Contrary to popular belief, all networks are not alike. Careful planning and a wise financial outlay can help dentists create systems to consistently meet their needs.
by Ekram Khan
Building a computer network involves more than buying a few computers and wiring them together. It requires as much thought and planning as a remodeling or new construction project. You must take into consideration space, electrical, storage, and expansion requirements for at least a three-year lifespan for the computer network. It is difficult to prevent obsolescence, but a well-planned network should be able to support future additions and integration with little or no duplication of the original expenses. Future expansion of your network should be as simple as adding new workstations and software with no modifications to your digital infrastructure.
You should begin by envisioning your immediate needs and then projecting what technologies you plan to add in the next three years. Split your planning into administrative and clinical networks. The main dedicated server will connect both halves of the network. Therefore, it is feasible to implement a two-phase strategy beginning with the administrative network and then extending into the operatories. This process is simplified by choosing to run Category 5e or Category 6 ethernet cabling at the outset. You can then feel free to explore adding any technology to the network without fear of a bandwidth limitation that may result in a poor performing network. The core components of the network are the server, networking equipment, and administrative and clinical workstations. Selection of the core components will largely be determined by your choice of add-on technologies like practice-management software, cosmetic-imaging software, digital X-ray systems, and other digital dental tools that will most definitely stretch the capacity of any network. Therefore, careful initial planning without cutting corners for budget constraints will reduce the long-term total cost of ownership. Your computer network will be the foundation upon which you will build your high-tech practice. Its design and implementation should be a priority and entrusted to systems integrators with specific experience in the dental environment. Contrary to popular belief, all networks are not alike.
Selecting the core components
The server. At the heart of every network is a true dedicated server with RAID Level 1 disk mirroring. There are several common levels of RAID (Redundant Array of Independent Disks), ranging from zero to five. I prefer using RAID Level 1 with hot-swappable hard drives for my clients because in the event of a disk failure, restoration of the server to operational status is achieved more efficiently than with the other RAID configurations. RAID Level 1 (Disk Mirroring) has another benefit in the fact that it maintains an exact copy of the stored data on each hard drive. In the event of a catastrophic server failure, an exact mirror enables easy recovery of your data by simply plugging the hard drives into another working server with the same operating system. While RAID disk arrays provide real- time data backup, a high-capacity, tape-backup system is crucial for a complete backup strategy that not only protects against disk and server failures, but also against real-time data corruption. Imagine that part of your database that contains ledger information becomes corrupted from a software glitch and you don't discover the error until three days have passed. If you use only one tape for daily backups, then, by the completion of the second daily backup, you no longer have an uncorrupted database. Even if you use a two-tape strategy, by the end of the third daily backup, all of your copies of the database are corrupt. Therefore, the strategy I recommend most often is a full tape backup for every day the office is open, as well as a separate tape for a full weekly backup. Achieving redundancy of data should be one of the major functional objectives for a network that will acquire and store virtually every piece of data generated by high-tech dental practices. Finally, use the following formula for calculating your storage needs: (Number of active patients x 30 MB)/1000. This will yield the total number of Gigabytes you will need for approximately the next three years; assuming you will be taking digital X-rays and capturing images from intraoral cameras.
Administrative workstations. The administrative workstations are the unheralded workhorses of the network that perform unglamorous, but nevertheless essential, tasks that keep the office running. Since most Windows-based, practice-management software applications run locally on the workstations, rather than centrally on the server, you should consider purchasing the most well-equipped computers that your budget allows. A popular misconception is that a computer's CPU speed is the sole determinant of its performance. That would be analogous to a car having a Ferrari engine with a Yugo chassis. Class-leading performance is achieved by mating the latest Pentium processor with at least 128 MB of RAM, a video card with at least 16 MB of RAM, and a hard drive with a rotational speed > 7200 rpm. Additions of accessory hardware to administrative workstations are not common. Therefore, I recommend implementing the new slim-profile workstations that are barely thicker than a textbook. Remember, you won't be interfacing these workstations with intraoral cameras, digital X-ray sensors, or other devices. All that is required of administrative workstations is to optimally run the practice-management software. Therefore, combining a slim-profile workstation with a flat-panel display and wireless mouse/keyboard provides the ideal combination of computing power and ergonomic efficiency for the often cramped front desk/business office area.
Operatory workstations. The operatory environment is the most demanding for digital-technology integration. The following issues directly affect your choices in operatory computing:
Space constraints/ergonomics. The operatories are notoriously cramped in the majority of existing dental offices. Even in new constructions, the designers often disregard the specific requirements for implementing computers in the operatory. Every location throughout the office that will have a workstation should be considered a data point. Each data point should be provided with dual 110-volt outlets, as well as an ethernet jack. Careful consideration for the ergonomics involved with computers in the operatories highlights the importance of display placement. After all, the display will be the primary communication interface between your technology platform and all who interact with it — including patients. Dr. Larry Emmott emphasizes the importance of a "public" patient display and a "private" staff display in the operatories. Dual displays enable efficient multi-tasking in the operatories because you can perform clinical data entry using the "private" display, while showing patient-education and entertainment content on the "public" display. Having dual displays in the operatories was formerly cost-prohibitive, but with the recent drop in price of flat-panel displays, having an elegant dual-display setup in the operatories can be a reality. Also, due to the intense level of wiring and plumbing necessary in the operatories and the lack of storage space, a little planning and good design will result in an elegant installation with as many cables and installation hardware hidden from view as possible.
Integration/compatibility. With myriad digital devices and software available for operatory computing, the ensuring that all of these devices will co-exist within a seamlessly integrated system is a monumental task. Hardware incompatibility is the number one reason for poorly functioning digital X-ray systems and mysterious software glitches. Cutting corners to save a few dollars on operatory computers can result in years of degraded performance and lost productivity. For optimum operatory-workflow efficiency, I recommend a multi-tasking configuration with dual displays, DVD multimedia capability, and intraoral video capture capabilities. Upgrading the RAM to 256MB and using video cards with more than 32MB of memory yield the best performance. Although many computer manufacturers can build computers with similar capabilities, it is rare that these companies will provide warranty support after third-party devices and hardware have significantly altered the original configuration.
Asepsis/suitability to task. Asepsis concerns involving a computer may not be an obvious issue that needs to be addressed; but, if you carefully consider the deployment of computers in the operatory and the number of times the clinical staff interacts with a computer, it becomes clear that all surfaces of any computing device installed in the operatory should be disinfectable. Generic and brand-name computer manufacturers have not addressed this significant issue which is relevant to the health-care environment. You also must consider the high level of integration required in the operatories.
Devices like digital X-rays and intraoral cameras often are required to co-exist without conflicts. Seamless integration has been difficult to achieve. With input from our clients, Cieos developed an operatory computer that incorporates all of these features into a zero-footprint package.
To Dell or not to Dell?
Most niche market systems integrators are faced with the question, "Why can't I use Dell or a name-brand computer for the network?" While the name-brand computers are fine for home or generic office computing, the high level of systems integration required in dental offices dictates that a standardized configuration be used universally. You have to discover what works and consistently repeat it. The following points should be considered:
Software that is bundled with name-brand computers may be incompatible with software and capture devices common in dentistry. I have seen several offices struggle with seemingly inexplicable computer crashes, only to discover that the version of the video drivers that came with the brand-name computer is incompatible with the digital X-ray system.
Branded computers often have chipsets of several devices like video, sound, and network cards embedded onto the motherboard. This reduces the manufacturing cost of the product, but introduces significant compatibility issues when you attempt to install capture boards for digital dental devices. Often, embedded chipsets on branded computers can't be disabled. Therefore, even if you want to install boards that are compatible — you can't.
Branded computers come with warranty service that will be voided once you add proprietary digital dental devices. If you have warranty service/repair performed, such as replacement of a failed hard drive, the factory technician will only restore your computer's software to the manufacturer's specifications and will not reconfigure or install all of your dental-related software and devices.
When you consider long-term service, support, and total cost of ownership, it becomes apparent that mass-market computers are not the great value that they appear to be. Reputable systems integrators use high-quality components to build their custom computers. All that is missing is a brand name. The best way to guarantee a quality installation is to check the references provided by the systems integrator. And last but not least, choose an integrator that has extensive experience in dental-systems integration.
These days, even small companies spend hundreds of thousands of dollars on computer equipment. Protecting that investment is critical — and keeping servers and associated equipment in a controlled environment is an essential part of protecting that investment.
But how do you set up a server room that's secure and effective? Rather than discussing expensive, custom-built computing facilities, I'm going to examine practical steps that will work in most of the organizations we deal with.
The server room is sometimes given low priority when premises are located. But if you have the chance to offer input on the room at the planning stage, these suggestions can help you strengthen your case. And even if the server room is something of an afterthought, you'll benefit from thorough and realistic planning.
Lay out the contents
Give yourself elbow room. Whether you have racks of equipment or just a couple of freestanding servers on desktops, give yourself some space at the back of your computers to get to the cables. You will save much time and effort when it comes to that inevitable time when you need to unplug, move, or open the server. Leave enough space between the back of the equipment and the wall to walk behind and access plugs and cables without stretching (and accidentally nudging other cables). Keep the cabling tidy, and you will thank yourself later.
Provide yourself with workspace. If you have the space, include a PC in the server room to work on, and preferably configure it for Internet access. You may need to add it to a KVM switch to save space by using the same monitor and keyboard. With this facility, you have a workstation for researching problems, running batch jobs, and operating monitoring/performance software.
The server room also may be a good place to put a bookshelf for manuals and a fireproof safe for the backup tapes, disaster-recovery manuals, and procedures. And make sure you have enough desk space to set paper and pen down!
Document the setup. After you've installed the equipment in your room and tested it to make sure it all sits on the network happily, document it. Draw a diagram of the equipment in the room. Document which port each piece plugs into, which server does what, and which pieces of equipment each UPS covers. Colored cables often are used in server rooms, where the concentrated amount of cable can be confusing. Perhaps blue cables go from server to patch panel, while standard gray is for PC cabling and yellow is for the hotline to the pizza shop. If you have a labeling machine, the server name and network address are always useful when stuck directly to the front of the machine.
Keep the plans. When you have shoehorned every last piece of equipment into the former closet you now call a server room — and you've written down how it all connects, how many UPSs you needed, and how much space it required — keep the plans. Sometime in the future, you will either need to:
- Break it all up and relocate it;
- Put together an almost identical room for the same organization; or
- Put together an almost identical room for your next job.
Sign in/out. If you are the only person with access to the server room — or at least the only one who should have access to it — then signing a visitor's book may be academic. It's one method of tracking who's had access to the server room; however, you may find change-control documentation adequate.
Change control. This is just about the most important operating procedure and piece of documentation you could maintain. We will explore change-control documents and authorization in detail in future articles. However, even if this is only a logbook detailing self-authorized changes, it is essential.
What should you log?
- Operating-system updates
- Configuration changes
- Hot fixes
- Server-application updates and fixes
- Network hardware swap-outs and additions
If something has been altered in the server room, it probably will have a direct or indirect effect on a number of users. If you log each change in detail, you will have far greater insight into future problem solving when you can look at the history of each piece of hardware.
Logical security. If you have made your server room physically secure, you might assume that your servers are safe. However, when it's so simple, it's pointless not to lock the server consoles with a password or log off when you have completed a session.
Disaster planning. When the worst does happen, and some type of disaster hits the server room, your documentation and media store will be as important as your cabling.
Restoring a server configuration, or data, will be quicker if you have a written procedure that you or someone else can follow step by step. Rebuilding a server from scratch will be easier and more faithful to the original if you have the documentation detailing the operating system components originally installed, along with the updates applied under Change Control.
In all these cases, protecting the documentation and the media is important. Either use a fireproof safe or make copies and store them separately.
Just how many of these suggestions you take on board will depend on your individual situation — your available space, your resources to prepare the facility (money and people), and of course, your time.
Four final points:
- Your investment in computing equipment warrants separating and protecting it.
- Good planning can keep those investments providing a return and help keep downtime to a minimum.
- Putting a server room together in an established network can provide a fresh focus on procedure, control, and security.
- Choosing a systems integrator with extensive dental-systems integration experience will cost more initially, but will yield a computer network that has a high return on investment and a low total cost of ownership.
Plan the room
Size it up. Begin by determining how much space your current collection of equipment consumes. This includes racks and cabinets, freestanding servers, external units (backup units, UPSs, and so on), monitors, at least one chair and desk, the safe, and documentation storage. Next, add your expected growth in equipment ... and then round up. Remember that if you put everything in the room, then run out of space six months later and have to relocate to a bigger room, you will have another downtime project to run.
Prepare it. This room is going to have completely different power requirements than other rooms on the site. Draw up your equipment list and lay out the room on paper. When you've completed the planning exercise, count the power sockets you are going to need (and will need for expansion) and get the electrician. Decide which pieces of equipment and power rails are going to be protected by Uninterruptable Power Source (UPS) devices. Find out if a "clean" filtered power supply or surge protection is available.
When the power is going in, decide on the position and number of data points in the room. Make sure they are easily accessible once desks, shelves, and racks have been moved in. (It may be neater to have them at floor level in offices, but convenience is more important here.)
Finally, make sure the room is ventilated, air-conditioned, or just cool — depending on your budget. In an enclosed space, your equipment can create some heat, so if summer warms the room up, it's going to get especially hot. Remember, heat is your number one enemy. The cooler you keep all of your systems, the better they will run.
Announce it. If the room you take on was formerly used for another purpose, make sure everyone within the organization knows what the new function of the room is; explain that it no longer has any other function. This may be a problem only if you cannot secure it properly. This carefully planned room shouldn't be used for storage.
Secure it. Put a lock on the door and keep track of who has copies of the keys/access cards/combination. There is little point working through this exercise in control if "anyone" can walk in. Once the room is secure, make sure that someone is always on site who has access in case of emergencies.