Elements of a Typical Electronic Health Record System - Part 2

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Typical Server Elements

Different types of server elements combine to make an EHR system. Typical server elements include:

  1. An application server (or group of servers) which house the EHR or patient management application.

  2. A database server where compiled patient data is stored.

  3. Citrix or terminal server or servers which support thin clients. Thin clients are computers that require the server to fulfill much of the system’s functional role. A computer terminal is an example of a thin client. It holds no real computational programming. Instead, it is programmed only to focus on graphically displaying information requested from the server by the user.

In some cases, application, database, and terminal services may reside on the same computer system. However, due to the potential performance requirements of each service, this is not recommended except in the smallest of workplace environments.

Server Software Elements of the EHR

The Institute of Medicine lists eight crucial core server elements for an EHR system. These include:

  1. Health information and data storage component - that would be a database or a series of databases.

  2. Results management, which is, essentially, software that actively manages the results - particularly lab and radiology results that come into the EHR to assure that they are seen & dealt with appropriately by the clinician.

  3. Order entry and management, which is designed to effectively route clinician orders to the proper destinations.

  4. Decision support, which is a computer logic that presents information to help clinicians make correct decisions, such as displaying relevant reference information on the screen while orders are written or popping up warnings if a drug order appears inappropriate based on a patient's known allergies.

  5. Electronic communication and connectivity software, which allows the various applications to “talk” efficiently to one another over a network.

  6. Patient support.

  7. Administrative processes, and

  8. Reporting and population health management software

Vendors often supply additional modules and components customized to meet the specific needs of individual organizations and practices.

EHR Clients

We’ve defined servers and their role. So what does a client do?

EHR systems make medical records available to multiple simultaneous users. Tablets, laptops, and PCs allow instantaneous access for the healthcare staff who move around in the health centers.

Clients use client application software to securely connect to and pull data from the EHR server to fulfill user requests. After receiving the requested data, the client software then organizes and displays the data in a manner that the user can efficiently view.

Using an EHR system to read and write to a patient's record not only is typically done through a workstation but, depending on the type of system and health care setting, may also be possible via mobile devices that are capable of interpreting handwriting.

EHR Hardware - Defined

Let’s talk briefly about hardware found in an EHR system.

Hardware can best be described as the nuts and bolts that make things work.  The physical components of servers, workstations, laptops...the boxes and all the “stuff” that goes inside them are all hardware, as are printers, scanners, routers, and switches.

Having the proper hardware to run your EHR system is just as important as the software components. Without the proper hardware, the system may not run as efficiently and may exhibit compatibility issues.

EHR Hardware - Most Common

Some of the hardware components most often attributed to EHR systems include:
Servers, workstations, laptops and tablets, PDAs (also known as Portable Digital Assistants) and smart phones, flat panel monitors, scanners, storage and backup devices (including tape drives), shredding devices, and medical diagnostic and treatment devices.

These are just some of the major hardware components you’ll find in an EHR system and the network it operates on.

EHR Hardware - Servers

A server, in the hardware sense, is a computer designed to efficiently run server applications. In the EHR arena, that includes the patient index (where patient data resides), the patient management software, and various modules designed for the parsing of user requests. They also may house user management tools for making administrative changes to the software, including updates and error correction.

As stated earlier, a server essentially “serves” other computers on the network. It typically houses applications and databases required by desktops or laptops  to access information or run centralized programs. Because servers are a critical infrastructure component, they are usually located in a protected environment not generally accessible to the general public. Servers are expected to run pretty much continuously throughout their entire life cycle.

Most enterprise-level servers are known to be very fault tolerant and come with built-in redundant hardware systems to ensure reliable operation. In many healthcare environments, even a short-term failure can be more costly than the purchase and installation of such a system. Most of these systems come with “hot swappable” accessories (parts that can be changed out without turning off the server) to minimize downtime due to failure or maintenance.

Servers come in all shapes and sizes. You should consult your IT staff, hardware & EHR vendor(s), and/or consultant to determine the hardware specs required for your organization. In general, your server should be extremely reliable, with as many built-in redundancies as possible to minimize system downtime.

Data storage is a critical component you will have to address when deciding on the installation of an EHR system.

The storage requirements of an EHR system are largely dependent on the specific EHR/PM (patient management) application and the volume of scanned documents. For a typical practice, a rule of thumb is to expect 5 GB per year per provider. It’s important to discuss your patient load with your vendor to determine your short- and long-term storage capacity needs.

Some things to consider when choosing a server include:

  1. The brand: Is the brand of server consider reputable? How are the reviews for the particular model you are looking at? Do they provide a warranty consistent with the institution’s needs?

  2. The Operating System (OS): Is the server designed to work well with the operating system needed to run the EHR software?

  3. The processors and processing speed: The higher the processing speed, typically the faster the computer can make computations. Are the processor specs in line with the EHR requirements?

Additional items to consider:

  1. RAM (Random Access Memory) - that’s the “working memory” of the computer. Computers use RAM to store short term computations. Additional RAM allows a computer to work with more information at the same time which can have a dramatic improvement in total system performance.

  2. The hard drive configuration is important too – Is there enough hard drive space to accommodate our expanding storage needs over the next year? How about the next five years? Will it support redundant hard drive configurations, such as RAID 5, bearing in mind that many RAID configurations dramatically increase the amount of hard drive space needed?

  3. The network card – Does the network card adequately support the amount of network traffic expected on the server? Is there the capacity to add an additional network card or cards and options for load balancing?

Last but not least, think about other accessories for your server including the

  1. Monitor, keyboard, CD or DVD drives, and UPSs or Uninterruptible Power Supply in case of power outages.

For smaller practices, the added costs of a server infrastructure may not be warranted. Hosted solutions are available for such situations. When considering a hosted solution, these variables should be considered:

  • The cost
    • Internal servers mean higher initial costs, but external or hosted servers means monthly fees. Consider whether monthly fees will outpace the costs of purchasing and maintaining an in-house infrastructure.

  • Management
    • Internal servers mean staff is needed to implement and manage them and perform software and hardware maintenance and backup duties. External or hosted servers means the customer is dependent on the vendor for scheduled maintenance.

  • Power
    • With internal servers, your organization is capable of utilizing the full power of the server, whereas with external or hosted solutions, customers often share resources, and

  • Connectivity
    • Internal servers give your institution ability to control the speed of and connectivity to the server(s). External or hosted servers are in remote locations, and connectivity means they may be shared with other customers, reducing the speed available to you.

EHR Hardware – Clients

Let’s take a couple minutes to discuss client hardware.

Fixed workstations are one of the most prevalent client systems in today's healthcare settings. A typical workstation is a high end microcomputer connected to the computer network via a wired (cabled) interface and intended primarily to be used by one person at a time. Workstations (also known as desktops) can run a variety of operating systems, including Windows 2000, Windows XP, Windows Vista, Windows 7, and some flavors of Linux.

Generally, a laptop, or notebook, is a portable computer with a traditional screen (without touch input) and physical keyboard, meaning input methods are similar to a fixed workstation and generally consist of keyboard and mouse and/or touchpad.

A tablet, on the other hand, is a portable computer equipped with a touch screen and, in some cases, a stylus and intended to offer an even more mobile computer for when laptops are impractical or unwieldy or do not provide the needed functionality. Tablets usually use a wireless interface to connect to the network.

There are three types of Tablets available:

  1. Slate tablets, which resemble writing slates, are tablets without a dedicated keyboard. For text input, users rely on handwriting recognition software via an active digitizer, or touching an on-screen keyboard using fingertips or a stylus.

  2. Convertible tablets have a base body with an attached keyboard. Typically, the base of a convertible attaches to the display at a single joint called a swivel hinge or rotating hinge to allow for a 180 degree range of rotation. This type of tablet is pictured on the right in the above illustration.

  3. Booklet tablets have two separate screens and fold like a book.

Both laptops and tablets make use of rechargeable batteries to allow for several hours of extra mobility in the workplace without the use of a power cord. 

Tablets and laptops offer several advantages, as well as a few disadvantages, when compared to workstations.
Advantages of laptops and tablets include:

  1. Additional mobility compared to workstations
  2. Time savings by providing a data interface at the provider’s fingertips, negating the need for frequent trips to a workstation.
  3. Cost savings if additional infrastructure such as ports are going to be needed for additional workstations.

Disadvantages of laptops and tablets include that they are:

  1. Typically more expensive than workstations
  2. Subject to theft given their small size
  3. Likewise, easily broken – The average lifespan is about three years.
  4. And laptops and tablets generally need some sort of additional support, cleaning, and maintenance.

EHR Hardware – PDAs and Smart Phones

Personal Digital Assistants (PDAs) and smart phones are devices that combine computing, telephone, and networking features.

Like tablets, most PDAs are pen-based, using a stylus rather than a keyboard for input.

PDAs and smart phones allow users to remotely access patient data from any location with connectivity. They usually also contain other software specific to the user’s tastes.

They offer similar advantages & disadvantages to laptops and tablets. Many providers incur the expense of a mobile device since they support personal notes and applications, phone capabilities, and calendars.

Integrating PDA and Smart Phone support into the existing computer environment may require additional hardware and other infrastructure resources.

Network

Let’s discuss briefly the network the EHR system will sit on and use to communicate with its users.

First, let’s define a network.

A network, quite simply, is a collection of computers and devices connected by communications channels that facilitates communications among users and allows users to share resources with each other.

It generally uses wired cabling and a protocol called “Ethernet” to communicate between the various components.
Ethernet uses physical wiring to connect devices. Frequently deployed devices include hubs, switches, bridges, and/or routers.

Additionally, wireless LAN technology is designed to connect devices without wiring. These devices use radio signals as a transmission medium.

Some additional terms to know include:

  • LAN or Local Area Network – connects workstations and servers within a single demographic location.

  • WLAN  or Wireless Local Area Network – current most common technology referred to as “WiFi”.

  • A WAN on the other hand, or Wide Area Network, connects workstations across multiple locations, often great distances.

  • Point-to-point T1 and fractional T1. These are all dedicated broadband lines that connect locations in a WAN.

  • Bandwidth – That’s the rate of data transfer, usually measured in bits per second.

  • A VPN or Virtual Private Network is a way of securely accessing a specific network over the internet.

  • Firewall is software or hardware that prevents unauthorized access to network; monitors network traffic; may include VPN, virus scanning.

Local Area Network (Corporate Offices - New York)

As the above image illustrates, a local area network is defined by a single demographic location consisting of, typically, a building, or grouping of buildings which are supported by a single network. Here, server rooms, wiring closets and individual desktops and laptops are connected through a variety of methods to comprise a Local Area Network.

Wide Area Network

A wide area network (WAN) on the other hand is usually used for connecting computers and other network resources, spanning a wide geographical area. WANs can by used to connect cities, states, or even countries, often using a variety of methods to ensure redundancy or security. In this instance, the corporate offices are connected to both its regional offices in Raleigh, North Carolina, and its Tokyo branch office through its Wide Area Network.

Network – Assessing Usage

Your network infrastructure must be able to reliably support the data requirements of your EHR application.

Insufficient network capabilities will degrade application performance and increase the risk of user rejection.

Some things to consider when assessing network usage:

For instance, how many users will need simultaneous access to the network?

And, what are the bandwidth requirements (the flow of data that can traverse the network at a given moment) of the EHR system, per the vendor?

In particular, special bandwidth needs of scanning equipment and other medical equipment factor into this equation as well. This is a question for your vendor.

Also, sufficient connectivity between internal resources and remote resources such as satellite facilities.

In most healthcare settings today, the wireless network has become a prominent medium for connecting a wide range of devices to the EHR system, making access to patient records even more efficient.

Before adding additional wireless infrastructure to your system, be sure you have adequately addressed these wireless needs...for the short and long term. Because many IT departments have limited experience at deploying wireless systems in an enterprise environment, it’s important to have a consultant conduct a wireless connectivity survey to ensure adequate coverage throughout the entire facility and to adequately address any potential wireless bandwidth issues.

Also, as demand for remote off-site access continues to grow, be sure to explore with your vendor how efficiently the EHR system will integrate with your existing VPN network.

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