Special Topics in Vendor-Specific EHR Systems Architectures

1. Special Topics in Vendor- Specific Systems System and Database Architectures Used in Commercial EHRs This material (Comp14_Unit5) was developed by Columbia University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 1U24OC000003.

2. System and Database Architectures Used in Commercial EHRsLearning Objectives • 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 the importance of security, privacy, auditing and performance monitoring in EHRs Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

3. What is an 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 Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

4. Sample EHR Architecture (Vawdrey, 2011.) Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

5. EHR Hardware Platform • “Back-end” • Database server • Application server • “Front-end” • Where clinician interaction occurs • Desktop PC, mobile device Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

6. EHR Hardware Platform • Thick-client • a 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 • a 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) • A 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 Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

7. Example EHR Hardware Configuration Using Citrix Production Application Servers Production Database Servers Desktop Computers User Access to EHR Test Environment Development Environment Training Environment (Vawdrey, 2011). Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

8. 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 Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

9. Databases • Relational • IBM DB2, Oracle, Microsoft SQL Server • Hierarchical • InterSystems – Caché, IBM DB2 PureXML Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

10. Relational Databases • A relational database is 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 • The standard user and application program interface to a relational database is the structured query language (SQL) Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

11. Hypothetical Relational Database Model (Vawdrey, 2011). Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

12. 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 Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

13. Hypothetical Hierarchical Database Model Vawdrey, D. (2011) Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

14. Vendor Comparison of System Architectures • Inpatient EHR • Epic, Allscripts (formerly Eclipsys), Quadramed • Ambulatory EHR • NextGen, eClinicalWorks • http://onlinebuyersguide.himss.org/ • http://www.klasresearch.com/Search/Browse.aspx?t=2 Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

15. HIMSS Online Buyer’s Guide (HiMSS online buyer’s guide, 2011). Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

16. KLAS Research, LLC (KLAS, 2011). Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

17. Epic • Epic offers 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, is a programming language created in the late 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 Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

18. Epic • 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 Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

19. Epic (EpicCare impatient EMR-KLAS Performance Ratings, 2011). Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

20. Allscripts • Their acute care EHR offering, Sunrise Clinical Manager, uses SQL Server as its underlying database, and operates as a thick-client, Windows Forms application • The application was developed using Microsoft .NET technologies Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

21. Allscripts (Eclipsys Sunrise Clinical Manager: KLAS performance ratings, 2011). Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

22. Quadramed CPR (QuadraMed CPR: KLAS Performance Ratings, 2011). Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

23. NextGen EMR (NextGen EMR: KLAS Performance Ratings, 2011). Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

24. 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) Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

25. Monitoring the EHR • Security and Privacy • System Use • Performance Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

26. Security and Privacy • The Health Insurance Portability and Accountability Act of 1996 (HIPAA) contains rules on privacy and security • The HIPAA Security Rule specifies a series of administrative, physical, and technical safeguards for covered entities to use to assure the confidentiality, integrity, and availability of electronic protected health information • The HIPAA Privacy Rule provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

27. Security and Privacy • The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009 strengthened the HIPAA Privacy, Security, and Enforcement Rules • Certain aspects of the Privacy and Security Rules apply to the business associates of covered entities • Individuals’ rights to access their information are expanded • HIPAA’s enforcement provisions are strengthened and expanded Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

28. Recommended EHR Security Features • User-based and role-based security that 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 that restrict access to information from specially identified patients to those individuals with permission • Ability to assign an alias to a patient or encounter to mask patient identity • Ability to restrict patients from physicians who are not the “physician of record” (e.g., attending, admitting, surgeon, and consulting) • Ability to block access to a specific progress note or lab result • Ability to track versioning or mask sensitive entries for release of information • Detailed audit logs that record data access and data entry, with the ability to generate reports of actions performed by a specific user or for a specific patient Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

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? Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

30. Who Reads Whose Notes? (Hripcsak et al., 2011). Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

31. System Performance • EHRs should provide tools to assess system performance, including: • Database growth and response time • Memory and processor utilization • Experience of application users, such as measuring delays during screen transitions • A mechanism for users to send feedback to system administrators Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

32. System Performance Monitoring Example (Corman, R., 2011). Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

33. System and Database Architecture in Commercial EHRs Summary • Defined EHR and EHR Architecture • Discussed EHR hardware and software • Relational Databases and Hypothetical Relational Database model • Hypothetical Hierarchical Database • Various Vendor Systems • Privacy and Security • System use and performance Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

34. System and Database Architecture in Commercial EHRs References References 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. Hripcsak et al. (2011). Use of electronic clinical documentation: time spent and team interactions. J Am Med Inform Assoc. 2011 Mar-Apr;18(2):112-7. Corman, R. (2011). Prototype dashboard for real-time monitoring of EHR system use and performance. Corman Technologies, INC. Santa Rosa, CA. http://www.cormtech.com/examples.html Electronic health records for the primary care providers. (2007). The New York City Department of Mental Hygiene: City Health Information, vol.26(1), p.1-6. Retrieved on August 25th, 2011 from http://www.nyc.gov/html/doh/downloads/pdf/chi/chi26-1.pdf Pricing structure (2011). Retrieved from eClinicalWorks on August 25th, 2011 from http://www.eclinicalworks.com/products-pricing.htm. Summary of HIPAA Security Rules. Retrieved from U.S Department of Health and Human Services: Health Information Privacy on August 25th, 2011. Notice of Proposed Rulemaking to Implement HITECH Act Modifications. Retrieved from U.S Department of Health and Human Services: Health Information Privacy on August 25th, 2011. http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/hitechnprm.html Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs

35. System and Database Architecture in Commercial EHRs References Images Slide 4: Vawdrey, D. (2011). Sample EHR architecture. Department of Biomedical Informatics, Columbia University Medical Center. Slide 7: Vawdrey, D. (2011). Example of EHR hardware configuration. Department of Biomedical Informatics, Columbia University Medical Center. Slide 11: Vawdrey, D. (2011). Hypothetical Relational Database Model. Department of Biomedical Informatics, Columbia University Medical Center. Slide 13: Vawdrey, D. (2011). Hypothetical Relational Database Model. Department of Biomedical Informatics, Columbia University Medical Center. Slide 15: HiMSS online buyer’s guide (2011). Retrieved from Health Information and Management Systems Society on August 23, 2011 http://onlinebuyersguide.himss.org/ Slide 16: Retrieved from KLAS on August 23, 2011. http://www.klasresearch.com Slide 19: EpicCare impatient EMR-KLAS Performance Ratings. (2011). Retrieved from KLAS on August 23, 2011, http://www.klasresearch.com/Vendors/OnlinePerformanceRatings.aspx Slide 21: Eclipsys Sunrise Clinical Manager: KLAS performance ratings. (2011). Retrieved from KLAS on August 23, 2011, http://www.klasresearch.com/Vendors/OnlinePerformanceRatings.aspx Slide 22: QuadraMed CPR: KLAS Performance Ratings. (2011). Retrieved from KLAS on August 23, 2011, http://www.klasresearch.com/Vendors/OnlinePerformanceRatings.aspx. Slide 23: NextGen EMR: KLAS Performance Ratings. (2011). Retrieved from KLAS on August 23, 2011, http://www.klasresearch.com/Vendors/OnlinePerformanceRatings.aspx Special Topics in Vendor Specific Systems System and Database Architecture in Commercial EHRs