance & Upgrades:
Structured Approach
Upgrade team
Works with vendor.
Reads upgrade documentation.
Analyzes functional enhancements.
Works with vendor on unknown variables.
Makes plan to configure & test affected applications.
Technical team develops alternative testing
environment (test bed).
Upgrade team compiles pre-installation & installation
checklists, determines downtime.
After first testing, logs reviewed & errors/discrepancies
reported to vendor.

12
Lecture b
Structured Approach (contd)
After vendor resolves issues, upgrade process
retested, ensuring data integrity.
Consider software to simulate workflow & users;
track data for performance analysis.
Unified spreadsheet to track issues.
Once testing complete & upgrade approved, final
documentation prepared & training scheduled.
Installation team finalized & assigned roles.
Upgrade scheduled during off-peak times.
EHR shadow copy (read-only, without real-time
interfaced results) accessible during upgrade.

13
Lecture b
14
Lecture b
Structured Approach (contd)
Upgraded system tested immediately after
completion.
Once testing complete, help desk notified
& systems brought back online.
Dedicated team available for several
business days to resolve issues.
(Follow similar processes for upgrades to
server OS, workstation OS, databases.)
Interacting with Users
Stay up to date
Set realistic expectations
Value your users time
Be friendly, but stay on task.
Listen Closely, and acknowledge the users issue
Use the opportunity to educate
Be patient

(Boyer, 2005)

15
Lecture b
16
Lecture b
Essential not only for successful implementation, but also for
continued success of product.
Issues will arise beyond scope of your IT workforce.
Routine upgrades needed.
Vendor plays pivotal role in these & other events.
Successful partnerships built on mutual goals, trust.
In this together.
Success of vendor depends on success of product.
Long-term commitment between organization & vendor.
Relationship becomes complex once organization dependent on
fully embedded EHR.

(Boyer, 2005)

Client-Vendor Relationship
17
Lecture b
Client-Vendor Relationship:
Before Purchase
Understand vendor company & culture.
Visit headquarters, talk with as many as you can (including
development & support).
Follow the money. What drives revenue stream?
Dependent on support fees? Understand support-fee
structure.
Financially solvent enough to provide long-term support?
Hosted and SaaS (Software as a Service) solutions: understand
vendors upgrade strategy.
Will it conflict with your business practices?
Impressions of vendors support staff

(Boyer, 2005)
18
Lecture b
Performance baseline
Helps gauge system health & isolate problems.
Structured approach for upgrades
Separate environment for testing upgrades prior
to rollout. Work closely with vendor to resolve
issues. Rollout during non-peak hours.
Client-vendor relationship
EHR purchase brings long-term commitment.
Complexity once dependent on EHR. Understand
vendor & culture before purchase.
Summary
References Lecture b
References
Boyer, E. and M. Soback (2005). Production Support. Implementing an Electronic Health Record System. J. M. Walker,
E. J. Bieber and F. Richards, Springer London: 95-100. http://www.springerlink.com/content/n520ghg078416463/
Event Tracing for Windows (2011). Microsoft.com. [Internet]]. http://msdn.microsoft.com/en-us/library/ff545699.aspx .
Guide to Reducing Unintended Consequences of Electronic Health Records (2011). AHRQ. [Internet].
http://www.ucguide.org/
Halamka, John. 10 tips for troubleshooting complex EHR infrastructure problems. KevinMD.com. [Internet].
http://www.kevinmd.com/blog/2010/09/10-tips-troubleshooting-complex-ehr-infrastructure-problems.html.
SQL Server Security, Performance & Tuning. (2009).SSQA.net. [Internet]. http://sqlserver-
qa.net/blogs/perftune/archive/2009/07/26/5820.aspx
Technical Comparison of Oracle Database 10g and SQL Server 2005: Focus on Manageability, May 2005 (2005,
May). Oracle. [Internet]. http://www.oracle.com/technetwork/database/focus-areas/manageability/ss-1.pdf
Wunder, Bill Benchmarking Techniques Using T-SQL Part 1 - System Statistical Functional. [Internet].
http://64.29.220.154/articles/viewarticle.aspx?id=17797.

19
Lecture b

08 - Installation and Maintenance of Health IT Systems - Unit 8 - Troubleshooting Maintenance and Upgrades Interaction With Vendors, Developers, and Users - Lecture B

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