Special Topics in Vendor- Specific Systems Unit 5 System and database architectures used in commercial EHRs

Health IT Workforce Curriculum Version 1.0/Fall 2010 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

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

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

Sample EHR Architecture Comp 14/Unit 5 Health IT Workforce Curriculum Version 1.0/Fall 2010

EHR Hardware Platform “Back-end” “Front-end” Database server Application server “Front-end” Where clinician interaction occurs Desktop PC, mobile device Comp 14/Unit 5 Health IT Workforce Curriculum Version 1.0/Fall 2010

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

Example EHR Hardware Configuration Using Citrix Comp 14/Unit 5 Health IT Workforce Curriculum Version 1.0/Fall 2010

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

Health IT Workforce Curriculum Version 1.0/Fall 2010 Databases IBM DB2, Oracle, Microsoft SQL Server Relational InterSystems – Caché, IBM DB2 PureXML Hierarchical Comp 14/Unit 5 Health IT Workforce Curriculum Version 1.0/Fall 2010

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

Hypothetical Relational Database Model Comp 14/Unit 5 Health IT Workforce Curriculum Version 1.0/Fall 2010

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

Hypothetical Hierarchical Database Model Comp 14/Unit 5 Health IT Workforce Curriculum Version 1.0/Fall 2010

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

HIMSS Online Buyer’s Guide Comp 14/Unit 5 Health IT Workforce Curriculum Version 1.0/Fall 2010

Health IT Workforce Curriculum Version 1.0/Fall 2010 KLAS Research, LLC Comp 14/Unit 5 Health IT Workforce Curriculum Version 1.0/Fall 2010

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

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

Health IT Workforce Curriculum Version 1.0/Fall 2010 Epic (cont.) Comp 14/Unit 5 Health IT Workforce Curriculum Version 1.0/Fall 2010

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

Health IT Workforce Curriculum Version 1.0/Fall 2010 Eclipsys (cont.) Comp 14/Unit 5 Health IT Workforce Curriculum Version 1.0/Fall 2010

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

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

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

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

Health IT Workforce Curriculum Version 1.0/Fall 2010 Monitoring the EHR Security System Use Performance Comp 14/Unit 5 Health IT Workforce Curriculum Version 1.0/Fall 2010

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

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

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

Health IT Workforce Curriculum Version 1.0/Fall 2010 Who Reads Whose Notes? Comp 14/Unit 5 Health IT Workforce Curriculum Version 1.0/Fall 2010

Health IT Workforce Curriculum Version 1.0/Fall 2010 System Performance Prototype dashboard for real-time monitoring of EHR system use and performance Courtesy of Roger Corman, Corman Technologies, Inc. Comp 14/Unit 5 Health IT Workforce Curriculum Version 1.0/Fall 2010