Download System and database architectures used in commercial EHRs

Comp 14 - Special Topics in
Vendor- Specific Systems
Unit 5 - System and Database
Architectures Used in
Commercial EHRs
This material 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.
Objective
• Compare database architectures
employed by various vendor applications,
for fulfilling different user purposes
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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
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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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Sample EHR Architecture
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EHR Hardware Platform
“Back-end”
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“Front-end”
Database
server
Where clinician
interaction
occurs
Application
server
Desktop PC,
mobile device
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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)
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• 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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Example EHR Hardware
Configuration Using Citrix
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EHR Software Platform
Operating
system
Database
Servers
Clients
Unix (AIX, HPUX, Solaris,
etc.), Linux,
Windows Server
Windows, Linux,
MacOS
IBM DB2,
Oracle,
Microsoft SQL
Server,
InterSystems Caché
Mobile:
Blackberry,
iPhone, Android
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Databases
Relational
Hierarchical
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• IBM DB2, Oracle, Microsoft SQL Server
• InterSystems – Caché, PureXML
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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)
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Hypothetical Relational
Database Model
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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
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Hypothetical Hierarchical
Database Model
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Vendor Comparison of
System Architectures
• Inpatient EHR
– Epic, Eclipsys, Quadramed
• Ambulatory EHR
– NextGen, eClinicalWorks
• http://onlinebuyersguide.himss.org/
• http://www.klasresearch.com/Search/Brow
se.aspx?t=2
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HIMSS Online Buyer’s
Guide
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KLAS Research, LLC
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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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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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Epic (cont.)
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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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Eclipsys (cont.)
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Quadramed CPR
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NextGen EMR
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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
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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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Monitoring the EHR
Security
System Use
Performance
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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
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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.
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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?
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Who Reads Whose Notes?
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System Performance
Prototype dashboard for real-time monitoring of EHR system use
and performance
Courtesy of Roger Corman, Corman Technologies, Inc.
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