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

2. 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

3. 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

4. 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
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Health IT Workforce Curriculum Version 1.0/Fall 2010

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

7. 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
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Health IT Workforce Curriculum Version 1.0/Fall 2010

8. Example EHR Hardware Configuration Using Citrix
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9. 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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10. Health IT Workforce Curriculum Version 1.0/Fall 2010
Databases
IBM DB2, Oracle, Microsoft SQL Server
Relational
InterSystems – Caché, IBM DB2 PureXML
Hierarchical
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11. 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

12. Hypothetical Relational Database Model
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13. 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

14. Hypothetical Hierarchical Database Model
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15. Vendor Comparison of System Architectures
Inpatient EHR
Epic, Eclipsys, Quadramed
Ambulatory EHR
NextGen, eClinicalWorks
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16. HIMSS Online Buyer’s Guide
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17. Health IT Workforce Curriculum Version 1.0/Fall 2010
KLAS Research, LLC
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18. 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
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19. 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
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20. Health IT Workforce Curriculum Version 1.0/Fall 2010
Epic (cont.)
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21. 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
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22. Health IT Workforce Curriculum Version 1.0/Fall 2010
Eclipsys (cont.)
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23. Health IT Workforce Curriculum Version 1.0/Fall 2010
Quadramed CPR
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24. Health IT Workforce Curriculum Version 1.0/Fall 2010
NextGen EMR
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25. 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)
Comp 14/Unit 5
Health IT Workforce Curriculum Version 1.0/Fall 2010

26. 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
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Health IT Workforce Curriculum Version 1.0/Fall 2010

27. Health IT Workforce Curriculum Version 1.0/Fall 2010
Monitoring the EHR
Security
System Use
Performance
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28. 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

29. 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):
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30. 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:
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31. Health IT Workforce Curriculum Version 1.0/Fall 2010
Who Reads Whose Notes?
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32. 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