EHR Hardware

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EHR RoadmapWebEx

• EHR Hardware

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Presenter

• Margret Amatayakul
• RHIA, CHPS, CPHIT, CPEHR, FHIMSS
• President, Margret\A Consulting, LLC,
  Schaumburg, IL
• Consultant on the DOQ-IT Project for several
  QIOs
• Independent information management and
  systems consultant,
  focusing on EHRs and
  their value proposition
• Adjunct faculty College of St. Scholastica,
  Duluth, MN, masters program in health informatics
• Founder and former executive director of
  Computer-based Patient Record Institute,
  associate executive director AHIMA, associate
  professor Univ. of Ill., information services
  IEEI
• Active participant in standards development,
  HIMSS BOD, and co-founder of and faculty for
  Health IT Certification

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Objectives

• Describe the purpose of understanding hardware
  requirements for EHR
• Compare and contrast various human-computer
  interfaces
• Identify hardware for user authentication
• Define different networking architectures and
  criteria for service evaluation
• Identify considerations for data management and
  storage

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EHR Hardware

• Understanding
• Hardware (H/W) Requirements

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Hardware Requirements

• Hardware inventory provides baseline for vendors
  to develop EHR price proposal
• Vendors often have hardware preferences to
  which they have developed their applications and
  know they work
• Vendors may require hardware certification
  if purchased separately

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Hardware Preferences

• IT staff may have preferences based on past
  experience
• End users may have preferences based on
  familiarity or comfort
• Organizations may have preferred vendor
  relationships that ease cost

• Technology is continuously advancing, and so must
  IT staff skills
• Device standards make it easier to maintain
  equipment
• New applications, such as EHR, may require
  hardware not supported by present trading partner

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Hardware Considerations

• Servers
• Database
• Application
• Terminal
• Domain
• Network
• E-mail
• Fax
• Others . . .
• Clients
• Workstations
• Desktops
• Notebooks/laptops
• Tablets
• PDAs

• Peripherals
• Keyboard
• Navigational devices
• Monitors
• Other input/output
• Printers
• Scanners
• Document
• Card
• Bar Code
• RFID
• Network
• Data Storage

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EHR Hardware

• Human-Computer Interfaces
• (HCI)

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a.k.a. User Input Devices

• Monitors
• High resolution
• Flat panel
• Touch screen
• Keyboards
• Ergonomic
• Liquid proof
• Navigation
• Wireless
• Tethered
• Foot controlled

• Workstation
• Personal computer
• Desktop
• Notebook/ laptop
• Tablet
• Slate
• Convertible
• PDA
• Cellular phone

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Desktop vs. Tablet PCs

• Desktop PCs
• Require space for monitor and keyboard
• User position
• Patient position
• Some space issues can be overcome by
• COWs
• Suspended/flat panel monitors
• Special trays for keyboards
• Some issues of infection control
• Require log-on/log-off
• Always available
• Network connection
• Power
• Lower cost

• Tablet PCs
• Including
• Slate
• Convertibles
• Issues of
• Weight
• Heat
• Space
• Navigational precision
• Mobility
• Affords continuous log-on
• Requires wireless network or docking stations
• Battery life issue
• More expensive

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Speech Recognition

• Speech is digitized and matched against coded
  dictionaries to
  recognize words
• Older voice recognition systems required discrete
  speech
• Newer speech recognition systems accommodate
  continuous speech
• Many systems must be "trained
• All words or sample of words that will be spoken
  by user
• New systems are speaker-independent, requiring no
  training
• Speech recognition is improving in accuracy, but
  it is often in commonly used terms rather than
  medical terms where errors occur
• Next week is spoken as nexweek
• Correction may be performed
• Retrospectively by a correctionist
• Concurrently by the user
• Speech recognition is not natural language
  processing.
• Speech recognition at the point of care can be
  cumbersome, unless used primarily to issue voice
  commands to a structured data template. Even
  then, many clinicians find this more awkward/less
  natural than navigating a template by hand or
  keyboarding

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Bar Code / RFID

• Line of site requires human intervention to
  scan a barcode, whereas an RFID tag can be
  detected "hands off"
• Barcodes must be visible on outside of product
  packaging. RFID tags can be placed inside of
  packaging or in the product itself to reduce
  counterfeiting and black marketeering
• RFID tags are not impaired by dirt, moisture,
  abrasion, or packaging contours as are barcodes
• RFID tags have a longer read range than barcodes
• RFID tags have read/write memory capability
  barcodes do not
• More data can be stored in an RFID tag than can
  be stored on a barcode

• FDA will require manufacturers to apply bar code
  labels for all human drug and biological products
  by April 26, 2006
• Bar codes/RFID has been primarily used in
  hospital medication administration (and
  pharmaceutical inventory) scenarios, but, they
  can also be used for
• Lab specimen management
• RFID chips can be implanted in persons to track
  their movement

Also for lab specimen management
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EHR Hardware

• User Authentication

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Authorization, Access Controls, and
Authentication(All Required by HIPAA)

• Authorization is the process by which someone is
  allowed to have information they are permitted to
  have
• Access controls provide the means to allow or
  disallow someone information they want
• Administrative
• Physical
• Technical

• Authentication is the process by which you verify
  that someone is who they claim they are

Microsoft Active Directory
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Access Control List
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Authentication

• Wet signature
• Digitized signature
• Electronic signature
• UserID and password
• Token
• Biometric
• Digital signature

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Public Key Infrastructure (PKI)

• A system of digital certificates, certificate
  authorities, and other standards and programs
  that verify and authenticate the validity of each
  party involved in an Internet transaction.
• PKIs are currently evolving.
  There is no single PKI nor
  even
  a single agreed-upon
  
  standard for setting up PKI
• PKI is also called a trust
  hierarchy

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EHR Hardware

• Network Computing

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Networking Basics

• Networks transport data among computers
• Network components
• Architecture
• Topology and protocols
• Media
• Devices
• Routers
• Hubs
• Switches
• Bridges
• Repeaters
• Gateways

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Client/Server Architecture (C/S)

• A network architecture in which each computer or
  process on the network is either a client or a
  server
• Servers are powerful computers or processes
  dedicated to managing specific functions
• Clients are PCs or workstations on which users
  run applications. Clients rely on servers for
  resources, such as files, devices, and even
  processing power
• Clients
• Thick/Fat Clients are traditional PCs or
  workstations
• Thin/Network Clients
• Software and hardware configuration of client in
  which bulk of processing occurs on the server
• Often lower cost, but may not be suitable for all
  EHR applications (check with your vendor first)

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Servers

• Variety of server functions
• Database server supports multiple, simultaneous
  transactions
• Application server middleware that connects a
  database server and end user
• Other servers include file servers print
  servers Web, email, and fax servers
• Proxy server sits between client and an external
  server to filter requests, improve performance,
  and share connections
• Server platform is the servers operating system
• Blade servers are circuit boards that slide into
  existing servers
• Servers are often rack mounted for convenience

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Web Services Architecture

• Web services architecture (WSA)
• A standardized way of integrating Web-based
  applications using open standards over an
  Internet protocol backbone
• Unlike traditional C/S architecture using a Web
  server, WSA does not provide a graphical user
  interface (GUI).
• Instead, WSA shares business logic, data, and
  processes through a programmatic interface across
  a network.
• The WSA can then be added to a GUI to offer
  specific functionality to users
• WSA allows different applications from different
  sources to communicate with each other without
  time-consuming custom coding.
• Because all communication is in XML, WSA is not
  tied to any one operating system or programming
  language. Web services do not require the use of
  browsers or HTML

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OSI Model of Computer Networks
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Local Area Networks (LAN)

• Means to communicate data
• Twisted pair wire
• Inexpensive wire cable, limited speed and
  capacity, subject to interference
• Coaxial cable
• Expensive wire cable, not as susceptible to
  interference, widely used
• Fiber optics
• Extremely expensive threads of glass that carry
  data very rapidly with little interference
• Radio waves (wireless)
• Many standards, susceptible to interference
  bandwidth increasing and cost decreasing
• Transmission Control Protocol/Internet Protocol
  (TCP/IP)
• Used in private networks to mimic Internet
  functionality
• LAN Intranet
• WAN Extranet

• Protocols - rules for sending data from one node
  (place) on the network to another
• Speed
• Ethernet
• Supports very fast data transfer
• Token ring
• Closed loop around a central hub, relatively slow
• Fiber Distributed Data Interface (FDDI)
• Dual rings in token ring structure, supports many
  users at relatively fast speeds

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Wide Area Networks (WAN)

• Geographically dispersed LANs
• Connected by telephone lines or radio waves
• Leased lines are permanent trunk lines offered by
  the telephone company (e.g., T1, T3)
• Dial up connection via modem and public telephone
  network
• Plain old telephone service (POTS) slow, some
  potential interference
• Frame relay and Integrated Services Digital
  Network (ISDN) offer increased speed to POTS
• Digital subscriber line (DSL) special
  configuration to link two specific locations
  (e.g., provider and a switching service) for
  faster and less expensive service than ISDN

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Virtual Private Network
IPSec
SSL
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Wireless Network

• Wi-Fi refers to a network based on the IEEE
  802.11 standards
• Consider the data transfer rates, security
  standards supported, and other factors for LAN
• 802.11a
• 802.11b
• 802.11g
• Metropolitan Area Networks (MAN)
• 802.16 (WiMAX)
• Bluetooth short range radio
  technology

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VoIP

• VoIP allows you to make telephone calls using a
  computer network, over a data network like the
  Internet
• VoIP converts the voice signal from your
  telephone into a digital signal that travels over
  the internet then converts it back at the other
  end so you can speak to anyone with a regular
  phone number
• When placing a VoIP call using a phone with an
  adapter, you'll hear a dial tone and dial just as
  you always have
• VoIP may also allow you to make a call directly
  from a computer using a conventional telephone or
  a microphone

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Important Security H/W

• Firewall hardware, software, or combination
  thereof that is designed to prevent unauthorized
  access to or from a private network by screening
  the messages against specific criteria
• Anti-Virus (AV) software that detects known
  malware, including spyware, spam, adware, content
  filtering, etc.
• Vulnerability Assessment (VA), Intrusion
  detection systems (IDS) and intrusion prevention
  systems (IPS) more sophisticated software that
  analyzes patterns and either provides an alert
  about a potential problem or restricts entry

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Key Network Capabilities

• Bandwidth - Data carrying capacity, usually
  expressed as megabits per second (Mbps)
• Latency - Time required for a packet of data to
  be transmitted between communicating entities on
  a network
• Response Time Amount of time required for
  entire message or file to be transferred and
  acknowledged
• Availability - Likelihood that the network is
  able to provide service and is functioning
  properly
• Security - Capability of a network to ensure
  confidentiality and integrity of information
  transmitted across it.
• Ubiquity - Degree of access to a network

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EHR Hardware

• Data
• Management
• and Storage

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Document Imaging Systems

• Electronic document management systems (EDMS) are
  transition systems to EHR
• Basic functions include
• Creating document repositories
• Profiling document properties
• Managing document versions
• Searching and retrieving documents
• Viewing, editing, printing, importing and
  exporting documents
• Scanning documents
• Routing documents for workflow
• Content management through indexing

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Storage

• Redundant Array of Independent (or Inexpensive)
  Disks (RAID)
• A category of disk drives that employ two or more
  drives in combination for fault tolerance
• Network attached storage (NAS)
• Device dedicated to file sharing, capable of
  adding hard disk storage space to a network
• Storage area network (SAN)
• High-speed sub-network of storage devices
• Content-addressed storage (CAS)
• System for storing data that are not intended to
  be changed (e.g., medical images, archived email)

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Important Data Back Up Concepts

• Uninterruptible power supply (UPS), provides a
  battery to keep a computer running for several
  minutes after a power outage,
• Enables the ability to save data that is in RAM
  and shut down the computer gracefully.
• Many UPSs offer software that automates backup
  and shut down
• Dual-core refers to a CPU that includes two
  complete execution cores per physical processor.
• Failover is the capability to switch over
  automatically to a redundant or standby computer
  server, system, or network upon the failure or
  abnormal termination of the previously active
  server, system, or network. Failover happens
  without human intervention.
• Fault-tolerance, or graceful degradation, is the
  property of a system that continues operating
  properly in the event of failure of some of its
  parts.

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This presentation was created by MetaStar under a
contract with the Centers for Medicare Medicaid
Services (CMS). The contents do not necessarily
reflect CMS policy.