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Electronic Health Record (EHR) Adoption in Arizona:A View from the Frontlines
Scott Endsley MD MSc Medical Director, System Design
Health Services Advisory Group
http://www.ahcccs.state.az.us/eHealth/Presentations/Endsley.ppt
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Health Services Health Services Advisory GroupAdvisory Group
• Medicare Quality Improvement Organization (QIO) for Arizona
• Founded in 1979 by Arizona doctors and nurses, HSAG is one of the most experienced QIO’s in the nation.
• Dedicated to improving quality of care delivery and health outcomes through information, education, and assistance
• Partner with physicians, health plans, nursing homes, hospitals
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Most Healthcare Comes from Small Practices
1460 primary care practices
92% 1-3 physicians
98% less than 8 physicians
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Health Information Technology Use in Arizona
AzAFP/ACP/AOMA Survey (Jan-March 2005)
Harris Survey (Maricopa County Medical Society) Summer 2004
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Key Findings 87% have high-speed
Internet access
13.5% currently using electronic health records
25% ready to purchase in next 2 years
29+ electronic health record vendors active in Arizona market
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Office Practices are Saying….
Drug checking, reminders sound great, but can I afford this as a solo practitioner?
Will I be able to connect with my hospital?
Will the vendor be able to support my needs?
Will my patient’s information stay private?
Most of my colleagues still use paper, shouldn’t I wait till electronic medical records are the standard of care?
I have been using paper for 20 years, how will I ever get them all into my electronic medical record?
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The IT Adoption ‘Gap’
We are here
How do we get here
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Source: Ford et al. “Predicting the Adoption of Electronic Health Records” JAMIA, 2006, 13: 106
Tipping point in next 3 years
Interpersonal effect 20x more potent than mass marketing effect
PREDICTING THE FUTURE
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IT Market Failure: A Prisoner’s Dilemma
$1.6 billion in health care
Highly fragmented delivery and financing models
Asymmetric risk assumption and benefit sharing
12% DECLINE in proportion of pay for performance programs with IT incentives
IT incentives small = 4% of total incentive.
Are you locked behind your medical loss ratio?
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If HIT were a Gallon of Gas….
We spend 400X LESS than Great Britain
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Per “Average” Provider Annual Cost Saving Projections
$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
$14,000
$16,000
$18,000
Basic Rx Basic Rx-Dx Int Rx Int Rx-Dx Adv Rx-Dx
ADE Reductions
Laboratory
Radiology
Medication
$28K
$16.6K$12.3K
$2.5K$2.2K
Only 11% ($3080) accrues to physician
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The Market Opportunity
$200 Billion Market
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Costs Highly
variable (e.g. $3,000- $134,000)
Components:o Hardwareo Application (both
primary and 3rd party)
o Trainingo Supporto Maintenanceo Interfaces
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Bridging the GAPTen Key StrategiesTen Key Strategies
Demonstrate relative advantage Triability Observability Use multiple channels of communication Work with homophilous groups Stay tuned to changes Social networks Opinion leaders Compatibility Infrastructure
Source: Cain and Mittman, Diffusion of Innovation in Health Care, Institute for the Future, May 2002
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Barriers to Electronic Transformation
Financial High up-front cost Underdeveloped business
case High initial physician time
costs
Technical Inadequate technical
support Lack of standards Security and privacy
Behavioral Concerns about IT effect on office culture
Organizational ChangePatient-physician communicationWorkflow changesTechnical competenceStaff Training
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Hard Dollar Benefits
Hard DollarBenefits
Capture lost charges IF charges are now being lost
1% - 5% revenue gain
Reduce ‘defensive downcoding’
IF downcoding is prevalent
5% - 11% revenue gain
Reduce claims denials & delays
IF denials or delays are common
15 – 30 day A/R speedup
Increase preventive and management
services
IF new services are profitable AND capacity exists
5% revenue gain
Reduce transcription IF dictating AND willing to change
$5k - $15k/yr costs cut
Example Conditions Amount
ROI ~$33,000/provider starting at 2.5 years after investment, most of which accrues from better coding and charge capture
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3-year initiative of Centers for Medicare & Medicaid Services (CMS) focused on small to medium sized primary care practices
Aim: transformation of care through widespread adoption of electronic technologies in office practice
State Quality Improvement Organizations have developed technical assistance services
Doctors Office Quality Information Technology (DOQ-IT) Initiative
Expand the Adoption Rate by 5-
6%
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Roadmap
AssessmentVendor
SelectionPlanning ImplementationCare
Management
ASSESSMENT – practice readiness, workflow analysis
PLANNING – make business case, prioritize needs, set goals
SELECTION – identify options, evaluate, decide, contract
IMPLEMENTATION – prepare, build interfaces, go-live, problem solve
CARE MANAGEMENT- chronic care redesign, report data, improve
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DOQ-IT Services
EHR UniversityOnsite consultationsWeb resources – www.azdoqit.org
Physician Champions Network IT Events/ Vendor Fairs
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DOQ-IT Support
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• Tools & Resources
• Consulting Services
• Arizona IT news & events
• Register for EHR University
• Complete Practice Readiness Assessment
Our Website – www.azdoqit.org
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Early Lessons from Frontlines
Cost and loss of productivity concerns
Huge disinterest on part of payers
Second wave of adoption
Free isn’t free enough
Waiting for the government solution
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University of Arizona implementing Allscripts systems across 22 site network
Arizona Community Physicians implementing Allscripts across 89 providers
Arizona State Physicians Association promoting Synamed to 900 practice network
Arizona Medical Clinic implemented GE Centricity, uses as basis for pay for performance
Canyonlands Community Health Centers rolling out NextGen across 5 clinics
…..and many more clinics and organizations engaging in electronic transformation
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Yuma Regional Center for Border Health
Administer a discount care program – Community Access Program of Arizona (CAPAZ)
52 providers, 500 patients
Exploring use of CCR-based technology to track patients (especially medications across Arizona/Sonora border)
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Our ChallengeDefine electronic health care as the standard
Close the technology gap-help small offices find ways to finance technology
Assist practices accomplish the practice redesign to effectively use new technologies, including use of data for improvement
Connect all parts of the healthcare system including consumers
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THANK YOU!
Email:
Website:
www.azdoqit.org
Scott Endsley 602.745.6342
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Gary A. Christopherson, Senior Advisor to Under SecretaryVeterans Health Administration, Department of Veterans Affairs
May 13, 2003
Presentation to TEPR
1/7th of US Economy“Electrifying”
http://www.informatics-review.com/talks/TEPR-2003/max.ppt
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Birth Direct Care / Info/Prevention
Quality Assurance
National Health Policy
Health
RisksUS Health – Goals, Strategic Principles, Outcomes,
Leadership/Management, Benefits, Culture/Environment, Resources, Information, History
“Occu
pation
al” En
vironm
ent“C
omm
un
ity”
En
viro
nm
ent
Research & Development
US Health SystemUS Health SystemUS Health SystemUS Health System
DeathCare Episode /Chronic Care
H&ITBP/
Ideal
H&ITBP/
Ideal
Clinical Care Population,Person/Enrollee,
Episode
Maximize Health/Ability & Satisfaction
Status - Well, Acute Illness, Chronic
Illness, Custodial
Health Surveillance
Preventive Measures
Education
Evaluation/Diagnosis
In-/Outpatient Treatment
Community Treatment
Rehabilitation
Information
Health SurveillancePreventive Measures
EducationEvaluation/Treatment
RehabilitationInformation
Community Care (Home / Workplace)
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Drivers for health
• Maximize health/abilities• Maximize satisfaction• Maximize quality• Maximize accessibility/portability• Maximize affordability• Maximize patient safety (defects/errors to zero)• Minimize time between disability/illness &
maximized function/health (time to zero)• Minimize inconvenience (inconvenience to
zero)• Maximize security & privacy
312001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Standards• Data• Communications
---------------------
Health Info Systems• Electronic Health
Records Systems (EHRs)
• Personal Health Record Systems (PHRs)
• Info Exchange
Paperless (IOM)
Affordable, high quality, standards-based EHRs, PHRs & Info Exchange
Potential timetable to “paperless”
Adoption by health
organizations
Adoption by persons
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Toward standards & high performance info systems• HealthePeople Strategy:
•Move Federal & Nation to national standards & high performance health info systems – EHR, PHR, HIE – supporting ideal health systems
• HealthePeople Concept:•Collaboratively develop by public & private sectors•Support by consumers, providers, payers & regulators•Meet consumer, provider, payer & regulator needs •Achieve info standards for data, communications, security, systems & technical
•Build/buy & implement high performance systems •Public ownership/sharing of at least one high performance system for special needs populations
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Management & Financial System
Health Provider (including clinical Interface, e.g. CPRS, CHCSII, & RPMS) & Data System
Registration, Enrollment & Eligibility System
Database/Standards
“e” communications/ transactions
Billin
g System
Provid
er Paym
ent
System
Ph
armacy S
ystem
Lab
oratory System
Rad
iology System
En
rollmen
t System
Sch
edu
ling S
ystem
Blood
System
Outside health organizations
My HealthePeople[web site, virtual health
record, trusted information, self-reported information,
link to other health providers]
HealthePeople - High Performance Information Systems Components/Links/Standards
Database/Standards
Database/Standards
S
S
S
S S
S
S S
SS
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Management & Financial System
Health Provider (including clinical Interface, e.g. CPRS, CHCSII, & RPMS) & Data System
Registration, Enrollment & Eligibility System
Database/Standards
“e” communications/ transactions
Billin
g System
Provid
er Paym
ent
System
Ph
armacy S
ystem
Lab
oratory System
Rad
iology System
En
rollmen
t System
Sch
edu
ling S
ystem
Blood
System
Outside health organizations
HealthePeople - High Performance Information Systems Components/Links/Standards
Database/Standards
Database/Standards
S
S
S
S S
S
S S
SS
Personal Health Record
My HealthePeople[web site, virtual health
record, trusted information, self-reported information,
link to other health providers]
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Other health organi-zations
My HealtheVet / My HealthePeople
My HealtheVet / HealthePeople[Personal Health Record System]
“health in a box” on PC & web site via community, health, non-health, government
S
Electronic Health Record System (e.g. VistA)
Database/Standards
S
Primary healthprovider
Software & Hardware
Person
Health Record•Access to health records•Sharing health records•Self-entered health record
Services•Checking/filling prescriptions•Checking/confirming/making appointments•Checking/paying co-payments•Participating in support groups•Health decision support•Health self-assessment•Messaging with health provider•Diagnostic/therapeutic tools•Reminders•“Checking in”•Safety services/tools•Links to other health sites
Information•Trusted information
Electronic Health Record System
Database/Standards
Software & Hardware
SS
S
S
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• Phase 1• Presentation framework• Health education content• VA developed content (e.g., seasonal health bulletins, health tip of the day,
Veterans Health Initiatives, interactive chat)• Portal personalization features
• Phase 2• Rx Re-fill • Self Entered Data (excluding self entered metrics)
• Phase 3 • View Co-pay balance • View Appointments • Self Entered Metrics
• Phase 4 (Electronic Health Record) • eVAult• VistA extracts• Delegate function• User and system administration functions
My HealtheVet Phasing
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• Summer 2003• Foundational online environment with VA-developed
content, health education information, and self-assessment tools
• Fall 2003• Prescription refill and self-entered data*
• Winter 2004• View total co-payment balance, view next scheduled
appointment**• Spring 2004
• Electronic patient record data and migration from pilot to national system***
* Requires proofing solution in place ** Requires Secure Web Transaction Architecture; otherwise, reduced-capability service still possible.*** Requires Secure Web Transaction Architecture implementation
My HealtheVet Timeline
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Potential of “Best Practices” / Ideal Systems
Veteran (and their families) not receiving care currently
20+ million veterans not receiving VHA care currently can benefit via My HealtheVet getting trusted info, keep a personal health log, store their non-VHA health record, do internet dialogue with health advisor, help family & friends get care, form peer-to-peer support groups, be notified of benefit & care site info, be notified of service-related illness information (e.g. SHAD, Gulf War Illness), register/apply for benefits & arrange for first appointment. Ideal – Via My HealtheVet, veterans entering VHA for care have already established/trusted relationship & VHA already has basic info on which to base care; veteran is strong partner in health.
Family of veteran not yet receiving care
Via My HealtheVet, can assist veteran with accessing care or benefits, get trusted info, do an internet dialogue with a health advisor with their veteran family member, form peer-to-peer support groups, be notified of benefit & care site info, be notified of service-related illness information (e.g. SHAD, Gulf War Illness), register/apply for benefits & arrange for first appointment for their veteran family member. Ideal – veterans families feel VHA cares & can be trusted; family is strong partner in health.
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Potential of “Best Practices” / Ideal Systems
Person (and their families) not receiving care currently
People can benefit via My HealthePeople where they get trusted info, keep a personal health log, store their health records, do internet dialogue with health advisor, help family & friends get care, form peer-to-peer support groups, be notified of benefit & care site info, be notified of work-related illness information, register/apply for benefits & arrange for first appointment. Ideal – Via My HealthePeople, people entering for care have already established/trusted relationship & provider already has basic info on which to base care; person is strong partner in health.
Family of person not yet receiving care
Via My HealthePeople, can assist person with accessing care or benefits, get trusted info, do an internet dialogue with a health advisor with their family member, form peer-to-peer support groups, be notified of benefit & care site info, be notified of work-related illness information, register/apply for benefits & arrange for first appointment for their family member. Ideal – persons’ families feel health provider cares & can be trusted; family is strong partner in health.
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National standards & high performance systems
Convergen
ce
Convergence
DoD CHCS II
IHS (upgraded RPMS)
Public/Private (CMS, VA, health providers/ payers/regulators, private sector vendors)
Standards – Jointly develop/set/use.Systems – Develop/enhance/use high performance, interoperable.Exchange – Develop two way with computable data.
Standards – Nationally accepted.Systems – High performance, interoperable.Exchange – Two way with computable data.
2001 2010
HealthePeople(Fed)
HealthePeople
VA HealtheVet-VistA
National Health
Information Standards
Exchange/ Sharing
High Performance
Health Info Systems
Personal Health Record
Systems
VA, DoD, IHS individual/joint adoption
Public/Private•Individual (e.g. Kaiser Permanente)•Joint (Connect. Health, eHealth, NCVHS, SDOs, …
HealthePeople(Fed)
HealthePeople
Consolidated Health Informatics (CHI)
Hea
lth
In
form
atio
n
Sys
tem
s
Sta
nd
ard
s
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Back-up Slide
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This & Next Generation Strategy
HealtheVet-VistA• Operate current generation VistA• Develop, implement & operate HealtheVet-VistA,
incl. My HealtheVet• Develop, implement & operate Next Generation
HealtheVet-VistA as open source, componentized high performance system with partners
HealthePeople, including HealthePeople-VistA• Push development & adoption of health information
standards• Push availability & use of public/private sector high
performance health information systems, including NextGen HealtheVet-VistA used externally as HealthePeople-VistA, and personal health records
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MAINTAINING SECURITY AND PRIVACY OF PATIENT INFORMATION
September 2, 2006
Frank E. Ferrante, MSEE, MSEPP
President FEFGroup, LLC
Past Chair, Medical Technology Policy Committee
IEEE-USA, Washington, DC
Presented at28th IEEE EMBS Annual International Conference
Aug 30-Sept. 3, 2006, New York City, New York, USA
http://www.ieeeusa.org/volunteers/committees/mtpc/documents/EMBC06-NYC-Panel.ppt
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Outline
• Why Electronic Medical Records? • Software Sample/hardware samples • Barriers/Standards for EHR• HIPAA Security and Privacy Regulations • Medical data transmission requirements• Wireline and Wireless Telecommunications
Services Security• Security of Patient Medical Records• References
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Why Electronic Medical Records (EMRs)
• Time spent filing and pulling patient charts, searching for charts
• Time re-creating records if destroyed by natural disaster or accident
• Cost of supplies to maintain charts• Cost of facility space for records (can better use of space
be made?)• Storage and Backup Cost • Transcription services cost• Cost of doing nothing today• Better Security/Privacy Maintainable
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Software/Hardware Supporting Digital Medical Records
• Electronic Medical Record (EMR)Software– Soapware - check it out $300 Starting Price see: http://soapware.com/
– e-MDs Electronic Medical Record Support Software http://www.e-mds.com
– a4Healthsystems EMR and Access systems http://www.a4healthsystems.com
• Companion Technologies http://www.companiontechnologies.com
• Security and Privacy - all EMRs must be protected– Sample approach: indigenous authentication of digital information (US
Patent 6,757,828 B1 of June 29, 2004) by Signa2 http://www.gjtdc.com
– Backup routinely onto remote servers or storage offerings
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What are the Barriers to EHR and e-Health Implementation?*
• Lack of a Unique Personal Identifier• Lack of HIPAA Compliant Middleware• Lack of Incentives• No Paradigm or “First Mover” for Some System
Components• Evolving Standards• Disincentives• Lack of an NHIN Architecture• [Fear of Cost/Benefit]
* [Corr 06]
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Barriers and SolutionsIdentifiers and Middleware
HIPAA compliantIdentification,
Authentication, and Access
Lack of a Unique Personal Identifier:• Solutions:
•Voluntary Personal Healthcare Identifier (IEEE-USA Voluntary Healthcare Identifier Position Statement, 17
June 2004)•Center for Certification of Health Information Technology Multiple ID Approach (Provider ID + Provider Unique Personal ID)•DOD Common Access Card Model
Lack of HIPAA Compliant Middleware:•Solutions:
•RHIO Contracts•Marketplace Solutions
•Shortcomings:•Public Health and Research Interfaces may not be included
* [Corr 2006]
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EHR Standards Evolution*
• International Statistical Classification of Diseases and Related Health Problems (ICD) from ICD-9 to ICD-10
• ASCI X12 Version 4010 to ASCI X12 Version 5010 (HIPAA Business Transactions)
• National Council for Prescription Drug Programs Telecommunication Standards from version 5.1 to version D.0
• Conversion of all standards to XML* [Corr 06]
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HIPAA Security and Privacy Regulations
• Health Insurance Portability Assurance Act (HIPAA)– Security - Required stronger and more focused
provision of security around medical information (supports maintaining of information privacy)
– Privacy - Enforces increase in privacy protections for medical information (Not just speaking privacy- required under penalty if failure occurs)
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Electronic Medical Record (EMR) Data Requirements
• Page of text for entering and storing non-image information– Less than 64 Kbytes(large file)
• Image Data– (Refer to estimate table)
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Medical Images Data Transmission Requirements*
*Source: Ferrante, F.E.,“Evolving Telemedicine/eHealth Technology,” Telemedicine and e-Health, Vol 11,
Number 3, June 2005, Mary Ann Liebert, Inc Publisher, ISSN-1530-5627.
I mage Type I mage resolutionI mageSize
Spatial Size(bits/pi xel)
lessControl &error bits
Ultrasound 512x512 x8 256 KbytesOther (Angiography,Endoscopy, Nuclear Med.,Cardiology, Radiology) 512x512 x8 256 KbytesComputed Tomography 512x512 x12 384 KbytesMagnetic Resonance Imaging 1024x1024 x12 1.5 MbytesDigitized (Scanned) X-Ray 1024x1280 x12 1.9 MbytesDigital Radiology 2048x2048 x8 4 Mbytes “ “ (high quality) 2048x2048 x12 6 MbytesMammography 4096x4096 x12 25 Mbytes
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Wireless Telecommunications Services
– Broadband Services• 802.11n• WiMax
– Security• PKI• VPN• Secure ID• WEP/WPA/WPA2 (802.11i)
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How New Technologies Stack UpD
ata
Rat
e(m
egab
its p
er s
econ
d)
Source: Technology Review, October 2005Established Emerging
Actual performance will vary depending on factors such as how the technology is deployed, the user’s distance from base stations, and interference.
1,000
-1
1
10
100
WPANWPAN WLANWLAN WMANWMAN WWANWWAN
Bluetooth 1.2
Bluetooth 2.0
Ultrawideband
Wi-Fi (802.11b)
Wi-Fi (802.11a/g)
Wi-Fi (802.11n)
WiMax (802.16)
WiMax mobile(802.16e)
2G cellular
2.5G cellular
3G cellular
3.5G cellular
4G cellular
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Security of Patient Records• Wireline Communications/Computer Access
– Database Encryption– Public Private Key access control– Routine Password Control and Management– Isolation of Database Server from outside access
• except via Virtual Private Network (VPN) and Secure ID hand-held devices or Secure Private Key system
• Wireless Communications– Wire Equivalent Privacy (WEP)
• Poorly designed, vulnerable
– Wireless Protocol Architecture (WPA)& WPA2• Improved Security Encoding • Enterprise Security Offering(Both WPA and WPA2 now available for Wireless
operations as alternate to WEP)
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References
• [Corr 2006] Corrigan, Mike (Current Chair MTPC), “Consumer-Centered Electronic Health Records and e-Health - Roadblocks and Opportunities,” presented to GEIA Roundtable, June 29, 2006 -
Available at: http://www.ieeeusa.org/volunteers/committees/mtpc/index.html
• [IEEE-USA]IEEE Medical Technology Policy Committee Web Site - ttp://www.ieeeusa.org/volunteers/committees/mtpc/index.html
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Backup Slides
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Other HealthcareSystem Records
Payer Recordsor Payer EHRs
Healthcare Provideror
Clinical EHRs
Top Level EHR Components
Glue
Personal Health Record(PHR)
orPersonal EHR
59EMT Records
RadiologicalRecords
LaboratoryRecords
PharmacyOffice Records
DentalOffice Records
PhysicianOffice Records
HospitalRecords
PersonalHealth Record
Health Insurance PayerRecords
Per
sona
l EH
RP
rovi
der
EH
Rs
Car
rier
EH
R
PersonalHealth Record
Per
sona
l EH
R
Uncertified• Demographics• Allergies• Medications•Inoculations
Certified• Demographics and Identity• Links to other EHR components
Limited PHR Full PHR
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PersonalHealth Record
Lifetime Full PHR
Prenatal and Pediatric Records
Medicare Records
Employer and SelfInsuranceCarrier Records
Military and VARecords
ResearchRecords
Public HealthRecords
Anonymized Links with Trusted Reverse Channel
EnvironmentalRecords
GenomicRecords
Links
Death Certificateand AutopsyRecords