Fluent Essays

Imagine you have been selected to participate in a prestigious internship in a health care organization working for the chief information officer (CIO). Your internship consists of a series of projects you will complete throughout this course.  Consider the following scenario: In the first week of your internship, the CIO approaches your team and asks you to research electronic health records (EHRs). She says, "I must give a presentation at a staff meeting next week, and I'd like you to complete the research and create the slides and notes for me. The presentation must focus on EHRs, which our organization is considering implementing. Please be thorough with the speaker notes."  List major points in the slides. Include detailed explanations in the speaker notes that correlate to each point.  Include videos, audio, photos, diagrams, or graphs as appropriate.  Include at least 2 references to support your presentation.  Format your presentation according to APA guidelines.  The CIO adds that you must consider: (2- PowerPoint Slides on the information listed below) As the privacy and security implications of adopting the EHRs. Topics Blog News Data About ONC Was this page helpful? Who are the key stakeholders during electronic health record (EHR) implementation? Building the EHR Implementation Team Your electronic health record (EHR) implementation team, also known as the steering committee, can make or break the implementation process. Members of your EHR implementation team should possess: Differing perspectives on how the EHR will be used A wide array of skills and knowledge An ability and willingness to devote sufficient time to the EHR implementation process A consistently positive point of view toward the EHR implementation process EHR Implementation Team You should include the following EHR implementation team members on your EHR implementation team. EHR Team Lead EHR Implementation Manager Physician Champion Nurse Lead Medical Assistant Lead Scheduler Lead Registration Staff Lead Laboratory Staff Lead Information Technology Lead Billing Staff Lead EHR Builder Meaningful Use Lead Workflow Redesign Lead Super-User/Training Lead EHR Implementation Team Tools Depending on the size and type of your organization, your organization may assign employees to more than one role. You can use the Creating a Leadership Team for Successful EHR Implementation template to learn more about the different EHR implementation team roles and as a template to document important planning decisions. For More Information For more information on building an EHR implementation team, see the following resources. Creating a Leadership Team for Successful EHR Implementation When should I create the electronic health record implementation team? How can I increase stakeholder involvement during electronic health record implementation? Content last reviewed on May 21, 2019 Yes No Next Form Approved OMB# 0990-0379 Exp. Date 9/30/2023 How Do I? News Topics Archived Content Privacy Policy Disclaimers Viewers & Players GobiernoUSA.gov Stay connected with ONC Please, enter your email address. Sign Up Subscribe to our Email Updates! Home CONTACT EMAIL UPDATES NEW: Health IT Feedback Portal | | | | TOPICS BLOG NEWS DATA ABOUT ONC Official Website of The Office of the National Coordinator for Health Information Technology (ONC) Connect with us: Check ONC's LinkedIn Page Follow ONC on Twitter Check ONC's YouTube Channel Subscribe/RSS Search https://www.healthit.gov/topics https://www.healthit.gov/buzz-blog/ https://www.healthit.gov/topic/news-and-updates https://www.healthit.gov/data https://www.healthit.gov/topic/about-onc http://www.hhs.gov/ http://whitehouse.gov/ http://www.usa.gov/ https://www.healthit.gov/topic/contact-us https://cloud.connect.hhs.gov/HIT https://www.healthit.gov/ https://www.linkedin.com/groups/3993178/ http://www.twitter.com/ONC_HealthIT/ http://www.youtube.com/user/HHSONC/ http://feeds.feedburner.com/healthitgov 1114237 - Jones & Bartlett Learning © CHAPTER 4 HIS Application Systems and Technology LEARNING OBJEC TIV ES By the end of this chapter, the student will be able to: • Understand how the software development life cycle is used to develop health information systems (HIS) applications. • Determine the relationship between HIS programming languages, applications, and databases. • Identify the benefit of application integration over application interfaces. • Describe the inpatient and outpatient clinical and administrative HIS applications in use today. • Explain how computer networks work, their importance in supporting HIS applications, and the different network architectures in use today (e.g., local area networks, wireless local area networks, wide area networks, wireless wide area networks, and storage area networks). • Understand how emerging technologies such as voice over Internet Protocol, unified communications, and video/web conferencing are affecting HIS initiatives. • Identify why data center infrastructure, cloud computing, backups, and disaster recovery are critical to properly maintain HIS applications. • Define the essential components of modern server computing, including unified computing systems, server virtualization, and single sign-on. • Describe the key benefits of client, device, and mobile computing that are being used specifically to enhance HIS deployments. • Understand the importance of technologies that deliver privacy and security benefits to HIS applications. INTRODUCTION In this chapter, we examine the applications and technology requirements needed to support the health information systems (HIS) and technology environment. There is little doubt that healthcare delivery is complex and that HIS can deliver considerable value in improving the quality of care and reducing the costs of care. However, the technology being used to support HIS has been viewed as complicated and, in many instances, well beyond the understanding of nontechnical individuals. As sophisticated as HIS applications and technology may appear to be, when they are examined at their more fundamental levels, HIS can be readily understood. Understanding how HIS applications are developed is essential to ensuring they produce the desired functionality. In this chapter, we review one of the primary HIS application development methods in use today—the software development life cycle. We also look at the relationships between HIS programming languages, applications, and databases. The benefits of application integration over application interfaces are also reviewed. To clearly understand HIS, we discuss the clinical and administrative HIS applications being used by healthcare organizations today. 1114237 - Jones & Bartlett Learning © HIS applications require a robust, high-performing, and highly available underlying technical infrastructure. Unless this technology is deployed correctly, HIS users will not be able to access their systems to perform their work—the HIS applications will perform slowly, be inaccessible, or experience data corruption. In this chapter, we examine how computer networks work, consider their importance in supporting HIS applications, and outline the different network architectures in use today. We review emerging technologies that are affecting HIS applications, such as Voice over Internet Protocol, unified communications, and video/web conferencing. Data center infrastructure, cloud computing, backups, and disaster recovery—all aspects that are critical to properly maintain HIS applications—are discussed as well. The essential components of modern server computing, including unified computing systems, server virtualization, and single sign-on, are analyzed, along with other key client, device, and mobile technologies. Finally, this chapter highlights the importance of technologies that deliver privacy and security benefits to HIS applications. HIS APPLICATIONS An important concept to understand is that all HIS applications are developed using a programming language, which allows them to operate by executing programming code. Data can be created or modified by programs based on input received from end-user input devices or other software programs and are stored in computer-based files. Large instances of data are normally stored in a database, which offers distinct advantages over other file types, such as documents, spreadsheets, and various forms of graphic and multimedia files. Some of these benefits include support for very large file sizes, the ability of multiple users to edit data at the same time, advanced data recoverability security, and data normalization (i.e., organizing and distilling data). While responsibilities for process redesign and implementation depend on resources within organizations, in healthcare environments, the technical work of developing and maintaining application programming is most often delegated to the vendors who own the application product or to consultants who focus specifically on application programming. Relying on the software vendor to manage software application development, upgrades, and customization allows healthcare organizations to focus on their core business objective of delivering quality health care. Traditionally, healthcare organizations have purchased licenses for many of these vendor applications, or commercial off-the-shelf (COTS) products, causing healthcare data centers to be filled with many “best of breed” applications. Although best-of-breed applications provide healthcare organizations with advanced application functionality for specific service lines or departments, they are generally not developed to integrate or interoperate with other applications. Today, application integration is one way to eliminate application and data silos, and to help organizations achieve efficiencies and healthcare reform criteria. For those healthcare environments large enough to require their own customized application development, programmers are typically added to the internal information technology (IT) department to build customized applications that are specific to their organizations. Web services, Microsoft’s .NET, and Sun’s Java development platform are three prevalent programming languages in use at many health systems today. Regardless of the programming platform used to develop application programs, one of the standard development frameworks in use today is the software development life cycle (SDLC) methodology. When applied to the development of HIS applications, the SDLC process is designed to ensure end-state solutions meet user requirements in support of the healthcare organization’s strategic goals and objectives. The SDLC methodology includes seven stages (Figure 4.1)1: 1. Conceptual Planning. This phase involves the identification and assessment of the system requirements and enhancements, feasibility, costs, and risks. 2. Planning and Requirements Definition. This phase involves identifying functional, support, and training requirements, as well as developing the initial life-cycle management plans, the project plans, and other operations requirements. 3. Design. This phase comprises developing the preliminary and detailed designs, including how the system will meet functional requirements. 4. Development and Testing. This phase includes the system development, testing, and validation activities, which are designed to ensure the system works as expected and that the project sponsor’s (i.e., customer’s) requirements are satisfied. 1114237 - Jones & Bartlett Learning © 5. Implementation. In this phase, the system is installed in the production environment, the training of users is completed, data conversions and system issues are resolved, and the newly designed system is turned over to the project sponsor. 6. Operations and Maintenance. During this phase, the new or upgraded system is operationalized, with routine maintenance, upgrades, feature enhancements, and bug fixes completed. 7. Disposition. This phase represents the end of the system’s life cycle, when the system is scheduled to be decommissioned and retired. The emphasis of this phase is to ensure that the system is disposed of in accordance with proper procedures. HIS applications are software programs of similar functionality that are used to support and facilitate work in a given area within a healthcare setting. HIS applications have historically been developed according to the healthcare organization’s functional departments, divisional areas, or service lines, as opposed to being developed for the organization as a whole. Some of these applications include laboratory systems, nursing systems, patient billing and accounting systems, payroll and time and attendance systems, and human resources information systems. As a result, most of the early HIS applications were specific to the functional unit for which they were developed, causing the proliferation of many non-integrated systems operating within the same organization. FIGURE 4.1 Software Development Life Cycle The development of application interfaces was the initial attempt to bridge these various systems in hopes that common data sets could be leveraged by multiple departments and functional areas. However, maintaining interfaces—essentially data-translation programs—between disparate applications proved to be expensive, time consuming, and inefficient. System developers soon found that application integration, the process that brings data or functions from different application programs together at the point when the applications themselves are first being developed so that they share common data elements and use a common data base, is much more efficient. Essentially, integration avoids building applications in silos, which in turn eliminates the need to build and maintain 1114237 - Jones & Bartlett Learning © interfaces on a regular basis after the initial development. Application programs that are integrated use data from the same shared data repository, whereas application programs that are interfaced exchange and maintain data repositories between separate databases for each application using one- or two-way data transfers. Middleware is a type of software that is designed to provide application integration by interfacing between two existing application programs that are already fully developed and in use. Clinical Applications One of the most important types of applications in healthcare organizations is clinical applications. A clinical application can be defined as any system that supports clinical care (e.g., electronic health record systems), ancillary clinical support processes (e.g., laboratory testing, radiology), clinicians (e.g., computerized physician order entry, clinical decision support), and patient flow (e.g., registration, scheduling). Clinical applications are designed to improve the quality of care; increase efficiency; provide better patient services; reduce medical record transportation costs; and improve a number of processes, including workflow, patient communications, accuracy for coding evaluation and management, drug refill capabilities, charge capture, and claims submissions. An electronic health record (EHR) application is an example of a clinical application that supports clinical care. EHR applications enhance communication and enable the computerized documentation of patient care activities and health services from myriad settings. Key functions supported by EHR applications include electronic capture of data for subsequent storage in a data repository, real-time order entry and results reporting, administrative processes linked with clinical activities, electronic data interchange (EDI) with agencies and partners, clinical decision support for diagnosis and care management, performance reporting internally and to external agencies, and individual patients’ access to their own records.2,3 Another clinical application commonly found in healthcare organizations is a clinical information system (CIS). A CIS application is a computerized system that supports clinical diagnosis, treatment planning, and medical outcomes evaluations. This computerized system organizes, stores, and double- checks all of a patient’s medical information. Such an application keeps health history, prescriptions, doctor’s notes and dictation, and all other information together electronically, and replaces the paper charts of the past. Examples of departmental and service lines systems that are considered CIS applications include quality management, laboratory testing, radiology, endoscopy, nursing, surgery, operating room, and pharmacy. Nursing and physician documentation are also CIS applications. CIS systems include embedded clinical guidelines and treatment protocols, establish rules and alerts, and provide evidence-based treatment plans. An important success factor for achieving future CIS viability and integration throughout the organization’s HIS applications is the need for enterprise-wide strategic HIS planning. A laboratory information system (LIS) is a CIS application that supports chemistry, pathology, blood bank, instrumentation, calculations, calibrations, and results management areas within clinical settings. Core functions of a lab system include test requisition processing, scheduling and cataloging specimen collection, and test processing; delivering results of completed tests that have been verified and recorded, and results reporting directly into patient records; identifying abnormal results and alerts; providing statistical reports for lab management and patient summary reports; performing quality control and charge capture functions; and supporting lab operations management. A pharmacy information system (PIS) is a complex CIS application that is tightly integrated with clinical care, particularly with nursing personnel and workflows. Because medication errors are always a concern with pharmacy systems, integration to ensure the proper delivery of care is a high priority. Workflow redesign is especially important when implementing medication administration management processes; pharmacy system automation requires a different approach than automation of paper- based processes. It is critical that pharmacy applications are tightly integrated with nursing medication administration records (MARs) and other order processes such as computerized physician order entry (CPOE) to ensure patient safety. Additional areas that pharmacy systems automate as part of their effort to improve the quality of care and patient safety are drug inventory management, charges, medication error tracking, profile orders, performance management, drug–drug interactions, allergies, and other screenings. 1114237 - Jones & Bartlett Learning © Radiology information systems (RISs), medical imaging systems (MISs), and picture archiving and communication systems (PACSs) are all CIS applications that provide clinical support processes. MISs support image management, image processing, enhancement, visualization, and storage. RISs provide functionality that manages test requisitions, schedules procedures, manages test results, identifies charges, and delivers patient test and department management reports. In addition, radiology systems are capable of performing image enhancements, computed tomography (CT) scans, ultrasound imaging, angiography, magnetic resonance imaging (MRI) scans, nuclear medicine functions, radiation therapy, computerized patient-specific treatment planning programs, and surgery. PACS applications manage image storage, local and remote retrievals, and distribution and presentation of PACS files. Recent advances with PACS applications have added features such as improved turnaround time for results, elimination of film loss, support for teleradiology, and reduction of physical space requirements for storage. Outpatient systems are CIS applications designed to assist in the delivery of care for patients who are hospitalized for less than 24 hours. These ambulatory care systems are CIS applications that assist caregivers in performing consultations, treatments, or interventions in an outpatient setting, such as a medical clinic. Examples of the types of procedures that are performed in this environment include minor surgical and medical procedures, dental services, dermatology services, and diagnostic procedures such as blood tests and X-rays. Ambulatory care settings have needs similar to those served by inpatient clinical and business applications, but slightly different priorities. Two important areas of emphasis in ambulatory care settings are financial and administrative systems—which include billing, eligibility determinations and authorizations, claims processing, general financial, human resources, and materials management applications—and clinical systems—which support scheduling, appointment reminders, EHRs and personal health records (PHRs), transcription, prescription management, disease management, and patient communications. Long-term care (LTC) systems are CIS applications designed to aid in the delivery of care for patients who are older than age 65 or who have a chronic or disabling condition that needs constant supervision. LTC facilities can provide nursing home care, home health care, and personal or adult day care for individuals. LTC systems include clinical, financial, and administrative management functionality that is designed to address the unique requirements of the LTC environment. Adoption of CIS applications in LTC settings has been slow to date, but transitioning to computerized systems in these environments has been shown to improve care delivery. Two special challenges are encountered in LTC environments: (1) They are not tightly integrated with health systems and (2) physicians are not routinely present at LTC facilities. CPOE systems are CIS applications that directly support clinician workflow requirements. CPOE comprises the electronic entry of medical practitioner instructions, referred to as “orders,” for the treatment of patients under that practitioner’s care. Typically, these orders are communicated within and through an EHR application to departments such as pharmacy, laboratory testing, or radiology, where they will then be filled. CPOE applications have the benefit of decreasing delays in order completion, reducing errors related to handwriting translation or transcription, allowing order entry at the point of care or off-site, enabling error checking for incorrect or duplicate doses or tests, and streamlining the posting of charges and inventory management. CIS applications have many benefits for both healthcare organizations and patients. These advantages include reduction of staffing requirements over the long term, attaining eligibility for pay- for-performance payments, recruiting and retaining physicians, enhancing the legibility of clinical documentation notes, reducing spelling errors within CIS applications, improving access to medical charts, reducing costs associated with transcription and facilities used for storing paper, and improved recovery of medical data following a disaster. Additional benefits include allowing multiple clinicians to simultaneously access medical charts, having lab and X-ray results returned automatically, checking for drug–drug and drug–allergy interactions, integrating physician dispensing software, and improving patient safety. Figure 4.2 summarizes the key CIS applications that healthcare organizations are seeking to deploy in their efforts to achieve technology adoption and meaningful use of EHRs.4 Administrative Applications Historically, health care has lagged behind other industries in the development of robust administrative and financial systems. Healthcare reform has brought increased pressure on healthcare organizations 1114237 - Jones & Bartlett Learning © to take a more strategic approach to managing these systems. In response, healthcare providers and payers are now deploying systems that integrate administrative and financial systems. These include EHRs, along with enterprise resources planning (ERP) systems, customer resource management (CRM) systems, and supply chain management (SCM) systems. Patient accounting is an administrative application that manages billing and accounts receivable, and is often integrated into a health provider EHR application. ERP systems are bundled applications that manage a healthcare organization’s financial and accounting applications. They can include general ledger, accounts payable, material management, human resources management, and facilities management applications, which have been traditionally installed at healthcare organizations as separate or “point” solutions (silos). FIGURE 4.2 Healthcare Provider Technology Adoption Map In the Robert Wood Johnson Foundation’s annual report, Health Information Technology in the United States: Better Information Systems for Better Care (2013), 44% of hospitals reported having a basic EHR system as of 2012.5 This was a 17% increase from 2011, demonstrating that hospitals, physicians, and other providers have made significant strides in the adoption of health information technology and the integration of healthcare data. Physicians were reported to have also made substantial progress, with 38.2% having adopted basic EHR functionalities by 2012. Despite these advances, many organizations have not taken steps to achieve an integrated ERP solution and, therefore, may face challenges in generating comprehensive reports due to the existence of data silos and data integrity issues. Home health care is an evolving method of care delivery that is increasingly using administrative applications of HIS. With the advent of healthcare reform and technology advances, including mobile devices that are being used by nurses in the field, delivery of care outside of traditional hospitals and clinics is becoming more feasible and widespread. With a laptop computer and broadband card, a nurse can make home visits, enter updates into his or her laptop, and automatically update central medical office systems. Home healthcare organizations require the same types of administrative, financial management, and clinical applications as other healthcare organizations. The only difference is that home health HIS applications need to be customized to meet the unique requirements found in the home health environment. This functionality includes monitoring patients for specific conditions, developing treatment plans, identifying measures that can be taken and communicated to the home health site, and communicating with caregivers in homes between visits using mobile technology. Home health care is a highly regulated arena of healthcare delivery, so automation saves caregivers the time associated with filling out the many required forms by hand, leaving more opportunity for caregiver–patient interaction, an outcome that is satisfactory for caregivers and patients alike. 1114237 - Jones & Bartlett Learning © TECHNOLOGY Essential to the success of an HIS deployment is first ensuring that the basic building blocks of data communication are architected and maintained properly. Many HIS implementations risk failure or high user dissatisfaction if the infrastructure supporting the transfer of voice and data is outdated, unstable, or not managed efficiently. Two related important areas that we will cover are telecommunications and networking. Each of these technology areas is one of the most complex topics in the computer-related field. Telecommunications and Networking Telecommunications is defined as the electrical transmission of data among systems, whether through analog, digital, or wireless media. Data transmissions can occur across a variety of media types, such as copper wires, coaxial cable, fiber, or airwaves. Both large and small healthcare organizations today utilize these data transmission types and mediums. Data communication networks consist of three basic hardware components: servers, clients, and circuits. A server is a host computer that stores data or software and is accessed by clients. While a server resides at one end of a communication circuit, a client is the input/output hardware device at the user’s end of a communication circuit. A client typically provides end users with access to the network and a server. A circuit is the pathway by which messages between servers and/or clients travel. Copper wire, fiberoptic cable, and wireless transmissions are three of the most common circuit types deployed today, with switches, routers, and gateways being three of the many devices used to enable circuits to transmit information. An example of these three components in a healthcare setting can be seen with an LIS. The LIS servers hosting the data and providing the application processing will be located in the organization’s data center. The doctors and nurses who need to access the LIS information will use their client computers—usually a personal computer (PC) or mobile device. The hospital or clinic’s wireless or wired network, along with the Internet, can be considered the circuit that is used to transfer data between the client and the server. Types of Networks Networks are commonly categorized into four different types: local area networks (LANs), backbone networks (BNs), metropolitan area networks (MANs), and wide area networks (WANs). LANs are groups of devices located within the same geographical area, such as one or more floors within a building, or multiple buildings in close proximity to each other. BNs are designed to connect LANs, WANs, and other BNs at high data transfer speeds and typically span several miles. MANs connect LANs, BNs, and WANs that are usually located within 3 to 30 miles of each other, and are often referred to as campus networks. WANs connect BNs and MANs and can connect devices that are located around the world. Whereas healthcare organizations can create and maintain their own LAN, BN, and MAN infrastructure, commercial carriers are the primary providers of WAN infrastructure, which consists of fiber-optic cable, switching equipment, and microwave towers or satellite equipment. LANs, BNs, MANs, and WANs support data transmission speeds of up to 10 gigabits per second (Gbps) between each other, with higher speeds currently being developed. Data transfer rates via devices connected to LANs can range from 10 megabits per second (Mbps) or 10 million bits per second to 1 Gbps or 1 billion bits per second. Networks may also be classified as intranets or extranets. Intranets are LANs that function similar to the Internet, providing web-based technologies that are accessible only to internal users of an organization. Vendor-developed and internally customized web-based applications can be found on an intranet. Examples of web-based applications that are often found in healthcare organization intranets include company directories, user account request systems, collaboration and file sharing sites, human resources information systems, purchasing systems, and help desk ticketing systems. Extranets are similar to Intranets but provide web-based content and access to applications and databases for users who are outside of the organization—for example, business partners, patients, vendors, and students/faculty. Both intranet and extranet content are most efficiently maintained using enterprise web content management (EWCM) systems, which allow individual departments to easily update their content made available on the network without knowledge of HTML programming or use of webdesign skills. In many cases, health organizations are leveraging remote hosting by engaging a third-party web- 1114237 - Jones & Bartlett Learning © hosting company to manage their external web content. This is often done by entering into a contract with a professional EWCM vendor, which then supplies all the necessary hardware, software, website address information, and website development. The healthcare customer simply needs to provide the Internet connectivity to the external website, along with supplying the web content. Network Models Networks perform the basic function of transferring data from a sending device to a receiving device. To make this process efficient and modular, the various functions necessary to complete the data transfer operation are divided into network layers. The two most important network models useful to describe these network layers are the Open Systems Interconnection model (OSI) and the Internet model. The OSI model was developed in 1984 and defines seven network layers (Figure 4.3(a))6: • Layer 1: Physical Layer. The physical layer is designed primarily to transmit data bits (0s and 1s signifying positive and negative electrical charges) over a communication circuit. • Layer 2: Data Link Layer. The data link layer is responsible for the physical transmission circuit in layer 1 and converts it into a circuit, ensuring the transmission is error free. • Layer 3: Network Layer. The network layer is responsible for routing—that is, identifying the best path through which to send the data—and ensuring the message arrives to the destination address. •  Layer 4: Transport Layer. The transport layer manages end-to-end network issues, such as procedures for …