Need IT help. Internet slow at work.

[rox]

Oh my a Citrix server? Oh yeah I can see how that would be sub optimal.
Right or wrong I always think of a Citrix server this way. The application runs on the server, the application does the work over there and then what it does is it sends a message back to your computer monitor telling your monitor which dots of lights to light up on your monitor to show you an image of the output of the servers work. Basically it sends you screenshots to your computer of what is done over on the server. There is no application on your computer, the apps are over on the server so basically all you are seeing is screenshots. That is why there is such limited functionality on your side.

 

[N80]

I think what I would do is, instruct everyone to power down their computers & laptops at the close of business. Then I would ask the IT dept to come over after hours and check your system. You can't very well have your entire doctors office shut down off the internet during the day, but at night you can.

Correct. There is no way we could shut anyone down from 7:30 am to 5:30 pm.

In this way the IT dept can check simply the access points with nobody on the network, as mentioned they will probably start with the router.

Sadly, I have no faith in our IT department and honestly doubt that they will do anything at all unless 1) 16 Mbps is, in fact, unreasonably slow (it sure seems that way to me) and 2) I complain to much higher management if 16 Mbps is in fact too slow.

There is a lot of junk cable from China being used. Your access points should be hard wired back to the router.

I remember when it was installed but couldn't tell you anything about it. Each office and exam room is also hard wired.

Ask the IT guys to examine the cables being used in your office for markings of the manufacturer.

I will. But they will laugh at me, if not to my face, definitely behind my back. As mentioned, for as long as I remember they have never fixed _anything_. Management said they were going to fire one of them a year ago because of complaints from all over the region. But he's still the main guy.

A 25 person doctors office is not that large square footage wise

It is actually huge. Two stories, something like 9000 square feet. We used to have 9 doctors in here and 50 employees. We were devastated by the ACA. Now you can't hire a primary care doctor anywhere. Anyway, the size could actually be a problem. Large closets upstairs and downstairs with all the lines,routers, etc etc.

Best of luck to you and don't give up! It's to annoying to have slow internet, I bet you can work this and get it resolved.

Thank you and everyone else for helping out. I'm going to push management hard on this. The EHR (in general) is an inefficient way to do medicine at this point. My volume has contracted considerably since they were mandated by the ACA and seeing fewer patients does not equate to spending more time with them since that time is monopolized by data entry. The net result is less access to care (volume=access!), less time with patients, epidemic levels of physician burn-out and falling income. When you make any worker do less work he likes to do, more meaningless work he does not like to do and pay him less you have a problem. And around here primary care physicians are leaving medicine. Sorry about the rant, but my point is, a slow EHR is an even greater frustration. If I could get some real internet speed with this new EHR, which is a huge step in the right direction, my job will be much more pleasant and patient care much more efficient and appropriate.

 

[N80]

I guess another question I need to ask you guys is: Does 16 Mbps seem unreasonably slow for a practice that runs 100% from check-in to check-out on web based software? If it is normal then I might just have to shut up and accept it. But it is slow in practice, feels slow all day and is slower than my home account. I noticed that even residential users can get gigabit internet for fairly reasonable prices around here.

 

[hawkeye08]

There are many variables and causes, but if I read correctly, all the devices are slow. Are there any security cameras streaming back to remote location? I had a period of slower than normal internet at home and find out by changing to a different DNS server, things sped up.

Things to suspect,

problem with a device consuming bandwidth
problem with configuration
someone outside your office stealing bandwidth (like a neighbor in next office using your network)

Also note, the same provider does not mean you will get the same speed at home, especially if your connection is DSL (the distance to central office might be much different).

 

[/pine]

FWIW...If "logging" is enabled on the router(s)...it should list the bandwidth usage on each node by IP

 

[N80]

Oh my a Citrix server? Oh yeah I can see how that would be sub optimal.
Right or wrong I always think of a Citrix server this way. The application runs on the server, the application does the work over there and then what it does is it sends a message back to your computer monitor telling your monitor which dots of lights to light up on your monitor to show you an image of the output of the servers work. Basically it sends you screenshots to your computer of what is done over on the server. There is no application on your computer, the apps are over on the server so basically all you are seeing is screenshots. That is why there is such limited functionality on your side.

That is exactly what it felt like. Fortunately we are done with Citrix.

 

[N80]

Also note, the same provider does not mean you will get the same speed at home, especially if your connection is DSL (the distance to central office might be much different).

It is the same provider. It is a local, privately owned tele-com company and they has a monopoly in this are. My account is cable modem but according to their map, it is fiber-optic and gigabit internet is available. Again, my account is a 25 mbps download and something like 1.5 mbps upload. I am a few blocks from their central office.

I certainly hope our office is paying for something better than 25 mbps. I'm going to find out exactly what we have if I can. I doubt that fiber optic has reached out to where our office is yet but it might have.

 

[KubotainNH]

If it's all web based and constantly being used then the bandwidth may be too small but you should prove that first. As mentioned, powering down or at least disabling the internet on all the PC's but one to test with should help narrow it down. Citrix is supposed to be faster for people that have a slow connection because all the work is being done at the server and all you see is a picture of it so the only data back in forth is that picture. Sadly it's a pig unless it's got better recently. It's not used anymore at my really large company, most items are browser based now. You may find that it's the back end server that is the bottleneck. Any peer sites that use the same system so you can call and see how fast there's is?

 

[JimRB]

For giggles have you ever been in the office on a weekend when no one else was in and tried this application?

Some cable systems put lots of user on the same connection. The same connection can only do so much. In days of old DSL, was really crummy from 4 PM until 10 PM. Or maybe it was old cable modems.

At one of our country offices they have 20/20 internet that works pretty well with Citrix applications. As mentioned, Citrix is keyboard strokes and mouse clicks, with screen refreshes coming back. Only when scanning does the bandwidth start to get eaten up.

My primary care physician left his hospital affiliation which was using Cerner. He moved to another hospital system affiliation and is using Epic. I have not heard how he likes it. The practice I work for uses Epic from the same hospital system. Some of my doctors fuss and cuss. Others suffer quietly. Some of the doctors use scribes so they can pay attention to the patients. Of course they are not primary care physicians so they have a little bit more mad money to spend on scribes. They also use Dragon Medical when they are not in the exam rooms or procedure rooms. Some guys can talk at over a 100 words a minute.

If you keep fussing about this you will force me to visit some weekend to take a look. Bicycle racing on the weekends for the next month, but after that I am more free.

 

[MossRoad]

You've said your internet is slow... but you never really said how you know its slow.

Is it just your medical software that is slow to respond, or is it all things, like surfing the internet, watching youtube, etc... that's also slow?

And you also have to find out if you're on a VPN (virtual private network) type connection back to your home office, and if ALL traffic goes through that VPN, or just your medical software goes through that VPN.

If you are on a VPN back to your office, then your home office is acting like your internet service provider, and they are the ones controlling the speed, not your local telecom company.

You could have a 50 pipe and only being allowed 15 by the home office.... and that's my guess as to what's happening.

 

[drssg]

If you saw 16mbps just by using one of the computers on your network, that doesn’t seem that slow to me.

Internet bandwidth is just one of the possible culprits. It could be something at the other end that is slow, or several other things. Unfortunately, I think it needs someone that understands the total picture.

Do you know of other offices that use the same services? It would be useful to know whether your experience is unusually slow.

 

[coldsteelva]

I'm going to take a shot across the bow here: It seems to me that the bandwidth may NOT be the problem at all. I suspect that the actual back-end server (running Athena) that is processing all of these transactions is either A) Low on resources (i.e. not built robust enough to handle all of the data simultaneously) or B) actually has poor bandwidth at its location meaning no matter how fast you are attempting to exchange data with it, it cannot get it back to you.

 

[MossRoad]

You've said your internet is slow... but you never really said how you know its slow.

Is it just your medical software that is slow to respond, or is it all things, like surfing the internet, watching youtube, etc... that's also slow?

And you also have to find out if you're on a VPN (virtual private network) type connection back to your home office, and if ALL traffic goes through that VPN, or just your medical software goes through that VPN.

If you are on a VPN back to your office, then your home office is acting like your internet service provider, and they are the ones controlling the speed, not your local telecom company.

You could have a 50 pipe and only being allowed 15 by the home office.... and that's my guess as to what's happening.

One more thing.... if the home office is your ISP, they could also have a packet shaper on you. If that's not a familiar term, its a device where they can throttle the bandwidth for various applications, websites, etc... For example, my old employer's parent company took over I.T. and put a packet shaper on us. THEY thought it was a good idea to throttle back internet speeds on sites with streaming video.... we were a news gathering organization! Pretty much all news is in video format! But THEY knew better.... took months to convince them we needed to watch news videos.

Anyhow, it goes like this...
You have an I.T. department. I.T. is a cost center, as they don't bring in any money.

So, the corporate I.T. director convinces his superiors to charge the child properties for I.T. services rendered by corporate I.T..... and just like that, overnight, corporate I.T. has switched from a cost center to a revenue center that brings in money (by canibalizing his own children)...... someone at corporate I.T. is kingdom building.

 

[MossRoad]

I'm going to take a shot across the bow here: It seems to me that the bandwidth may NOT be the problem at all. I suspect that the actual back-end server (running Athena) that is processing all of these transactions is either A) Low on resources (i.e. not built robust enough to handle all of the data simultaneously) or B) actually has poor bandwidth at its location meaning no matter how fast you are attempting to exchange data with it, it cannot get it back to you.

That's a very good possibility. However, until he confirms that its just Athena that's running slow, or everything is running slow, he can't prove it's the Athena system, or a slow network.

 

[rox]

One more thing you can do N80 is Google "Insert ->Name of your Internet Provider + throttling"
See what turns up.

 

[rox]

When I go to my doctor here he doesn't even write anything down unless it is serious, and I hardly ever have anything serious. You make an appointment through his answering service, go see him and it is just him, no nurse, not support staff just him. He pokes his head into the waiting room to call you in, he sits behind his desk and asks what you are there for and after listening you step into like a little alcove and hop on his exam table and he examines you. Afterwards you go back to his desk and he writes out his orders. I mean really what is the point of writing up, "She has a urinary infection" into a record that nobody is ever going to read anyway. He just writes a prescription or maybe an order for a lab test and that is it. When we get lab tests here, all done through private labs that are as plentiful as pharmacies, you go pick up your own lab results. You only even bring them back to the doctor if there is something really out of wack on them. The lab tests tell you what is normal and then shows you your results. All the patients keep their own records of lab tests and if you need to when you go to the doctor, you just bring them with you. In other words the patients themselves keep their own records. I like it this way, there is no waste in this system. Labs do not send results to the doctor, patients go get them themselves. I know it is a wee bit off topic but since this is your profession thought you might be interested.

When I went to see the orthopedic surgeon for my bad hip I brought my x-rays with me (patients even keep their own x-rays & ultasound records) and he didn't even want to see them, he siad they don't tell you that much. He examined me by moving my leg around asking if it hurt (it hurt!). Then he said I should have a hip replacement any time I wanted it. I could have one now or I could have one later, everything was on me when I was in enough pain that I wanted it done. I made the surgical appointment during the exam and that was that. I had it done about 6 weeks later. It's beautiful, no insurance companies get involved at all it's just what you and your doctor decide is best. AND I get no bills at all, never ever a bill from the doctor or the hospital or the labs, I have my medical card that has a chip in it, and they just slide that credit card like thing into their macines and that is it. Can you imagine life without ever seeing a doctor bill or a hospital bill or an ambulance bill? It's real nice. I have a supplemnatl policy for around 400 Euros a month that covers both Nico & I and that covers us 100% for everything even pharmacy. the supplemental insurance is some how inside that chip, even when you change supplemental companies it's all recorded somewhere through that chip and everything just runs smooth.

My mother in law in the last year of her life lived in a brand new full service nursing home, brand spanking new with great food and activities throughout the day, cost 2,000 a month and she didn't even have to pay that since she was poor. My mom who just went into a very nice nursing home, $11,000 a month. Okay yeah we do have high taxes here but at LEAST we get something out of it. I live my life without ever worrying that a major illness will put me in bankruptcy. Yup full pharmacy included.

 

[rox]

N80, what is the update on your slow internet?
Thanks, rox

 

[N80]

Nothing. Management says they are going to double our speed through the ISP but no one has actually done anything. Lots of messages between IT folks but not one single thing has been done and now my daily speeds are down around 12 Mbps. But, these are the same IT people who are replacing my current laptop because of a software problem in Dragon that they can't figure out. This level of slackness and incompetence is a new experience for me. Never seen anything like it.

 

[JimRB]

What is going on with Dragon? I must have over 20 users with Dragon and no drama. Two guys claim drama and went with the expensive $70 a month Dragon Medical One cloud offering. If you are using a SpeachMic you do not want to hold down the red button when setting up your profile the first time. I gather it causes all kinds of issues. You know when you read the first two boxes and maybe the third box of 5 minutes. Note that best performance if everything is on the laptop or desktop. No storing of profile off on some server off premise or even in your server closet. I have some users with SSD hard rives and others with spinning disks. I of course like the SSD drives as everything works faster, but the end users rarely seem to appreciate the SSD upgrade when I do it.

 

[N80]

I've been using Dragon for years now. I consider it a remarkable product that still isn't ready for prime time. At least not for medicine. Too many mistakes that it will never overcome without the speaker himself being trained to speak in a very unnatural fashion or spending a great deal of time proofreading. But, since mandate of the electronic health record thanks to the ACA and tightwad management have made actual human transcription a thing of the past, Dragon is my only alternative. The only other alternative is me typing my notes or using idiotic pick lists that generates notes that sound like they were written by a moron. I'm not a typist and while this might sound arrogant, my time (and my patient's time) is more valuable than to be spent by me typing. I didn't spend 4 years in med school and 3 in residency to be a typist. In any case, human transcription is the only truly safe and efficient form or dictation but that ship, sadly, has sailed.

Anyway, the problem is not entirely with Dragon. It is the interaction between Dragon and Athena, our new EHR (or possibly Chrome which is what Athena runs in). Dragon works fine with everything else. So IT is going to get me a new laptop to solve a software compatibility issue. I can tell you right now that it probably won't work.