Brents IT Blog

Random thoughts by an IT GOAT


An honest review of EclinicalWorks

Just some background:

We have been on Medical Manager for 10+ years.  Upgrade after upgrade went relatively smoothly.  We even migrated to a new box about 6 years in.  We went and looked at GE Centricity and had an indepth onsite review of Sage’s new product, Intergy.  Intergy was to replace the aging and no longer supported Medical Manager product.  Long story short, after several acquisitions, Sage Software ended up owning Medical Manager.

We have been running ECW( EclinicalWorks ) for over a year.  We have been through several upgrades and I personally have an in-depth knowledge of the whole architecture.

ECW is made up of several servers working in unison.  First you have the main database server, then two slave database servers, one for reporting from the application and an optional one for dedicated custom reporting that’s not completely baked as a product but will give you some useful information.  Next you have application servers, the number of application servers you have will depend on users.  Then there are three component servers:  One for FTP/File sharing, One for interfaces, One for faxing.  You then have the option of having a test server that comprises all of the above servers on one server.  Its essentially where you “test” new versions of the software or ideas, we also use it for training. 

ECW has a major flaw, now I see this as a flaw because it’s a redundancy and data availability thing.  The flaw is the fact that the desktop applications will only read and write the main database server.  This means that all the load is on this server, if its not up to snuff, your slower than a turtle.  Random freezing and slowness will plague you.  The next major issue is that they run that monstrosity they call a database in MyASM by default.  MyASM is ok, but when you need performance, especially when the database design is bad or faulty, INNODB is the only way to go!  So if you haven’t yet, get them to convert you to INNODB, you will see the performance increase overnight.  Let me end this paragraph on a good note, they also support MS SQL if you request it, my suggestion is to request it, but make sure you have weighed the cons of using MS SQL ( cost, feature loss, hardware and OS ).

Since ECW is using MySQL, apache and Tomcat, you can also run most of the servers on Linux, though they prefer windows.   I would recommend Linux if you know it, but make sure to choose a distribution they are ok with and you have staff that can support.

Clients are windows only.  They support Vista now and I believe by virtue of Vista they also support Windows 7.  If not, I know that ECW will work on it though.  The client is about 100MB+, so be ready when you upgrade, those packages are hard on your remote connections.   I also think the client is a kludgy.  Its bulky and they register all sorts of crap via command boxes when you install it.  I have run into several instances where things just won’t register properly which causes certain features to give random errors.  We generally reinstall the client manually to force a fix, though we have been successful with coping files and running the regs again.  It does communicate with the servers over HTTP or HTTPS.  It also users FTP to upload images and file sharing to download them(figure that one out).  FTP passwords are wide open on the network so make sure to deploy security on remote links( kinda obvious given its medical software, but just in case). 

The client itself is extremely comprehensive.  Our providers love the indepth abilities, our nurses love the details and tracking, our reports people like the ability to add fields and pull data till their hearts content.  So it’s a loss for IT but a win for staff and in the end, they win out.  Its not horrible though, so I would rate it one step below any of the office software from MS if that helps give an idea of problems.

The client is also bandwidth intensive and very chatty.  Be prepared to increase your site links to 3Mb or higher.  I would also recommend you enable QoS if you can.  Server side, the application sends queries for anything and everything the user sees.  This makes it very chatty, so be prepared for lots of small time traffic and heavy query loads on your server.

Speaking of connections, they say you are supposed to stay below 60ms on any client to server connection.  This latency requirement is tested during the implementation and recorded.  As far as client connectivity, you can use wireless or wired.  Just make sure to check your wireless card settings and ensure they do not decrease to save battery life.  I would also make sure you set a medium to high rate of Access Point ( AP ) switching.  This means that if another AP with a stronger signal is detected, the machine will swap to the next AP.  You will need to play with this setting to make sure it doesn’t swap to quickly though.  Users walking around the building may have issues if it swaps to much.

In order to fix some issues with the clients and the servers, we have deployed MS GPO’s to ensure certain settings are pushed to the clients.  These settings ensure the wireless works properly, Battery life is extended and various things users do when moving around do not put the tablet in sleep mode.  They also ensure that printers are assigned as lightly as possible to reduce startup and shutdown times.

When you first get ECW, the system will be blank.  You will need to fill in lots of stuff.  Be prepared for a lot of upfront data entry to get the system up to running speed.  Providers have to be added, staff have to be added and given permissions, security groups/templates need to be designed to ensure proper functionality, location information, billing tables, Medicaid/Medicare/Insurance information, and patient data migrated. 

I saved interfaces for last.  Most all health clinics have relationships with laboratories in the area.  The interface server discussed above will hold most of the data exported from your database and send it to the lab company of your choosing.  Keep in mind that most labs will pay for the interface to be built, but some will demand a certain level of volume in order to complete the transaction.  Make sure you and they know what each other want out of it and test it as much as you can before you make it live.

When signing with ECW there are a few contractual things you need to keep in mind.  Make sure to include deadlines.  Make sure to lock in interface pricing, maintenance pricing, license costs and labor costs.  Also include support expectations and response times if they will allow you.  Make sure to negotiate upgrade costs and if you want a feature not currently in the software, a deadline for inclusion.

If you think you are going to have trouble implementing it on your own, consider they provide hosting and that there are several companies out there that will provide consulting services that will keep you on track for your deployment dates.  You may also want to include penalties for failures.  Generally they will result in credits, but its nice to have a stick to go along with the carrot.

Final Thoughts

ECW is a good product.  While there are issues, every software has issues and none are perfect.  Remember to do as much preplanning as you can but also stick to your deadlines.  Keep on top of ECW for any additions to the software and installation/feature upgrades/fixes.  You are your best advocate.  Training your staff is very important.  Make sure to hold atleast two days of basic training and then follow up with another few days after they have had a week or so to use it in their day to day.  It is recommended that you have trainers onsite when a location goes live.


Few Notes on Hardware
-6130 Fujitsu scanners ( don’t bother with small card scanners )
-Logitech webcams, Business grade work the best and are supported
-Fujitsu tablets work fine and with the extended batteries, will last 6-7 hours on one charge.  This does not preclude other tablets, your providers may be more comfortable without a keyboard.  Motion has some great units that will fill that need.
-Any PC, we use Lenovo units with 4GB of RAM, will work.
-I have found that Brother 1270W monochrome lasers connected directly to the network work the best and fastest.  Though in some instances you may need two trays to allow for prescription paper.
-Servers are again up to you, they will provide a sheet with the requirements for each component.
-I do recommend SAN storage for any data drives if you go physical.  A SAN will give you flexibility, reliability and redundancy you cannot get from stand alone servers.