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 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 3 1
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 4 Sample EHR Architecture 5 EHR Hardware Platform Back-end Front-end Database server Where clinician interaction occurs Application server Desktop PC, mobile device 6 2
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 7 Example EHR Hardware Configuration Using Citrix 8 EHR Software Platform Operating system Database Servers Unix (AIX, HP- UX, Solaris, etc.), Linux, Windows Server Clients Windows, Linux, MacOS Mobile: Blackberry, iphone, Android IBM DB2, Oracle, Microsoft SQL Server, InterSystems - Caché 9 3
Databases Relational IBM DB2, Oracle, Microsoft SQL Server Hierarchical InterSystems Caché, IBM DB2 PureXML 10 Relational Databases A relational database is: A collection of data items organized as a set of formallydescribed tables from which data can be accessed or reassembled in many different ways without having to reorganize the database tables The standard user and application program interface to a relational database is the structured query language (SQL) 11 Hypothetical Relational Database Model 12 4
Hierarchical Databases A hierarchical database: 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 All attributes of a specific record are listed under an entity type 13 Hypothetical Hierarchical Database Model 14 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 15 5
HIMSS Online Buyer s Guide 16 KLAS Research, LLC 17 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 18 6
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 19 Epic (cont.) 20 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 21 7
Eclipsys (cont.) 22 Quadramed CPR 23 NextGen EMR 24 8
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 25 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 26 Monitoring the EHR Security System Use Performance 27 9
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 28 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. 29 System Use Audit logs are beneficial for enhancing information security, but also can provide data about system use For example: 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? 30 10
Who Reads Whose Notes? 31 System Performance Prototype dashboard for real-time monitoring of EHR system use and performance Courtesy of Roger Corman, Corman Technologies, Inc. 32 11