comp14 unit5 lecture - fresno city collegetegrity.fresnocitycollege.edu/fcc/healthit/component...

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Special Topics in Vendor- Specific Systems

Unit 5 System and database architectures used in

commercial EHRs

Objective

•  Compare database architectures employed by various vendor applications, for fulfilling different user purposes

Comp 14/Unit 5 Health IT Workforce Curriculum Version 1.0/Fall 2010 2

After this completing this unit, you should be able to:

•  Demonstrate concept knowledge of system and database architectures used in commercial EHRs

•  Describe the health information systems landscape, including how EHRs exchange information with ancillary systems such as Pharmacy, Laboratory, etc.

•  Identify the differences between thick and thin-client EHR deployments

•  Compare different operating systems and databases used by EHRs

•  Explain how database architecture can impact performance and extensibility

•  Articulate how system and database architectures impact security, auditing and performance monitoring


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What is an Electronic Health Record (EHR)?

Software program providing a systematic collection of electronic

health information about individual patients

Exchanges information with ancillary clinical

systems, such as Pharmacy, Laboratory,

etc.

Stores information in a database


Sample EHR Architecture


EHR Hardware Platform

“Back-end”

Database server

Application server

“Front-end”

Where clinician interaction

occurs

Desktop PC, mobile device


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EHR Hardware Platform (cont.) Thick-client

(or Fat-client) Application

•  Processes most or all of its business logic on local computing resources (e.g., a desktop PC)

•  Provides rich functionality independent of a central server

Thin-client Application

•  Relies on its server to process most or all of its business logic

Web-based •  Google Docs compared to traditional Microsoft Office

Citrix Independent Computing

Architecture (ICA)

•  Proprietary protocol for an application server system •  Permit ordinary Windows applications to be run on a

suitable Windows server, and for any supported client to gain access to those applications


Example EHR Hardware Configuration Using Citrix


EHR Software Platform

Operating system

Servers

Unix (AIX, HP-UX, Solaris, etc.), Linux,

Windows Server

Clients

Windows, Linux, MacOS

Mobile: Blackberry,

iPhone, Android

Database

IBM DB2, Oracle,

Microsoft SQL Server,

InterSystems - Caché


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Databases

•  IBM DB2, Oracle, Microsoft SQL Server Relational

•  InterSystems – Caché, IBM DB2 PureXML Hierarchical


Relational Databases

•  A collection of data items organized as a set of formally-described tables from which data can be accessed or reassembled in many different ways without having to reorganize the database tables

A relational database is:

The standard user and application program interface to a relational database is the structured query language (SQL)


Hypothetical Relational Database Model


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Hierarchical Databases

•  Organizes data into a tree-like structure •  The structure allows repeating information using

parent/child relationships: •  each parent can have many children but each

child only has one parent

A hierarchical database:

All attributes of a specific record are listed under an entity type


Hypothetical Hierarchical Database Model


Vendor Comparison of System Architectures

•  Inpatient EHR – Epic, Eclipsys, Quadramed

•  Ambulatory EHR – NextGen, eClinicalWorks

•  http://onlinebuyersguide.himss.org/ •  http://www.klasresearch.com/Search/

Browse.aspx?t=2


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HIMSS Online Buyer’s Guide


KLAS Research, LLC


Epic

An integrated suite of health care software centered around a hierarchical MUMPS/Caché database

MUMPS (Massachusetts General Hospital Utility Multi-Programming System), or alternatively M: •  A programming language created in 1960s, originally for use in

the healthcare industry •  Designed for multi-user database-driven applications •  Predates C and most other popular languages in current usage


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Epic (cont.)

InterSystems Caché is a database management system from InterSystems Corporation

Provides object and SQL access to the database, as well as allowing direct manipulation of Caché’s underlying data structures

The company claims Caché is the world’s fastest object database

Caché runs on Windows, Linux, Sun Solaris, HP-UX, Tru64 UNIX, AIX, Mac OS X and OpenVMS platforms


Epic (cont.)


Eclipsys

Eclipsys merged with Allscripts in September, 2010

Sunrise Clinical Manager (their acute care EHR offering) uses SQL Server as its underlying database & operates as a thick-client, Windows Forms application

The application was developed using Microsoft .NET technologies


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Eclipsys (cont.)


Quadramed CPR


NextGen EMR


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eClinicalWorks EHR (ECW)

Privately held, CCHIT-certified, winner of many awards (TEPR, KLAS)

One integrated system for practice management/EHR/billing/PHR system

Java, MySQL, and Apache Tomcat

Client/server and ASP models

Normally $10,000 + equipment (through PCIP is $4,000 + equipment)

http://www.eclinicalworks.com/cost.php


eClinicalWorks Small Practice Technical Requirements

Server (application/database/ftp/reporting) •  Two Intel Dual Core 1.6GHz+ processors •  4 GB+ RAM •  60 GB+ hard drive •  Windows 2003 Server 64 bit •  Minimum Raid 1 (mirrored drives)

Standard Tablet/Desktop PCs (with MS Office)

Fax server

Laser printer/scanner/UPS


Monitoring the EHR

Security

System Use

Performance


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Security

Set of administrative, technical, and physical safeguards established to secure protected health information

The 2009 HITECH Act expands the security and privacy requirements of HIPAA •  forcing health care organizations to address many

facets of electronic health record security


Recommended EHR Security Features

Role-based security:

•  Restricts access to predefined categories of patients, encounters, and documents based on the access a user needs to perform his or her job

VIP status indicators:

•  Restrict especially identified patients and encounters to those individuals with permission for VIP encounters and patients

Ability to:

•  Assign an alias to a patient or encounter to mask patient identity

•  Restrict patients from physicians who are not the “physician of record” (e.g., attending, admitting, surgeon, and consulting)

•  Block access to a specific progress note or lab result •  Track versioning or mask sensitive entries for release of

information


AHIMA e-HIM Work Group on Security of Personal Health Information. "Ensuring Security of High-Risk Information in EHRs" Journal of AHIMA 79, no.9 (September 2008): 67-71.

System Use Audit logs are beneficial for enhancing information security, but also can provide data about system use

•  How many clinicians are using the system? •  What are peak times of system usage? •  How much time do clinicians spend on specific tasks, such

as note-writing?

For example:


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Who Reads Whose Notes?


System Performance Prototype dashboard for real-time monitoring of EHR system use and performance Courtesy of Roger Corman, Corman Technologies, Inc.


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