HIT,electronica Health record

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Instructions: Answer ALL the questions below. You may use the text (chapter 3, Glandon for questions 1,2 and 3), slides from class and chapter 3, Sultz and Young. You may also use external sources (www.hit.gov) to answer these questions. Please also read chapter 1. PLEASE cite your work and sources. Upload a word document. All questions require a minimum of 200 words each.

Q1: Can Government intervention in HIT be justified? Why or why not? (Hint: Chapter 3 – pages 53-56.) 5 points

Q2: What is HIPAA? Why was it passed? What are the two key provisions of this legislation? What are the potential benefits to healthcareorganizations to be gained by compliance with HIPAA standards? What are the potential benefits to patients and consumers of health care? (Hint: read glandon, chapter 3 pages 59-64 + www.hit.gov - cite your sources; summarize benefits in your own words) 5 points

Q 3: What is the HITECH act? Why was it passed? What are the potential benefits to providers (doctors and hospitals) by responding to this legislation? What are the potential drawbacks? (Hint: read Glandon, chapter 3 pgs-64-70; summarize benefits and drawbacks in your own words) 5 points

Q 4: Read chapter 1 and then answer the following question: Order the following types of healthcare information systems from most important to least important to a healthcare organization, and discuss why you chose this order. (5 points)

a) Clinical information

b) Operational management

c) Strategic decision support

d) Electronic networking and e-health applications

Cite appropriately

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Chapter 9: Applications: Electronic Health Records (EHRs) Overview • Components of an EHR • EHR adoption model (7 stages) • Benefits, goals, and costs of an EHR • • • Meaningful use of an EHR Federal incentives to adopt an EHR Total cost of ownership (TCO) of an EHR Copyright 2013 Health Administration Press Learning Objectives • Define the term electronic health record (EHR) • Understand the key capabilities of a robust EHR • Articulate the benefits of a robust EHR • Articulate some of the key cost categories associated with the purchase and implementation of an EHR Copyright 2013 Health Administration Press Learning Objectives (cont’d) • Describe the EHR/EMR adoption model • Understand the concept of “meaningful use of an EHR” and describe some of the criteria that both individual providers and hospitals need to achieve to earn incentives for meaningfully using an EHR Copyright 2013 Health Administration Press Electronic Health Record (Defined) • A longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting • Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory results, and radiology reports Copyright 2013 Health Administration Press Electronic Health Record (Defined) • The EHR automates and (with appropriate operations management) can streamline the clinician’s workflow • The EHR has the ability to generate a complete record of a clinical patient encounter—as well as supporting other care-related activities directly or indirectly via an interface—including evidencebased decision support, quality management, and outcomes reporting Copyright 2013 Health Administration Press Some Key Benefits of an EHR • Access to information: Unlike paper records, EHRs provide a means for clinicians to have access to information 24 hours a day, 7 days a week from any authorized location. • Better organization of data: Rather than being housed in multiple silo applications, the EHR organizes all of the data relevant to a particular patient. . Copyright 2013 Health Administration Press Some Key Benefits of an EHR • • Bills/claims processing efficiency: Data that are accessible in electronic form can ease the process of gathering and providing documentation for billing/claims purposes. Improved monitoring and performance: Allows for individual provider profiles of performance as well as aggregate profiles of all providers. These data can be used within the organization to target quality improvement initiatives as well as inform cost-cutting initiatives. Copyright 2013 Health Administration Press Some Key Benefits of an EHR Source: Smaltz & Berner, 2007 Copyright 2013 Health Administration Press Some Key Benefits of an EHR Source: Smaltz & Berner, 2007 Copyright 2013 Health Administration Press The EMR Adoption Model (EMRAM): Stages of Adoption Sophistication + _ Source: HIMSS Analytics, 2011 Copyright 2013 Health Administration Press EHR Adoption Stage 1: All Ancillary Systems in Place The ancillary components of an EHR includes automated information systems to support workflow in the laboratory, radiology, and pharmacy departments. Examples of workflows include, but are not limited to: • • • Laboratory: capturing test results from various laboratory test devices and automatically pulling that into an automated stand-alone laboratory information system or an integrated laboratory EHR module that physicians and other caregivers can access to obtain their patients’ test results. Radiology: providing results of radiological exams to the physicians that ordered them Pharmacy: provides an automated means of managing the process of dispensing and delivering drugs to patients Source: HIMSS Analytics, 2011 Copyright 2013 Health Administration Press EHR Adoption Stage 2: Clinical Data Repository (CDR) with a Controlled Medical Vocabulary (CMV) The clinical data repository (CDR) collects data from a variety of information systems and makes the data available to physicians and other caregivers in a unified view of each of their respective patients. Ideally, the data presented to physicians and caregivers is presented in standardized medical vocabulary form such as that found in a controlled medical vocabulary (CMV). A CMV is an EHR tool used to standardize information for purposes of capturing, storing, exchanging, searching, and analyzing data. Sources: HIMSS Analytics, 2011; Health Informatics, 2012 Copyright 2013 Health Administration Press EHR Adoption Stage 2 (cont.): Examples of Uses of a Controlled Medical Vocabulary (CMV) • • • • • • Reducing ambiguity that is inherent in normal human languages (for example, how heart attack, myocardial infarction, and MI may mean the same thing when describing a patient condition but represent different conditions to a computer coding that information) Making the exchange of information consistent between different providers, care settings, and researchers over time Overcoming differences in medical information capture from one place to another Summarizing medical information (in a consistent manner) Allowing symbolic manipulation of data (searches for specific analysis) Providing automated reasoning (clinical decision support) Source: Health Informatics, 2012 Copyright 2013 Health Administration Press EHR Adoption Stage 2 (Cont.): Document Imaging and Health Information Exchange (HIE) Document imaging is the ability to take paper copies of medical records that patients typically bring in with them from other care settings, scanning an image of them, and storing it in the EHR for easy access by physicians and other caregivers. Health information exchange (HIE) is the ability to securely and electronically send and receive data about relevant patients to aid patient assessment and care decisions not only intra-organizationally (i.e., across all inpatient, outpatient, ancillary, and complementary care settings within the organization) but also interorganizationally (i.e., across distinct, legal, organizational entity boundaries) HIMSS Analytics, 2011 Copyright 2013 Health Administration Press EHR Adoption Stage 3: Clinical Decision Support Systems (CDSS) • A clinical decision support system (CDSS) is an information system designed to improve clinician decision making • In the CDSS component of an EHR, characteristics of individual patients are matched to a computerized knowledge base, and software algorithms generate patient specific clinical recommendations, typically presented in the form of an alert message to the physician or caregiver. Examples include: • • • Error checking for drug–drug or drug–food adverse effects, such as allergic reactions Providing evidence-based medicine applicable protocols, such as standardized order sets for patients with specific conditions Provide guidance on individual physicians’ practice variance with respect to evidence-based protocols and outcomes HIMSS Analytics, 2011 Copyright 2013 Health Administration Press EHR Adoption Stage 3 (Cont.): Nursing Documentation & Picture Archiving and Communications Systems (PACS) The nursing documentation component of an EHR has the ability to document vital signs, flow sheets (time-based trending of particularly relevant clinical data to assess a patient’s condition over time), nursing notes, and care plans. It can also keep a comprehensive record of all medications that have been administered to the patient. Picture archiving and communications systems (PACS) are information systems that capture radiological images from many different modalities (xray, CT scan, MRI, etc.). EHRs should have the ability to retrieve and display PACS images to caregivers throughout the organization Source: HIMSS Analytics, 2011 Copyright 2013 Health Administration Press EHR Adoption Stage 4: Computerized Provider Order Entry (CPOE) Computerized provider order entry (CPOE) is the component of an EHR that enables a patient’s care provider to enter an order for a medication, clinical laboratory or radiology test, or procedure directly into the computer. The system then transmits the order to the appropriate department, or individuals so it can be carried out. The most advanced implementations of CPOE also provide real-time clinical decision support, such as dosage and alternative medication suggestions, duplicate therapy warnings, and drug–drug and drug–allergy interaction checking. Source: HIMSS 2012 Copyright 2013 Health Administration Press EHR Adoption Stage 5: Closed-Loop Medication Administration Closed-loop medication administration, sometimes referred to as end-toend medication administration, includes CPOE with CDSS for error checks, bar code, or other automated methods for checks during medication administration, and an electronic medication administration record (e-MAR) linked to the pharmacy and the CPOE. Closed-loop medication administration obviously requires that the component parts (CPOE, CDSS, e-MAR) be in place and integrated into the EHR; thus, the process is clearly a later stage in the EMR Adoption Model (EMRAM) but is vital for achieving much higher levels of patient safety. Source: Smaltz & Berner, 2007 Copyright 2013 Health Administration Press EHR Adoption Stage 6: Physician Documentation Physician documentation, in the context of an EHR, provides a means for a physician to directly enter data that had historically been captured in paper records, into the EHR. Examples of these types of physician documentation include but are not limited to: • Progress notes (notes about the patients progress over time) • Consult notes (notes relating to a caregiver-to-caregiver consultation about the patient) • Discharge summaries (a summary about the patient’s hospitalization provided by their physician) • Problem lists (entries related to a patients various problems) • Diagnosis list (entries related to a patient’s diagnosis) HIMSS Analytics, 2011 Copyright 2013 Health Administration Press EHR Adoption Stage 7: The Complete EHR The characteristics of a complete EHR or a Stage 7 EHR, as it is sometimes called, includes: • Ability to generate, transmit and receive continuity of care documents (CCD) to and from other hospitals or caregivers • Have an enterprise data warehouse (EDW) to analyze and report on data generated within and without the EHR • Incorporates ambulatory EMR and the emergency department within the EHR HIMSS Analytics, 2011 Copyright 2013 Health Administration Press EHR Adoption Model (EMRAM) – Security and Access Security and Access While not specifically called out as a component of an EHR, security and appropriate access to an EHR are fundamental requirements of any health information system that an organization implements. Furthermore, the Health Insurance Portability & Accountability Act (HIPAA) legislation requires that EHRs must be able to rigorously track who has accessed the record over time. Copyright 2013 Health Administration Press EHR Adoption Model (EMRAM) Progress to Date Within the United States Copyright 2013 Health Administration Press The “Meaningful Use” of an EHR The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act (ARRA) of 2009, gives significant incentives both to hospitals and independent physicians that meaningfully use a certified EHR and imposes penalties to providers for not using a certified EHR by 2015. A simple definition of meaningful use of an EHR: use that results in significant measurable improvements in the quality and affordability of care ONCHIT, 2012; Blumenthal and Tavenner 2010 Copyright 2013 Health Administration Press The Meaningful Use of an EHR: Detailed Criteria The “Meaningful Use” of an EHR: Detailed Criteria PLACEHOLDER Homework: Meaningful use criteria continue to evolve. Suggest going to the ONCHIT website to also pull down for inclusion in your slide presentations the latest criteria found at: http://www.healthit.gov/policy-researchers-implementers/meaningful-use Currently, Stage 2 requirements/criteria can be found at: http://www.healthit.gov/policy-researchers-implementers/meaningful-usestage-2 http://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/Certification.html Copyright 2013 Health Administration Press The “Meaningful Use” of an EHR: Incentives for Individual Physicians and Hospitals Physicians Hospitals also have incentives that are based on a Centers for Medicare & Medicaid Services (CMS) formula that ranges from a base incentive of $2M to $10M+ Copyright 2013 Health Administration Press CMS, 2010 Costs of an EHR: The Total Cost of Ownership (TCO) The TCO of an EHR includes: • One-time, upfront costs of purchasing the hardware and software • The annually recurring costs of owning and operating the EHR Best practice is to estimate all foreseeable costs over a 5–10 year period as well as estimating a small but meaningful contingency fund for unforeseen costs Products FY06 Volume Based Software Licenses Chunk 1 (350K Visits) 25% at Signing 20 % at Delivery 5 % on final workflow walkthru 5 % on integrated testing kickoff 25 % on First Live Use (FLU) 10% FLU + 90 Days 10% FLU + 12 months Chunk 2 (up to 500K Visits) Chunk 3 (up to 750K Visits) Chunk 4 (up to 850K Visits) Oncology Module Third Party Database Addl Vendor One Time Products Third Party One Time Products Interfaces (Live) 25% at Signing 25% at Delivery 25 % at FLU 25% at FLU + 90 Medication Interfaces (Phase II) FY07 FY08 FY09 FY10 FY11 Capital Based License fees FY12 FY13 FY14 FY15 Total $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$,$$$ $$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $,$$$,$$$ $$,$$$ $$,$$$ $0 $$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ $0 $$,$$$ $$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ Capital Based Implementation Fees Implementation (Base) Implementation (Oncology) Implementation (Interfaces) Post-Live Activities Project Team Training Estimated Travel Rollout $$$,$$$ $$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $0 $$$,$$$ $$,$$$ $$$,$$$ $$$,$$$ Capital Based Hardware Fees Hardware Environment AIX Servers SAN Test/Training Server Clairty RDBMS Server Crystal Enterprise Server Print Server Patient Portal Server Cirtix Servers Citrix Server Optional Blade Enclosure Cirtix Licenses $$$,$$$ $$$,$$$ Citrix Administrator Citrix Technical Training $$$,$$$ $$$,$$$ $$$,$$$ $$,$$$ $$,$$$ $,$$$ $$,$$$ $$$,$$$ $$$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ $,$$$ $,$$$,$$$ $$$,$$$ $$,$$$ $,$$$ $$,$$$ $$,$$$ $$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$,$$$ $$,$$$ $,$$$ $$,$$$ $$,$$$ $,$$$ $$,$$$ $$$,$$$ $$$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ Training/Implementation for AIX SQL Enterprise Licenses $$$,$$$ $$,$$$ $$$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ $$$,$$$ $$,$$$ $$,$$$ $$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$,$$$ $$,$$$ $$,$$$ $$$,$$$ $$,$$$ $0 Volume Based PP Chunk 1 (350) Yearly Support - Optional Oncology Third Party dB - Required Third Party dB - Optional Third Party Maintenance Fees Vendor Consulting On Hand Patient Portal Software Interface Maintenance Subscription Applications Clinical Applications IS Team Oncology Specific IS Team Other IS Staff Core Trainers End User Trainers - Initial End User Trainers - Addtl. Onsite Support Personnel - Initial Onsite Support Personnel - Addtl. $$,$$$ $,$$$ $$,$$$ $0 $$,$$$ $$,$$$ $,$$$ $$,$$$ $$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ Total Spend $,$$$,$$$ $,$$$,$$$ $,$$$,$$$ Total Required Total Optional $,$$$,$$$ $0 $,$$$,$$$ $0 $,$$$,$$$ $$$,$$$ Total Capital Total Operational $,$$$,$$$ $$$,$$$ $,$$$,$$$ $,$$$,$$$ $,$$$,$$$ $,$$$,$$$ Legend: $,$$$ $$,$$$ $$$,$$$ $,$$$,$$$ $$,$$$,$$$ $$$,$$$ $$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ Operating Based Software Fees (Maintenance and Subscription Fees) $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ $$$,$$$ $$$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ $$,$$$ Operating Based Additional EMR Staffing $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $,$$$,$$$ $,$$$,$$$ $,$$$,$$$ Required and Optional Split of Costs $,$$$,$$$ $,$$$,$$$ $,$$$,$$$ $,$$$,$$$ $,$$$,$$$ $$$,$$$ Capital and Operational Split of Costs $,$$$,$$$ $$$,$$$ $$$,$$$ $,$$$,$$$ $,$$$,$$$ $,$$$,$$$ Thousands Tens of Thousands Hundreds of Thousands Millions Tens of Millions Notes: 1. For confidentiality reasons, real dollar figures could not be used 2. This 10-year total cost of ownership model is from a 5-Hospital, 1000+ bed academic medical center with 700+ physicians 3. The total estimated operational spend over the 10-year period is 75% of the total spend, while the capital spend is only 25% of the total spend Copyright 2013 Health Administration Press $$$,$$$ $$$,$$$ $$$,$$$ $$,$$$ $$$,$$$ $$,$$$ $$$,$$$ $$,$$$ $$,$$$ $$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$,$$$ $$$,$$$ $$,$$$ $$$,$$$ $$,$$$ $$,$$$ $$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$,$$$ $$$,$$$ $$,$$$ $$$,$$$ $$,$$$ $$,$$$ $$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$,$$$ $$$,$$$ $$,$$$ $$$,$$$ $$,$$$ $$,$$$ $$,$$$ $,$$$,$$$ $,$$$,$$$ $,$$$,$$$ $$$,$$$ $,$$$,$$$ $$$,$$$ $,$$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $0 $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $$$,$$$ $,$$$,$$$ $,$$$,$$$ $,$$$,$$$ $,$$$,$$$ $$$,$$$ $,$$$,$$$ $,$$$,$$$ $,$$$,$$$ $,$$$,$$$ $,$$$,$$$ $,$$$,$$$ $,$$$,$$$ $$,$$$,$$$ $,$$$,$$$ $$$,$$$ $,$$$,$$$ $$$,$$$ $,$$$,$$$ $$$,$$$ $,$$$,$$$ $$$,$$$ $$,$$$,$$$ $,$$$,$$$ $,$$$,$$$ $,$$$,$$$ $$$,$$$ $,$$$,$$$ $$$,$$$ $,$$$,$$$ $$$,$$$ $,$$$,$$$ $$,$$$,$$$ $$,$$$,$$$ Chapter 3: Government Policy and Healthcare Reform Learning Objectives 1. Describe a justification for government intervention in business processes. 2. List five major types of government intervention into the healthcare business, and explain the need for government to invest in healthcare information management and HIT. 3. Describe the eight components of the administrative simplification portion of the Health Insurance Portability and Accountability Act. 4. Assess your organization’s readiness for transactions and code set development. 5. Analyze why privacy and security are important and why HIT has a key role in protecting privacy and security. 6. Assess four key questions to answer in developing privacy policies. 7. Describe HIT leadership’s role in responding to legislation. Copyright 2013 Health Administration Press Government Policy and Reform Items to develop: • Government’s role in HIT • Justification of governmental intervention in business processes • Specific healthcare legislation • Health Insurance Portability and Accountability Act (HIPAA) • Health Information Technology for Economic and Clinical Health Act (HITECH) • Patient Protection and Affordable Care Act (PPACA) • HIT leadership Copyright 2013 Health Administration Press Government Intervention • Government intervenes if markets fail to allocate resources effectively. • Common reasons for intervention: • • • • Public goods Correct externalities Imperfect information Monopoly Copyright 2013 Health Administration Press Types of Government Market Intervention Purpose Government Initiative Provide public goods Funding of medical research Correct for externalities Tax on alcohol and cigarettes Impose regulations Federal Drug Administration Enforce antitrust laws Limit hospital mergers Sponsor redistribution programs Medicare and Medicaid Operate public enterprises Veterans Administration hospitals Copyright 2013 Health Administration Press Healthcare Is Different • Broad obligation to protect health and welfare of public • Challenges of (high) cost, (poor) quality, and (limited) access justify intervention Copyright 2013 Health Administration Press Government Policy: Benefits HIT may benefit from government involvement: • No compelling business case exists for investment in HIT. • The potential savings from implementing HIT do not accrue to providers making the investments but rather benefit insurers and others (public good). • For system benefits from HIT investment to be realized fully: • All components of the fragmented US healthcare delivery system must participate. • Interoperability among providers is a necessary step for true sharing to occur. • Government needs to impose common communication standards. Copyright 2013 Health Administration Press Select Legislation: HIPAA Portability and Simplification Sections • Portability was designed to enable individuals to retain insurance when they changed jobs. • Administrative simplification did not have a high profile but became a big deal for HIT. • Established national standards for electronic healthcare transactions and national identifiers for providers, health plans, and employers • Addressed the security and privacy of health data • Goal of improving efficiency and effectiveness of healthcare system via electronic data interchange Copyright 2013 Health Administration Press HIPAA: Simplification Provisions • • • • • Standards for electronic health information transactions Provider and health plan mandate Privacy Preemption of state law Penalties Copyright 2013 Health Administration Press Standards for Electronic Health Information Transactions Within 18 months of enactment, the Secretary of HHS is required to adopt standards from among those already approved by private standards-developing organizations for certain electronic health transactions, including claims, enrollment, eligibility, payment, and coordination of benefits. These standards also must address the security of electronic health information systems. Copyright 2013 Health Administration Press Provider and Health Plan Mandate and Timetable Providers and health plans are required to use the standards for the specified electronic transactions 24 months after they are adopted. Plans and providers may comply directly or may use a healthcare clearinghouse. Certain health plans, in particular workers’ compensation, are not covered. Copyright 2013 Health Administration Press Privacy Provision The Secretary is required to recommend privacy standards for health information to Congress 12 months after enactment. If Congress does not enact privacy legislation within three years of enactment, the Secretary will promulgate privacy regulations for individually identifiable electronic health information. Copyright 2013 Health Administration Press Preemption of State Law The bill supersedes state laws, except where the Secretary determines that the state law is necessary to prevent fraud and abuse, is necessary to ensure appropriate state regulation of insurance or health plans, addresses controlled substances, or is necessary for other purposes. If the Secretary promulgates privacy regulations, those regulations do not preempt state laws that impose more stringent requirements. These provisions do not limit a state’s ability to require health plan reporting or audits. Copyright 2013 Health Administration Press Penalties The bill imposes civil money penalties and prison for certain violations. Copyright 2013 Health Administration Press Government Policy: Privacy • Privacy Act of 1974 established key provisions. • Current concept of privacy: • • • • • Control of information concerning personal life Freedom from intrusion upon “seclusion” Limits on publicity that places one in a false light Prevention of identity theft and likeness Right to keep personal information confidential Copyright 2013 Health Administration Press Specific Legislation: HITECH Act • Part of American Recovery and Reinvestment Act (ARRA) • Passed February 2009 • Designed to promote electronic health record adoption—social benefits: • Complete and accurate information • Better access to information • Patient empowerment Copyright 2013 Health Administration Press HITECH Act: Meaningful Use • Meaningful use offers incentives for adoption and implementation of electronic health records • Total incentives for eligible providers: • $44,000 if start in 2011 or 2012 • $39,000 if start in 2013 • $24,000 if start in 2014 Copyright 2013 Health Administration Press HITECH Act: Meaningful Use (cont’d) • Meaningful use comes in stages: • Stage I: Install certified information systems, capture structured patient data, and share data with patients/other providers • Stage II: Greater data collection and reporting to advance clinical processes • Stage III: Demonstrate improved outcomes Copyright 2013 Health Administration Press HITECH Act: Core Measures To qualify, providers must report 15 core measures: 1. Implement computerized physician order entry 2. Perform drug–drug and drug–allergy checks 3. Maintain an up-to-date problem list of current and active diagnoses 4. Use e-prescribing (eRx) 5. Maintain active medication list 6. Maintain active medication allergy list 7. Record demographics 8. Record and chart changes in vital signs 9. Record smoking status for patients aged 13 or older 10.Report ambulatory clinical quality measures to CMS/states 11.Implement clinical decision support 12.Provide patients with an electronic copy of their health information, upon request 13.Provide clinical summaries for patients for each office visit 14.Establish capability to exchange key clinical information 15.Protect electronic health information Copyright 2013 Health Administration Press HITECH Act: Menu Objectives To qualify, providers must report five of ten menu objectives: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Submit electronic data to immunization registries Submit electronic syndromic surveillance data to public health agencies Perform drug formulary checks Incorporate clinical lab test results Generate lists of patients by specific conditions Send reminders to patients for preventive/follow-up care Provide patient-specific education resources Provide electronic access to health information for patients Perform medication reconciliation Maintain summary-of-care record for transitions of care Copyright 2013 Health Administration Press HITECH Act: Quality Measures To qualify, providers must report six quality measures: 1. Diabetes: Hemoglobin A1c poor control 2. Diabetes: Low-density lipoprotein (LDL) management and control 3. Diabetes: Blood pressure management 4. Heart failure (HF): Angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy for left ventricular systolic dysfunction (LVSD) 5. Coronary artery disease (CAD): Beta-blocker therapy for CAD patients with prior myocardial infarction (MI) 6. Pneumonia vaccination status for older adults 7. Breast cancer screening 8. Colorectal cancer screening For full list, see Exhibit 3.9. Copyright 2013 Health Administration Press Special Legislation: Patient Protection and Affordable Care Act • PPACA signed March 23, 2010, as HR 3590 and accompanying HR 4872 • Many features with immediate and far-reaching implications. • Key features: • Expand health insurance coverage to 30 million Americans • Change incentives to effect delivery system reform (enhance quality, reduce costs, improve care coordination) • Reduce rate of increase in Medicare and Medicaid spending • Expand healthcare workforce and graduate medical education • Fund wellness and prevention • Address quality, health disparities, and comparative effectiveness • Reduce fraud and abuse with regulatory oversight • Expand revenue through taxes on high-cost health plans and selected fees Copyright 2013 Health Administration Press Patient Protection and Affordable Care Act: Implications for HIT • Special stress for HIT: • Accountable care organizations: Assign financial responsibility for care to an ACO even if care delivered by other organizations. IT must find patient, exchange information with other organizations/providers, and maintain privacy and confidentiality of information. • Pay-for-performance initiatives demand linkage between provider cost and clinical performance both within and across organizations. These data are not uniformly collected and reported in a timely manner. • Expansion of covered lives creates IT challenges because of both greater numbers of individuals and a new population unfamiliar with the systems and documentation needed to process care. • Timing and uncertainty of PPACA implementation. Copyright 2013 Health Administration Press Government Policy and Reform • Environmental scanning and organizational education • Information security policies and procedures • Disaster protection and recovery procedures • Protecting information privacy and confidentiality Copyright 2013 Health Administration Press Environmental Scanning and Organizational Education • Determine breadth and scope of impending or actual legislation • Assess current organizational readiness for impact • Perform gap analysis within organization • Recommend strategies to meet legal/regulatory changes • Identify clinical and other resources within the organization that will be necessary to meeting standards • Outline timeline for implementation with key dates and milestones Copyright 2013 Health Administration Press Information Security Policies and Procedures Healthcare organizations must establish enterprise-wide standards to maintain data security and protect the privacy and confidentiality of health information (patient records). 1. Protect against system failures or external catastrophic events, such as fires, storms, and other acts of God, as well as deliberate sabotage, and where critical information could be lost, and 2. Prevent access to computer files by unauthorized personnel. Copyright 2013 Health Administration Press Disaster Protection and Recovery Procedures • Steering committee must ensure that effective data backup and recovery procedures are implemented. • CIO develops a data backup plan for approval by the steering committee. The plan should specify which files require duplication, frequency of duplication, and recovery procedures to be used if catastrophic events occur. • Disasters include: • Natural • Terror attacks • Computer viruses Copyright 2013 Health Administration Press Protecting Information Privacy and Confidentiality • Physical security • Hardware • Data files • Technical safeguards • Passwords • Encryption • Audit logs • Management policies • Written security policy • Employee training • Disciplinary actions for violations Copyright 2013 Health Administration Press Elements of Confidentiality Policy • Assign rights (who has access and why) • Release of information • Special handling for select information (HIV) • Special handling for select patients (VIPs) • Availability and retention policy for medical information • Integrity of medical information • Methods for communication of medical information Copyright 2013 Health Administration Press Web Resources • American National Standards Institute (www.ansi.org) • Center for Democracy & Technology, Health Privacy (www.healthprivacy.org) • Data Interchange Standards Association (www.disa.org) • IRM International (www.irminternational.com/rptcard.html), a checklist for disaster recovery • National Committee on Vital and Health Statistics (http://ncvhs.hhs.gov/index.htm) • National Uniform Claim Committee (www.nucc.org) • US Department of Health and Human Services: • Office of Civil Rights (www.hhs.gov/ocr/office/news/index.html) offers news releases announcing all of the major settlements of privacy and security breaches. • HealthCare.gov (www.healthcare.gov) provides information on evolving health insurance options available. • Centers for Medicare & Medicaid Services (www.cms.gov) points to detailed information about CMS’s core programs and to research and data of value to HIT professionals. General HIPAA information can be found here: www.cms.gov/Regulations-and-Guidance /HIPAA-AdministrativeSimplification/HIPAAGenInfo/index.html. Details of the EHR incentive programs are posted at www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html. • Workgroup for Electronic Data Interchange (www.wedi.org) Copyright 2013 Health Administration Press Chapter 6: HIT Architecture and Infrastructure Learning Objectives • • • • • Define and use in context technical terms related to information technology architecture. Distinguish between the hardware and software elements of an information system and provide illustrative examples. Identify the elements of a computer network and give examples of various network structures. Distinguish among operating systems, utility programs, and application software. Introduce basic telecommunication concepts. To be effective, managers must: • Not be intimidated by technical computer concepts or technology jargon. • Have broad-based knowledge • hardware and software elements • design and configuration principles. • Approach IT/IM like any other investment decision. • Ensure the size and power of the computer are appropriate for a given application. Physical Components and Devices • When configured into an information system are known collectively as hardware Computer Hardware • Spans a broad spectrum: small palmtop computers (PDAs) to the personal computer (PC) to extremely large and powerful supercomputers. Computer Hardware • Technology changes at a rapid pace • Keeping up with cutting-edge technology is not feasible for general managers. Computer • An electronic, digital device (hardware) that stores a set of instructions (program or software) and the data on which the instructions will operate First-Generation Technology • The Electronic Numerical Integrator and Calculator (ENIAC) • First computer in the US, completed in 1946 at the University of Pennsylvania • Launched the first generation of computer hardware—devices that used vacuum tubes Fourth-Generation Technology • Current technology has evolved to the fourth generation, which employs microprocessor technology • Fifth generation, parallel processing and artificial intelligence, is in development Thanks to the microprocessor… • A user can now hold in one hand a device that has more computing power than first-generation computers that required a large controlledenvironment room. Managers need to know: • A general description of application software • The distinction between integrated and interfaced systems • The role of system management software • Some general knowledge about programming languages and language translators Computing System Components • Central processing unit • Primary storage • Secondary storage • Input devices • Output devices • Communications devices Computer Components Communication Devices • Connect the computer to enable communication with other computers, either within the organization or external to the organization • Give rise to the concepts of networking and telecommunications Central Processing Unit (CPU) • Where the actual “computing” takes place • Consists of three major subcomponents • the arithmetic/logic unit (ALU) • the control unit • registers • Speed and power of the CPU greatly influence the computer’s capabilities The Arithmetic/Logic Unit (ALU) • Source of basic computational and comparison capability • Can perform arithmetic functions at high speeds. • Can perform the logical operation of comparison of both numeric and character (non-numeric) data The Arithmetic/Logic Unit (ALU) • Speed is an important performance characteristic, particularly in applications that involve a large number of arithmetic operations. • Examples include: • image processing • interpretation of EKG data • statistical analysis of very large data sets Control Unit • Regardless of programming language, the problem description ultimately is converted to a series of machine instructions stored in primary storage. • The control unit orchestrates sequential processing of machine instructions by coordinating retrieval of the data, retrieval and application of processing instructions, and storage of the results. Registers • When program instructions or data are transferred from primary storage to the CPU for processing, they are held in a high-speed memory area within the CPU known as registers. • Computer performance is enhanced by increasing the number of operations performed within the CPU’s registers and minimizing the number of accesses to data stored in memory. Primary Storage • Primary storage refers to internal memory, where data are stored for access by the CPU. • Capacity and speed of the primary storage greatly affect the computer system’s performance. • Read-only memory (ROM) stores sets of instructions for special tasks, such as the computer startup process. • Data can not be written to this storage area by the user, but the existing readable data is retained even when the machine is turned off. Primary Storage • Random access memory (RAM), the largest volume of primary data, stores data and processing instructions in specified locations that can be accessed in any order. • RAM contents are lost when the computer is powered off. • Cache memory stores data to be quickly accessible for high-speed processing. • Most cache storage is cleared when the computer is powered off. Secondary Storage • It is not possible to have sufficient primary storage to accommodate all information maintained and utilized. • Secondary storage devices include a variety of devices and media designed to maintain small or large quantities of data. • Personal and business users alike need large capacity, nonvolatile storage media. Secondary Storage • Speed of data entry and retrieval from secondary storage devices is an important system specification. • Ensuring the security of secondary storage devices and media is of paramount importance. Input Devices • Choice of device determined by application design, user preferences, accuracy and speed requirements, security. • Consider both efficiency and accuracy criteria. • Speed should not be gained at the expense of data quality and patient safety. Input Devices • Many current information systems are designed to facilitate data capture at the point of care, such as the patient’s bedside or in other diagnostic or treatment areas. Input Devices • Often data are captured concurrently with patient examination and treatment, through voice recorders or digitally-enhanced diagnostic devices. • Data also may be entered using computer workstations in or near the patient’s room, or by using a portable or hand-held device. Output Devices • The actual work performed by the computer system is of little value until it is produced (output) in a usable format accessible to the user, such as in print, digitally for future processing, or in audio or spoken form. • The goal of the industry is to make data entry and retrieval as simple as possible. Output • Visual displays • Printed documents • Audio (including voice) Video Display Terminal (VDT) • Oldest and most widely used form of displaying output • Typically called a monitor • Has evolved from small monochrome screens into large, high-resolution liquid crystal displays (LCD). • Can display images at resolutions high enough to support clinical diagnosis and treatment Printers • Early impact devices were similar to typewriters. • Color laser printers are capable of reproducing artwork and detailed diagnostic images. • Key printer characteristics to consider in purchase decisions include memory, resolution, and print speed. Audio Output • Current technology provides digitization of sound with good quality. • Digital text can be converted to understandable speech by voice synthesis. Computer Software • A detailed set of computer instructions is known as a program, and programs are collectively referred to as software. Computer Software • Applications, either general purpose or function specific • Operating systems • Utilities • Programming languages • Software development tools • Language translators Software Selection Factors • Number of existing and potential users • Required hardware configurations • Security considerations • Anticipated future growth in computer applications • Functional requirements for individual applications Computer Software Licenses • All software must be appropriately licensed. • Policies should be in place emphasizing the organization’s strong stance on exclusive use of legally licensed software. Computer Software Evolution • Software versions evolve rapidly. • Users may request upgrades even when the current version meets their needs. • Vendors may cease to support a given version, thereby forcing the user to upgrade. • Knowledgeable participation by the manager is valuable in making upgrade decisions. Computer Software Interfaces • Interfaces are required to link disparate software packages. • Interfaces can be costly, complex, and timeconsuming to develop. Application Software • Accomplishes the useful tasks that justify the purchase of the information system. • General purpose or application specific Application Software • Application software can be further classified as general purpose or application specific. • Many computer programs provide an environment in which a user can solve a particular class of problems rather than a single, narrowly defined problem. General Purpose Applications • Text processors • Desktop-publishing software • Spreadsheet software • Statistical packages • Database-management software • Presentation graphics software • Web browsers • Often purchased as a “suite” of integrated menudriven module programs Application-Specific Software • A computer program designed to solve a single, somewhat specifically defined problem • A good example is a payroll program developed to: • • • • • accumulate labor hours compute deductions write payroll checks post summaries to the general ledger complete forms required by federal and state governments. Application-Specific Software • Numerous vendors offer an array of applicationspecific software aimed at the healthcare industry. • Healthcare Informatics, a print and online technology journal, publishes a resource guide of information technology companies, products, services, and associations. • The online database (available at healthcareinformatics.com) may be searched by product category or by vendor. Application-Specific Software • In-house developed software can be tailored specifically to the organization’s needs; changes generally are easier to make. • Purchased (or leased) software is generally less expensive, requires less time to get running, and requires fewer in-house computer personnel. Changes must be negotiated with the vendor. • Modifying an existing package attempts to integrate the advantages of both alternatives. Application Service Providers • The high cost of specialized software has led some organizations to contract with application service providers (ASPs) that provide needed computing services via a network connection. Application Service Providers • ASPs may provide a single application or a full range of computing services. • Often an attractive option for small physician practices. • Key issues to include in contract negotiations are data ownership and return of data should the relationship be terminated. Purchasing Software • Involving key users in software purchase decisions is very important, especially when major systems are being acquired. • Other factors include required staffing and equipment resources, cost of maintenance, complexity of operations being automated, number of potential users, and data security issues. Integrated Information System • All modules required to satisfy the organization’s computing needs are purchased from a single vendor. • Modules are designed to work with one another so that data transfer among modules proceeds smoothly. Interfaced System • Each of the required modules may be purchased from separate vendors, usually those thought to be the leader in a particular application area. • Connecting a module to other modules may be problematic, as data formats may be incompatible. • The solution often an interface, which acts as a bridge between the two modules, and translates the data format into one that the receiving module can handle. Interfaced System • The use of an interfaced approach is made somewhat simpler if the modules comprising the interfaced system have all been developed in accordance with a standard that makes their data formats compatible. Integrated v. Interfaced • An integrated system ensures compatibility among the modules, and requires a single source for system support and maintenance. • Interfaced systems allow users to choose the leading system for a given module, can sometimes result in lower costs by leveraging one vendor against another, and obviate the need to replace all existing modules when updates are considered. System Management Software • The group of programs that manage the resources of a computer system and perform a variety of routine processing tasks • Utility programs Operating Systems • Operating systems serve as the interface between the human user and the computer. • Incorporate a graphical user interface (GUI) that uses icons (graphical symbols on the monitor screen) to represent available operating system commands. • User clicks on a given icon with the computer’s mouse or other pointing device to invoke the desired command. Multitasking • The computing power of a given computer can be more effectively utilized when multiple tasks can be run by either a single user or by multiple users. • In such an environment the operating system plays a more essential role. Multitasking • Operating systems must manage system resources, such as memory, CPU time, and file operations efficiently. • Multiple users must be able to perform a variety of tasks with no perceptible slowing of processing time. Utility Programs • Perform generalized data processing or computational functions not specific to any particular computer application • Examples include virus scan programs and encryption programs. Programming Languages • All software—application, system, or utility— consists of a detailed set of instructions describing the specific steps the computer is to perform. • This detailed set of instructions must be communicated to the computer in a specific programming language. Programming Languages • When a spreadsheet user enters a formula in a particular cell on the spreadsheet, that user is actually writing a program statement. Programming Languages • When computers were first developed, instructions were specified in machine language, strings of zeros and ones, which is the only language that a computer is capable of understanding. • The progression of programming languages can be tracked through successive “generations,” with each generation improving the computer–human interface. Programming Language • The evolutionary goal—not yet perfected—is to achieve natural language input, whereby the user is able to give commands to a computer as easily as communication with another person. • A translator program would convert natural language statements into the binary number commands intelligible to the computer. Rationale for Computer Networks • As department managers purchased minicomputerbased systems and other managers became increasingly dependent on personal computing, they soon realized a high level of interdependence existed among these programs. • The term typically applied to the capability of elements of an information system or network to communicate and exchange information is interoperability. Rationale for Computer Networks • This situation is particularly problematic in a healthcare system because data on a given patient might be found in a number of locations, and a single laboratory might serve widely separated patient-care locations. • Data must flow across a large area, and managers often require input from many sources to arrive at a solution to a problem. Rationale for Computer Networks • Linkages needed to facilitate data exchange and resource sharing are accomplished through the construction of a network. • When all components of the network are located within relatively close proximity to one another, perhaps within a single facility, the network is generally referred to as a local area network (LAN). • A network that extends into a broad geographical area is referred to as a wide area network (WAN). Network Configurations • Four configurations are in common use, ranging from a centralized computing environment (where the processing functions are concentrated in a single device) to a decentralized environment (where these functions are split or distributed among all of the users on the network). • Decentralized networks typically create greater managerial challenges, a fact that is particularly relevant for the healthcare manager. Terminal–Host Systems • In the most centralized computing environment, dating back to the 1960s, users work at devices known as terminals. • Early terminals had no processing capability and were often known as dumb terminals. • Today a PC is often used to mimic or emulate a terminal. Terminal–Host Systems • The terminal is connected to a large central host computer, typically a mainframe. • The important feature of this computing environment is that all computing takes place on the host system. Terminal–Host Functions • Depending on the level of sophistication of the program running on the host machine, the terminals allow users to perform a variety of functions, including: • entering a set of data for a program to be run at some later time in batch mode—that is, as part of a sequential stream of programs from several users; • real-time processing of a program immediately after entering data and/or programming commands; and • responding to a query such as a patient account balance. Remote Job Entry (RJE) • Terminals are located at considerable distance from the host machine. • Several major companies have specialized in providing computing services to healthcare organizations on an RJE basis. Client/Server Computing • Users of dumb terminals connected to a host computer easily recognized the advantage that would result from their terminals having computing capability. • Data could be edited, preliminary computations could be made, and other processing could be done that did not require the power of the host machine. Client/Server Computing • Client/server architecture divides applications into two components: • (1) client, or front-end functions, which include user interface, decision support, and data processing; and • (2) server, or back-end functions, such as database management, printing, communication, and applications program execution. • The server can be a personal, minicomputer, or mainframe computer, and multiple servers can often be found in a client/server network. Client/Server Computing • When all back-end functions are performed on a single server, the configuration is known as two-tier client/server architecture. • In a three-tier architecture, the user interface resides on the client, the relational databases reside on one server, and the application programs reside on a second server. • A three-tier configuration is easier to manage and offers faster information processing and distribution. Client/Server Computing Terms • Thin client—most processing is performed on the remote server. • This offers a cost savings on the client computers as they need only minimal processing capability. • Middleware connects applications in distributed networked systems. • Client and server vendors will typically offer middleware packages as options. File/Server Architecture • Less centralized than client/server installations • A relatively large number of network processors share the data contained in files on the server. • The actual processing of data is distributed across the network machines. Peer Networks • A decentralized computing environment where each computer on the network has either data or some hardware resource that it can make available to the other users on the network • There is no server; all computers on the network can be used as workstations. Peer Networks • Easy to install and configure • Relatively low cost compared to client/server networks • Suitable only for small installations as large peer networks may be nonsecure and unreliable Peer Network Configuration Access to Remote Data Storage Access to Document Scanner and External Drive A D C B Access to Printer Cloud Computing • Internet-connected computers emulate a supercomputer. • Wireless network of computers accessed remotely • Computing power or storage space purchased on “asneeded” basis. Network Components Transmission Media • Carry the signal being transmitted from one location to another • metal wires, which carry electrical signals • fiber-optic cables, which carry optical signals • air, through which radio waves travel. Wired Media • One or more strands of metal, frequently copper, which is an excellent conductor of electricity. • Data are transmitted along these conductors in the form of changing electrical voltages and may be represented as either a digital or analog waveform. • Digital transmission involves the representation of data with binary digits or bits. • Analog transmission represents data by varying the amplitude (height), frequency, and/or phase of a waveform. • Traditional telephone lines carry signals in an analog format, while integrated services digital network (ISDN) lines, digital subscriber lines (DSL), and the cable in a LAN carry signals digitally. Fiber-Optic Media • Data are carried in a fiber-optic medium in the form of light pulses. • The electrical data signal is used to turn a light source on and off very rapidly. • At the receiving end of the cable, an optical detector converts the light signal back to an electrical signal. • Fiber-optic cable is thinner and more durable than copper wiring, provides higher bandwidth, and is not subject to electronic eavesdropping. Radio Media • Use radio waves of different frequencies to transmit data through the air • Broadcast radio is used to support paging devices and cellular technology. • Microwave radio is capable of higher data rates than broadcast radio and is used in WANs and wireless LANs. • All communication using radio waves is subject to electronic eavesdropping, thus resulting in special security issues that must be addressed. Process of Communication • A transmitter sending information or data through a transmission medium to a receiver. • At any given time, one network component acts as a transmitter while a second component has the role of a receiver. Like personal conversations, the roles of these components can change frequently. • The devices used to connect transmitters and receivers to the transmission media depend on the media type and data format. Network Interface Card (NIC) • Serves as an adapter to allow a microcomputer to connect to a high-speed LAN • Specific card determined by the architecture of the microcomputer and the protocol of the LAN. • Requires appropriate software, known as the device driver, which allows the computer to “talk” to the NIC. • A unique 48-bit number (called a media-access control) identifies the computer to the network. Modems • A modem (MOdulator DEModulator) is a device capable of changing signals from one format to another and then back again. • Two types are available: copper-based and fiber optic. Copper-Based Modem • Converts a device’s digital signals to analog signals appropriate for copper media. • It can take the form of a card located inside the computer (internal modem) or a separate component connected to, but located outside, the computer (external modem). Fiber-Optic Modems • Convert a device’s digital signals to optical digital signals, which can then be carried over a fiber-optic network. Multiplexers • Several devices (computer, printer, and scanner) can be connected to a multiplexer. • The output of the multiplexer serves as the input to the transmission medium. • A multiplexer at the receiving end of the transmission medium separates the signals. • The devices appear to have their own transmission channel, when in fact they are sharing the transmission medium. Multiplexer Bridges, Gateways, and Routers Bridges • Interfaces that connect two or more networks that use similar protocols (rules or conventions governing the communication process). Gateway • Interface between two networks that use dissimilar protocols to communicate • Allows users to access data and programs outside their own region • Gateways play an important role in the interconnection of the many disparate networks that comprise the Internet. Router • Device located at any gateway (network entrance) to manage the data flow between the networks. • The router decides, on the basis of its current understanding of the activity state of the networks, which way to send each packet of information flowing on the network for greatest efficiency. Network Controller/Servers • A network controller is used in terminal–host networks consisting of a number of terminals connected to one or more mainframe host computers. • The function of this controller, which can be a minicomputer or microcomputer, is to direct the communications traffic between the host and the terminals and peripheral devices. Network Controller/Servers • LANs do not have a network controller. • Communication traffic is directed by a defined protocol that depends on the network topology. • The network may have one or more servers that provide network users with a variety of services, including access to files (file servers), help with passing files over the transmission medium (database servers), and a connection to network printers (printer servers). Network Controller/Servers • Associated with mainframe-based telecommunications networks. • The software resides on the host (mainframe), on a small computer (front-end processor) connected to the host and dedicated to communications management, and on other processors in the network. • Functions include controlling access to resources, regulating data transmission to and from terminals, improving network efficiency, and detecting and correcting errors. Network Controller/Servers • LANs and WANs employ network operating systems to coordinate and support the operation of the network, such as: • user access • data traffic • security Network Controller/Servers • Some network operating systems serve as supplements to the computer’s existing operating system. • Others, like Windows XP, constitute comprehensive computer operating systems where the networking capabilities have been integrated into the operating system. Software • The IS manager, when choosing network software, must consider several factors, such as: • the number of existing or potential users, • the type of network hardware available, • the type of application software programs needed, available resources (human and equipment), and network configuration costs. Network Topologies • The configuration used to connect the computers and peripheral devices in a LAN is known as the network’s physical topology. Network Topologies • Available network options: • bus • ring • star topologies • These topologies can be used singly or in combination with one another to form a hybrid network. Bus Networks • A single circuit, or bus, is used to link the computers and other devices comprising the network. • The medium employed for this single circuit can be twisted wire, coaxial cable, or fiber-optic cable. • A hardware device known as a terminator is used at either end of the bus. Bus Networks • Relatively easy to wire the network; relatively fast communication rate. • Limited length of the bus because of signal attenuation; a break in the bus disconnects all devices beyond the break. Bus Network Topology • Protocol controlling how devices send and receive messages is known as carrier sense multiple access with collision detection (CSMA/CD), trade name = Ethernet. • When a large number of users attempt to use an Ethernet network, a bottleneck can occur. • Fast Ethernet uses a higher-quality line and operates at ten times the speed of traditional Ethernet. • Switched Ethernet dedicates bandwidth space to segments of users. Bus Network Topology Ring Networks • Conceptualized as a group of devices (nodes) arranged in a circle with a connection between adjacent devices to form a closed loop. • Data travel in a single direction around the ring, and each device on the network retransmits the signal it receives from the previous device to the next device in the ring. Ring Networks • Facilitate high-speed networks over large distances through a fiber-optic transmission medium connecting adjacent nodes; uses an amplification device (repeater) at each node. • Difficult to troubleshoot or add new nodes. Ring Network Topology • Token-ring protocol passes an electronic token along the loop from node to node until it reaches its destination. • Only one node can access the network at a time, so the collisions possible with the CSMA/CD protocol (Ethernet) cannot occur. • A fiber distributed data interface (FDDI) uses a backup token ring that becomes operational in the event the primary ring fails. Ring Network Topology Star Networks • Each node has a single point-to-point connection to a center node, called a hub or concentrator. • When a given node wants to send a message to a second node, the message must first travel through the central hub. Star Networks • A passive hub simply serves as a connector for the wires coming from the various nodes. • An active hub serves not only as a connector but also regenerates message signals before sending them on to the other nodes. • Intelligent hubs are able to determine the destination address for a particular message and to route the message to that address only. Star Networks • Easy to wire, repair, and add new nodes. • A malfunctioning hub can bring the entire network down; use backup hubs to address this difficulty. • Can require more cabling than networks using other topologies. Star Network Topology Hybrid Networks • Two or more of network topologies can be combined into hybrid network, such as: • A WAN formed by linking several LANs having different topologies • The Internet, which consists of an interconnection of a variety of network types Logical Topologies • Closely related to physical topologies • Lay out the “rules of the road” for data transmission • Common options: • • • • Ethernet, including fast and switched Ethernet Token ring FDDI Asynchronous transfer mode (ATM) Asynchronous Transfer Mode (ATM) • Segments data to be transmitted into small packets called cells, directs the cells through switches to the appropriate destination node, and then reassembles the data • Allows voice, data, and video to be mixed over the network • Can run at speeds up to 1.5 billion bits per second Electronic Data Interchange (EDI) • Transferring structured information from one computer to another without human intervention • Needs to incorporate standards and procedures so the receiving computer will be able to interpret the output of the sending computer • The structure of the information differentiates EDI from electronic communication such as e-mail in which unstructured text is transferred in the form of messages. Electronic Data Interchange • Early healthcare applications of EDI included electronic processing of health insurance claims, which remains an important role for EDI today. • Geometrically increased numbers of claims can be processed daily; turn-around time is improved dramatically over paper-based claims. Mobile Computing • Mobile computing refers to the use of a portable computing device: • laptop • notebook • palmtop computer • Mobile computing and wireless communication make data retrieval and data entry at the point of care possible. Mobile Computing • Nurses and other caregivers providing healthcare services in patients’ homes can download the records of their patients for a given day from a central database into their laptop computer’s hard disk, enter new data and notes into their laptop computer over the course of the day, and then upload the newly acquired information back to the central system at the end of the day. Mobile Computing • Although this procedure is workable, it recreates the very difficulty that led hospitals to adopt networking technology. • Because the laptops function as stand-alone computers, the information in the central database is not current until data collected by the portable devices are uploaded back to the central system. • If a second provider, say a physical therapist, calls on the patient later in the day, the nurse’s notes, collected earlier but not yet uploaded, will not be available to the therapist. Wireless Communication • The combination of mobile computing and wireless communication enables portable computers to be connected to an established information systems network. • Computing activities performed on the portable devices occur in real time, and the central database, as well as the mobile device, always stays current. Wireless Communication • Despite the obvious benefits of data accessibility, mobile devices are not without drawbacks. • Portability, the feature that is a prime benefit, makes the devices physically insecure. • Devices may be lost or stolen, creating problems of data security. • Due to their size, devices may be easily damaged or need frequent replacement. • Special attention must be paid to removing or destroying data on devices that are taken out of service or reissued to new users. Wireless Topologies • Expansion of radio frequency and microwave technologies has enabled broadband wireless options with various ranges, many of which are well-suited to use in health facilities. • Ultimately, it is expected that availability of low-cost, open-standard wireless technology will lead to cable replacement. • With wireless communication networks, even patients and visitors can use their personal communication devices while inside the facility. Wireless Topologies • The advent of wireless networks has expanded the traditional classification of networks as LANs or WANs into five classes: 1) Wireless global area networks (WGANs) 2) Wireless regional area networks (WRANs) 3) Wireless metropolitan area networks (WMANs) 4) Wireless local area networks (WLANs) 5) Wireless personal area networks (WPANs). • The network range may be as extensive as nationwide or limited to a single room. Spread Spectrum • Spread spectrum is a type of radio frequency technology widely used in healthcare today for wireless communication between devices on a LAN. • Benefits of this transmission approach include improved privacy and decreased signal interference. Spread Spectrum • Four basic techniques: • • • • Frequency-hopping spread spectrum (FHSS) Direct sequence spread spectrum (DSSS) Time-hopping spread spectrum (THSS) Chirp spread spectrum (CSS) • Only FHSS and DSSS are widely used. Spread Spectrum • Decisions to use this technology in wireless LAN installations should be informed by range of the transmitted signal (to determine network access points), signal frequency (to avoid interference with other systems), and aggregate throughput (data transfer rate). Infrared Technology • Infrared radiation is a wavelength between visible light and radio waves. • Because infrared technology is “line-of-sight” and cannot pass through walls, it can only be used in a single room. • Commonly used in wireless keyboards and mouse devices, remote control units, and cordless modems. Cellular Digital Packet Data • Cellular digital packet data (CDPD) is a WAN architecture used in cellular networks, like those of cellular telephones, except the CDPD transmits and receives packets of data rather than continuous voice signals. • CDPD allows remote users to connect to a network without a phone jack. The Internet • Largest interconnection of networks in the world. • Began in 1969 as a Defense Department project designed to connect various government laboratories and contractors. • Soon recognized as an indispensable data link between researchers. • By the 1990s, the Internet had entered the domain of the general public. World Wide Web • The World Wide Web (www), developed in 1991, is a collection of electronic resources distributed over the Internet that combine text, graphics, sound, and video. • Not only have individuals found the Internet and the www to be valuable tools, but a wide spectrum of businesses has also developed numerous applications using these resources. World Wide Web • Technology issues associated with communication on the Internet include: • • • • Connecting to the Internet The concept of a website The role of an intranet The use of a thin client network computer. Connecting to the Internet • The majority of healthcare organizations obtain their Internet services through an intermediate provider. • An online service connection (OLSC), such as Verizon, provides an array of information services • An Internet service provider (ISP) whose function is to provide users with a link to the Internet. • Most Internet providers are reached using a direct network connection through high-speed cable, fiber optics, or DSL. Direct Network Connections • A direct network connection uses dedicated digital telephone lines that go directly from the computer to the ISP. • They can be fractional T1 lines (about 1 megabit per second) or T3 lines (45 megabits per second). • Telephone companies now offer digital subscriber line (DSL) service, which runs over standard telephone wire. • DSL is priced affordably and is found in many home computing environments. Direct Network Connections • Many cable companies offer direct connections between a computer and the cable television network. • The cable company then provides a connection between its cable network and an ISP or the company might serve as the ISP. • A cable modem must be added to the computer to facilitate making a connection into the cable network. Direct Network Connections • The Transmission Control Protocol/Internet Protocol (TCP/IP) manages the assembly and routing of the messages being transmitted between a computer and the Internet. • Although the IP takes care of handling the actual delivery of the data, the TCP takes care of keeping track of the individual units of data (called packets) that a message is divided into for efficient routing through the Internet. The Role of an Intranet • Once the Internet infrastructure is in place, the same technology can also support communication within the organization and is referred to as an intranet, or private network. • When an organization shares part of its intranet with customers, strategic partners, and other stakeholders, the intranet becomes an extranet. • An intranet or extranet uses the same protocols as the Internet and in general looks no different. Firewall • A security protocol to protect the intranet from outside access while permitting organizational access to the Internet. • The firewall can also contain software that establishes a virtual private network (VPN) that allows organizations to maintain privacy while sharing public networks for transmission of their data. • Data are encrypted before being sent through the public network and then decrypted at the receiving end. Special Attention • As developments in intranet applications continue, healthcare managers should monitor how their organizations are using this technology. • Special attention should be directed toward the security and confidentiality issues created by intranets. Thin Clients and the Internet • Thin client computers are minimally configured PCs that are suitable client machines in a client/server network. • These machines can also serve as user workstations on the Internet. • The healthcare manager will encounter a variety of terminology associated with this type of installation, including network computer (NC), net PC, and proprietary names like Windows Terminal or Winterm. Advantages • Cost: Thin clients carry a lower purchase price that can become significant as the number of computers connected to the Internet in typical healthcare settings continues to increase. • Ease of update: In an environment where thin clients are used, the software resides on the web server and can be updated quite easily. Disadvantages • Culture: Users are accustomed to the power of a fully configured PC. • Downtime: When the server is down, the user of a thin client is also down. Thin Clients and the Internet • In this area, as in all decisions concerning information systems acquisition and installation, the healthcare manager is well advised to be aware of all alternatives and select the one best suited for his or her organization.
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