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Electronic Health Records 2nd Edition Jerome H. Carter
Digital Instant Download
Author(s): Jerome H. Carter
ISBN(s): 9781930513976, 1930513976
Edition: 2
File Details: PDF, 153.44 MB
Year: 2008
Language: english
I
z ft 0
ACP
cr -
V
BIH
Electronic Health
Records Second Edition
A Guide for Clinicians and Administrators
Jerome H. Carter, MD
Electronic
Health
Records
Second Edition
ELECTRONIC
HEALTH
RECORDS
A Guide for Clinicians
and Administrators
Second Edition
Jerome H. Carter, MD, FACP
ACP PRESS
American College of Physicians Philadelphia

Associate Publisher and Manager, Books Publishing: Tom Hartman
Production Supervisor: Allan S. Kleinberg
Senior Editor: Karen C. Nolan
Editorial Coordinator: Angela Gabella
Cover Design: Lisa Torrieri
Index: Kathleen Patterson
Copyright © 2008 by the American College of Physicians. All rights reserved. No

part of this book may be reproduced in any form by any means (electronic, me-
chanical, xerographic, or other) or held in any information storage and retrieval
systems without written permission from the publisher.
Printed in the United States of America

Printing/binding by Versa Press
Composition by Atlis Graphics
Publisher's Note: Although a number of EHR vendors and products are men-
tioned within the text of this book, and some chapter authors are formally
affiliated with an EHR vendor, this in no way implies an endorsement of the
products or vendors by the editor or the American College of Physicians.
Library of Congress Cataloging-in-Publication Data
Electronic health records : a guide for clinicians and administrators / editor,

Jerome H. Carter.—2nd ed.
p. ; cm.
Rev. ed. of: Electronic medical records. c2001.
Includes bibliographical references and index.
ISBN 978-1-930513-97-6
1. Medical records—Data processing. 1. Carter, Jerome, 1955- IE Electronic
medical records.
[DNLM: 1. Medical Records Systems, Computerized. 2. Forms and Records
Control—methods. WX 173 E373 2008]
R864.A42 2008
610.285—dc22
2007049164
08 09 10 11 12 / 10 9 8 7 6 5 4 3 2 1
Dedication
This is to all those people who have made my life possible:
LaSalle and Viola Carter, my parents for inspiring me
Janice, my wife, for her love and support
Janie Herbert, the best mother-in-law ever
And my daughter Joy, whose name says it all.
V
Contributors
Jeroan J. Allison, MD, MS Daniel C. Davis, Jr., MD, FACP
Professor of Medicine, Divisions of CEO, Interactive Care Technologies
General Internal Medicine and Honolulu
Preventive Medicine Assistant Chief Department of
Assistant Dean for Continuing Medicine
Medical Education Queen's Medical Center
University of Alabama at Honolulu
Birmingham Clinical Associate Professor of
Birmingham, AL Medicine
John A Burns School of Medicine
Lyle Berkowitz, MD
University of Hawaii
Clinical Associate Professor of
Honolulu, HI
Medicine
Feinberg School of Medicine Erica L. Drazen, ScD, BS
Northwestern University Vice President
Medical Director of Clinical First Consulting Group
Information Systems Lexington, MA
Northwestern Memorial Physicians
Group (NMPG) Thomas K. Houston, MD, MPH
Chicago, IL Associate Professor of Medicine

LJniversity of Alabama at
Stephen E. Brossette, MD, PhD
Birmingham
Vice President
Birmingham, AL
Cardinal Health
Birmingham, AL JohnJ. Janas III, MD

CEO, Clinical Content
Consultants
CEO
Concord, NH
NT&M Informatics, Inc.
Adjunct Clinical Associate Professor Merida L. Johns, PhD

of Medical Education President, Holistic Solutions
Morehouse School of Medicine Visiting Professor
Atlanta, GA College of St. Scholastica
Woodstock, IL
Sarah T. Corley, MD, FACP
Chief Medical Officer Terri Thompson Mallett, Esquire
NextGen Healthcare Information Administrative Law Judge
Systems, Inc. District of Columbia Government
Horsham, PA Washington, DC
viii ELECTRONIC HEALTH RECORDS
Naveen Maram, MD, MSHI, MPH Ashwin B. Philar, MSEE
Medical Vocabulary Engineer McKesson Senior Software Engineer
Intermountain Healthcare San Francisco, CA
Salt Lake City, UT

Caroline Samuels, MD
Daniel R. Masys, MD Core Teaching Faculty
Professor and Chair Howard University Medical Center
Dept. of Biomedical Informatics Washington, DC
Vanderbilt University School of Teaching Faculty, Internal Medicine
Medicine Prince George's Hospital Center
Nashville, TN Bethesda, MD
Blackford Middleton, MD, MPH, Bruce Slater, MD, MPH
MSc, FACP Associate Professor (CHS) of
Assistant Professor of Medicine Medicine and of Biostatistics and
Harvard Medical School Medical Informatics

School of Medicine and Public Health
Associate Physician
University of Wisconsin
Brigham & Women's Hospital
Medical Director of Computerized
Boston, MA
Decision Support
Partners HealthCare System
University of Wisconsin Hospital
Wellesley, MA
and Clinics
Madison, WI
Suchit Mishra, MSEE
Security Researcher
Thomas C. Tinstman, MD
Adobe Systems Inc.
Independent Consultant and
San Jose, CA
Senior Advisor
Health Technology Center
Matthew Morgan, MD, MSc,
San Francisco, CA
FRCP(C)
Courtyard Group Ltd;

Feliciano B. Yu, Jr., MD, MSHI,
Faculty of Medicine University of
MSPH, CPHIMS
Toronto
Assistant Professor, Department
University Health Network
of Pediatrics
Toronto, Ontario, Canada
University of Alabama School of
Medicine at Birmingham
Jerome A. Osheroff, MD, FACP,
Medical Informaticist
FACMI
Children's Health System
Chief Clinical Informatics Officer
Information Technology
Thomson Healthcare
Division
Adjunct Assistant Professor of
Birmingham, AL
Medicine
University of Pennsylvania Health
System
Cherry Hill, NJ
Preface to the Second Edition
Much has changed in the world of electronic health records (EHRs)

since the first edition. What is perhaps the most important event
occurred in the summer of 2003 when the Department of Health
and Human Services asked the Institute of Medicine to provide specific

guidance in helping to understand what capabilities an EHR should
have in order to support patient care. The outcome of that request was
the document "Key Capabilities of an Electronic Health Record System".

This document was then used by HL-7 to create a functional model for
EHRs that then became the basis for the criteria used for certifying EHR
products by the Certification Commission for Health Information Technol-

ogy (CCHIT). EHRs are increasingly seen as the key technology in address-
ing concerns in patient safety, quality of care, and cost reduction. This
viewpoint is reflected by the 2005 creation of the federal-level Office of

the National Coordinator for Health Information Technology (ONCHIT),
which is charged with overseeing the widespread adoption of health infor-
mation technology. Many states, with California and Massachusetts being

excellent examples, are actively pursuing EHR adoption. Thus, EHRs,
which were little more than a curiosity when this book was conceived in
1999, have become mainstream products and a major part of health care
delivery.
On a more personal note, when the first edition of this book was
published in 2001, I was Director of Informatics at the 1917 Patient Care

and Research Clinic, University of Alabama-Birmingham. In that role I led
a four-year effort to design and implement an EHR. That effort was com-
pleted successfully in September 2004, and the 1917 Computer-Based

Patient Record is now in active use supporting HIV/AIDS clinical activities.
(Those who wish to know more about the 1917 CPR may download a
ix
X ELECTRONIC HEALTH RECORDS
presentation at www.mshug.org/docs/techforumRedmond2007/Carter_J_
Willig_J_8_21_HPT.pdf).
While the EHR was in the design phase, the 1917 Clinic became part of
a consortium of medical centers working to build a national HIV/AIDS out-
comes research network, GEAR Network of Integrated Clinical Systems
(C-NICS), an effort that brought to the forefront the complex issues of data
exchange, privacy/confidentiality and security. The content of this book has
been directly affected by these experiences and the ascendancy of EHRs in
public policy and the marketplace. These influences have resulted in new
chapters on decision support, informatics data standards, project manage-
ment, implementation planning, practice analysis, workflow analysis, and
common security problems.
Changes to the Second Edition
The main goal of this book is to provide practical information and guidance
to those interested in implementing an EHR. We have retained the overall

organization from the first edition in which the book is divided into two
major parts. Part One consists of 13 chapters that are best thought of as in-
depth tutorials that address major technical and policy issues such as hard-
ware, database systems, informatics standards, decision-support, and
security and confidentiality. When applicable, references/resources for fur-
ther reading are provided.
Part Two has a completely different approach. It is designed as a "Work-
book". Here the goal is to offer practical advice on the actual steps involved
in selecting and implementing an EHR. In response to the many questions
received regarding the best way to select an EHR product, Part Two is now
divided into separate "Selection" and "Implementation" sections. We have
strived to better explain how to select the best EHR for your office by of-
fering a method with clearly defined steps and outcomes based on the au-
thors' real-world experiences.
New in the implementation section are chapters on workflow and proj-
ect management because experience has shown that these two areas cause
the most trouble during implementation. Security is another area often
overlooked and for that reason we have added a second chapter focusing
on security best practices.
We recognize that readers hail from a wide variety of practice environ-
ments, and we have endeavored to address their varied needs as best we
could without making the text too long or suffering a loss of focus. We have
adapted the chapters that discuss practice analysis, product selection, secu-
rity, and team building with consideration for the limited resources that ex-
ist in small practices.

PREFACE TO THE SECOND EDITION xi
How to Use This Book
It is expected that readers will come to this work with quite different back-
grounds, and to that end the following suggestions are offered based upon
the knowledge of the reader and the type of resources that are at his or her
disposal.
Clinician/Administrator in a Small Group
Often in small groups or solo practices the clinician or administrator has lit-
tle technical knowledge and access to limited resources. A major consult-

ing firm is out of the question, and the technical person involved may be
the retailer who sold you the practice management system (or possibly a
relative who "knows a lot about computers"). The cost of failure will be
high in terms of dollars and morale. If you fall into this group, caution is
the keyword. Read Chapter 1 to get a feel for what an EHR is and what ba-
sic EHR designs are available. Next, move on to Chapter 11 and finally Part
Two, the workbook chapters. These chapters contain the bulk of what you
will need to know to understand your needs, interact with vendors, select
a product, and plan your implementation. Using this approach, chapters in

Part One may be used as a reference when there is a need for additional
information. Do not allow your desire to do "something" make you do
something that you later regret.
Clinicians/Administrators Who are Members of

"Selection Committees"
Usually a selection committee implies a fair-sized practice or a more diverse
setting (e.g., hospital, multi-specialty group). Since there are so many back-
grounds and skill sets represented on these committees, effective communi-
cation is often a real problem. Words and concepts are tossed about that are
not understood by all members. If your understanding of technical issues is

minimal, then start with Chapters 1-6. If product selection is the main focus
of the committee, move on to the "Selection" section of the workbook. The
process chapters (Chapters 7 and 8) in Part One will also be enlightening.
Clinicians/Administrators who are Members of an

Implementation Group
Because organizations vary widely in how they name committees, the ad-
vice given here assumes that a product has been selected. During imple-
mentation the main issue is how to fit the organization to the product in
terms of features, functions, and workflow. The most useful chapters in Part
One are likely to be those that deal with informatics standards and business
xii ELECTRONIC HEALTH RECORDS
and clinical processes: Chapters 1, 6-9, 11, and the Implementation section
of the workbook.
Quality Improvement Initiatives
Patient safety and quality improvement are two of the major drivers behind
the current interest in EHRs. However, even though EHRs may be quite ef-
fective in patient safety and quality efforts, the benefits are not necessarily
automatic. Specific features and functions are required in EHRs to support

anything beyond basic quality/safety initiatives. Review Chapters 7-10 for a
discussion of EHR-related process and quality improvement issues. Next,

move on to Chapter 6, Informatics Standards, and finish with workbook
chapters that address product features, workflow, and process analysis
(Chapters 16, 17, 21, and 23).
Medical Directors
The implementation of an EHR may be either a godsend or the worst thing
that has ever happened in your professional life. As the spokesman for the
medical staff, your opinion counts tremendously and therefore should be well
informed. Very likely you have access to technical staff and consultants. Un-
fortunately, they may have a vested interested in influencing your opinion.
Part One has the information you need to understand the terms and concepts
that will be discussed repeatedly in your meetings, demonstrations, and site
visits. If quality improvement is a major reason for EHR implementation, you
should give Chapters 1, and 6-10 particular scrutiny. If a clinical data reposi-
tory is being considered, add Chapter 4 to your must-read list. If your major
concern is selecting and implementing an EHR, read the workbook (Chapters
14-25) and refer to the Part One chapters to fill in knowledge gaps.
CEO/CIO and Other High Level Administrators
All of the issues covered in the book are important to you. However, be-
cause many jobs will be delegated to those with appropriate expertise, the
information that you require is likely to be at a fairly high conceptual level.

Consequently, Chapters 1, 11 and 12 will probably be most useful. In ad-
dition, the chapters in the Workbook that discuss contracts, RFPs, and proj-
ect management (18, 19, and 22) should be informative.
Technical Personnel with Little EHR Knowledge
Your major challenges will be understanding how EHRs differ from other
types of software and dealing with the new group of clinical users that you
will inherit with the EHR. Chapters 1, 4, 6, 7, 8, 11, 12, and 13 should be
useful.
PREFACE TO THE SECOND EDITION xiii
Final Remarks
Privacy, security, and the legal aspects of EHRs are important topics that
most people find less than interesting reading. However, these are veiy im-
portant topics, and everyone should read these chapters. Supplement your
reading with other materials from the reference listings and the resources
in Appendix B. You will be surprised at how quickly once incomprehensi-
ble technical articles and discussions begin to make perfectly good sense.
Acknowledgements
I would like to thank the editorial staff of American College of Physicians,
Thomas Hartman, Angela Gabella, Karen Nolan, and Maria Sussman, who
helped in so many ways to improve the content and readability of the
book, as well as to produce a beautiful design. Once again the College's
informatics staff helped with the glossary: Thorn Kuhn, Steve Spadt, Margo
Williams, and Maria Rudolph.
Taking an EHR from an idea to a fully implemented system is a once-
in-a-lifetime experience. T would like to thank those brave souls at the
1917 Clinic at the University of Alabama-Birmingham who believed in the

project and supported me: Michael Saag, Executive Director of the clinic
and current Director, Division of Infectious Diseases, for making the entire
effort possible, and the rest of the administrators at the clinic, especially Jim
Raper, Karen Savage, and Michael Kilby for their help and support.
Building and deploying an EHR takes many hands and I could not have
done it without dedicated and brilliant assistants: Ashwin Philar, software
engineer; Suchit Mishra, systems and security; Naveen Maram and Pradnya
Warnekar, vocabulary/terminology specialists; Robin Hood, HIPAA guru;

Davendra Sohal, workflow and support; and Ray O'Neil, end-user support.
I would also like to thank James Willig and Manojkumar Patil for their on-
going efforts to update and expand the system since my departure.
I was very pleasantly surprised by the enthusiasm expressed by my fel-

low authors when they were informed that a second edition was underway.
The dedication to quality and patience with my critiques demonstrated by

all has made my task as editor much easier. I am grateful for your efforts
and honored by your commitment to produce the best possible text.

Finally I would like to thank everyone who sent thoughtful comments
and suggestions for changes to the second edition. I hope that you are
pleased with the outcome. As always I would love to hear from you, and
should you be so moved stop by www.computingforclinicians.com.
Jerome H Carter, MD, FACP

Atlanta, Georgia
January 2008
Preface to the First Edition
The inspiration for this book came from the many clinicians whom I
have encountered over the past four years who found themselves in
the frustrating position of wanting to implement an electronic medical
record (EMR) system and having no idea where to start the process. Invari-
ably, their first words to me after the usual pleasantries were "Which sys-
tem should I buy?" My response always began with "That depends ..." and
the ensuing brief discussion was rarely sufficient to answer their query.
This book is an attempt to answer the many questions that arise when
implementing an EMR system. As an aid to the reader, the book is divided
into two parts. In Part One the reader will find in-depth discussions of tech-
nologies, issues, and processes. When applicable, references for further

reading are provided. However, this should in no way be understood to im-
ply that Part One is an academic work with little practical value. It offers
the background information required to understand the important EMR is-

sues that arise as one journeys from initial curiosity to final implementation.
Think of Part One as providing the "what" and "why" of EMR-related tech-
nologies and issues.

Part Two has a completely different approach. It is designed as a Work-
book. Here the goal is to offer practical advice on the actual steps involved
in implementing an EMR system. The information provided in its chapters
is thoroughly infused with the "hands-on" experience of the authors.
Though Part Two offers useful advice for readers in all practice environ-
ments, it should be particularly useful to those in a solo practice or small

group and to others who cannot afford to retain the services of major con-
sulting firms or do not have access to a good deal of on-site technical ex-
pertise. Part Two covers the everyday issues of negotiating a contract,

evaluating products, understanding practice needs, and planning.
XV
xvi ELECTRONIC HEALTH RECORDS
How To Use This Book
Electronic Medical Records for Clinicians and Administrators contains a

good deal of information, much of it quite technical—all of it necessaiy to
achieve a working knowledge of the important issues faced when moving

from paper to an EMR. It is expected that readers will come to this work
with quite different backgrounds, and to that end the following suggestions
are offered based upon the knowledge of the reader and the type of re-
sources that are at his or her disposal. The following groups should encom-
pass the majority of readers.
Clinician/Administrator with Little Technical
Knowledge and Access to Limited Resources
Often in small groups or solo practices the clinician or administrator has lit-
tle technical knowledge and access to limited resources. A major consult-

ing firm is out of the question, and the technical person involved may be
the retailer who sold you the practice management system (or possibly a
relative who "knows a lot about computers"). The cost of failure will be
high in terms of dollars and morale. If you fall into this group, caution is
the keyword. Take time to read Chapters 1-3, 5-7, 10-12, and all of the
Workbook (Part Two). These chapters offer insight into the issues most
pressing for those in your situation. Once you have become familiar with
the concepts and issues that they discuss, then go back and finish the re-
maining chapters. Do not take lightly the admonitions offered in the Work-
book. Most of all, do not allow your desire to do "something" make you do
something that you come to regret.
Clinicians/Administrators who are Members of

"Selection Committees"
Usually a selection committee implies a fair-sized practice or a more diverse
setting (e.g., hospital, multi-specialty group). In such cases technical per-

sonnel and consultants are often available, both of whom can be very help-
ful during product selection and implementation. If you are a member of
this group, you will likely have little direct say over the most important
issues. Your role becomes that of protecting the interests of those you rep-
resent (unless of course you are the committee chairman!). Your under-
standing of the key issues is extremely important. If you have a fairly good
grasp of technical matters, then issues related to work-flow, practice envi-
ronment, and general operations should guide your reading. Chapters 6-12
will probably be most helpful initially, with Chapters 1-5 acting as an oc-
casional reference. The Workbook will be useful in helping you prepare
your colleagues for the changes that lie ahead.

PREFACE TO THE FIRST EDITION xvii
Medical Directors
The implementation of an EMR system may be either a godsend or the
worse thing that has ever happened in your professional life. As the
spokesman for the medical staff your opinion counts tremendously and
therefore should he well-informed. Very likely you have access to technical

staff and consultants. Unfortunately, they may have a vested interested in
influencing your opinion. Part One has the information you need to under-
stand the terms and concepts that will be discussed repeatedly in your
meetings, demonstrations, and site visits. If quality improvement is a major

reason for the implementation (e.g., order entry, guidelines), Chapters 6-10
and 16 should be given particular scrutiny. If a clinical data repository is

being considered, Chapter 4 should be added to the must-read list.
CEO/CIO and Other High Level Administrators
All of the issues covered in the book are important to you. However, be-
cause many jobs will be delegated to those with appropriate expertise, the
information that you require is likely to be at a fairly high conceptual level.
Consequently, Chapters 8-12 will probably be most useful. In addition, the
chapters in the Workbook that discuss Requests for Proposals and contracts
might provide a few useful insights (see especially Chapter 18).
Technical Personnel with Little EMR Knowledge
Few health care sites have installed an EMR system, and there is no short-
age of horror stories of failed implementations. Many of the failures are
caused by nontechnical issues (e.g., poor planning, inadequate training).
However, often the problem is a poor understanding of the technical issues

associated with EMR software. For example, response times under full load,
file importation, database structure, clinical vocabulary, and system integra-
tion are technical matters that can delay or doom an EMR installation. Those
who may be best able to understand the potential pitfalls at an early stage
are knowledgeable technical personnel. Chapters 1-3 and 16 should be of
particular value to technical personnel involved in EMR projects.
Final Remarks
If you find that you do not fit into any of these groups, reading the book
from beginning to end also works quite well. But do not read this book in
a vacuum. Many vendors offer fully functioning demonstration programs, at
little or no cost, that may be used to aid in understanding EMR features and
issues. Supplement your reading with other materials; there are a number
of helpful Web sites and magazines (see Appendix B). One result of the
xvi ii ELECTRONIC HEALTH RECORDS
diligent reading of this book will be the mastery of the concepts and jar-
gon associated with EMR systems. You will be surprised at how quickly
once-incomprehensible technical articles and discussions begin to make

perfectly good sense.
Acknowledgements
I would like to thank all those who have made this book possible. The
Editorial Staff members of ACP-ASIM—Mary Ruff, David Myers, and Alicia

Dillihay—have been very understanding, supportive, and patient. Former
staff members of the College's Medical Informatics Department—Bob
Spena, Jerry Osherhoff, Linda Sundberg, Chris Dwyer, and Steve Spadt—
provided very helpful comments and suggestions.
Michael Saag, Jim Raper, Betty McCulloch, Michael Kilby, Tracey Reid,
and the staff of the 1917 Research Clinic at the University of Alabama-
Birmingham demonstrated exceptional patience and understanding during
my many months of endless questions, interviews, meetings, and repoit
writing. Having gone through a full-scale systems-and-requirements analy-

sis for our home-grown EMR project, they remain cheerful and eager to
continue. Thank you for your support and good humor.
Doing a book of this scope would have required more time than I alone
could possibly have dedicated to such an important task. Also, the quality
would not have been nearly as high without the valuable contributions of
my fellow authors. I am honored to be in such good company.

Finally, I would like to thank all those who have attended my talks and
seminars over the years for helping me to focus the content of the book
and to understand what the important issues really are.
February 2001
Contents
PART ONE
Electronic Health Records for Clinicians and
Administrators 1
SECTION
Infrastructure and Supporting Technologies
1 What is the Electronic Health Record? 3

Jerome H. Carter
2 Computer Hardware and Enabling Technologies 21

Daniel C. Davis, Jr.
3 Operating Systems and Programming Languages 53

Stephen E. Brossette
4 Databases, Warehouses, and Data Repositories 69

Ashwin B. Philar
Jerome H. Carter
5 Internet and Intranet Technologies 91

Daniel R. Masys
6 Informatics Standards 119

Naveen Maram
SECTION
II Understanding Processes and Outcomes
7 Identifying and Understanding Business Processes in

Clinical Practice 143
Blackford Middleton
John J. Janas III
8 Identifying and Understanding Clinical Processes 169

Matthew Morgan
9 Clinical Decision Support 193

Bruce Slater
Jerome A. Osheroff
10 Quality Improvement and the EHR 215

Feliciano B. Yu, Jr.
Jeroan J. Allison
Thomas K. Houston
11 Physician Adoption Strategies 249

Lyle Berkowitz
xix
XX ELECTRONIC HEALTH RECORDS
SECTION
III Legal and Regulatory Issues
12 Legal Issues and Health Care Information 275

Terri Thompson Mallett
13 Privacy and Security of Health Information 295

Merida L. Johns
PART TWO
Electronic Health Records Selection and
Implementation (Workbook) 325
Introduction 327
SECTION
IV Electronic Health Records Selection
14 Starting the Electronic Health Records Selection Process 329

Jerome H. Carter
15 How to Use Consultants Effectively 337

Erica L. Drazen
16 From Process Analysis to Product Evaluation 345

Jerome H. Carter
17 Evaluation of Product Features 357

Jerome H. Carter
18 Vendor Evaluation 373

Sarah T. Corley
19 Creating a Request for Proposal and

Negotiating a Contract 383
Sarah T. Corley
20 Gathering Information:
Site Visits and Demonstrations 393
Bruce Slater
SECTION
V Electronic Health Records Implementation
21 Planning Your Implementation? 407

Jerome H. Carter
22 Project Management: Concepts and Methods 419

Thomas C. Tinstman
23 Workflow 453
Caroline Samuels
CONTENTS xxi
24 Going Live: Training, Data Migration, and Interfaces 473

Sarah T. Corley
25 EHR, HIPAA & Security: Practical Implications 481

Suchit Mishra
Appendix A: Glossary of Selected Terms 491

Thomson M. Kuhn, Maria Rudolph,
Steven Spadt, Jerome H. Carter
Appendix B: Electronic Health Record 499

Resources
Jerome H. Carter
Appendix C; Using the EHR Evaluation Form 503

Jerome H. Carter
Index 511
A
ONE
Electronic Health Records for
Clinicians and Administrators
1
SECTION
I Infrastructure and Supporting Technologies
What Is the Electronic
Health Record?
Jerome H. Carter, MD
Reports of using computers to support clinical data management activ-
ities date back to the late 1950s. Over the years systems have been
designed that support most major activities related to health care busi-
ness practices and clinical processes. The most common systems are listed
below (Table 1-1).
Until recently, hospitals have led the way in the development of clini-
cal information systems. This was owing, in part, to several factors: 1) the
cost of these systems (including personnel) made information technology
too expensive for smaller entities, and 2) hospitals had greater need of
meeting regulatory and financial requirements. Hospital information sys-
tems (HIS) usually have, as their central component, an Admission, Dis-
charge, and Transfer (ADT) system that manages census and patient
demographic information. Billing and accounting packages are also fre-
quently included as core components. In many community hospitals, fi-

nancial and ADT systems, along with Laboratory Information Systems
(LIS), comprised the complete HIS package until recently. In the past fif-
teen years, most hospitals, regardless of size, have begun to create infor-
mation systems solutions via integration of departmental systems with the
core HIS, although almost 20% still do not have electronic implementations
of all major ancillary systems (1,2).
Departmental systems, especially those for pharmacy, radiology, and lab-

oratory, have evolved from a focus on administrative tasks (scheduling, or-
der entry, billing) to more clinically oriented functions. For example, modern
pharmacy systems commonly provide drug interactions, allergy alerts, and

drug monographs as part of their standard feature set. When looking at
the evolution of clinical information systems, it is instructive to consider how
the end-user has changed over the years. Departmental systems were de-
signed primarily for use by workers within those departments, not health
3
4 ELECTRONIC HEALTH RECORDS
Table 1-1
Hospital Information Technology Applications
System Type Function
Master patient index Registration and assignment of unique identifiers

for all systems within a hospital or integrated
delivery network.
Pharmacy information system Medication dispensing, inventory, billing, drug

information, and interactions.
Radiology information system Scheduling, billing, and results reporting.
Picture archiving system Storage and presentation of radiological images.

Nursing information system Storage and collection of nursing documentation,
care planning, and administrative information.
Hospital information systems Core system manages hospital census (admission,

discharge, transfer) and billing. Most often
linked to departmental systems (pharmacy,
laboratory, etc.).
Chart management/medical Assists in the management of paper records and

records systems aids with required statistical reporting. Used by
medical records personnel.
Practice management system Outpatient system for managing business-related

information. May contain some clinical
information (CPT, ICD).
Laboratory information system Orders for lab tests and results reporting. Covers
blood bank, pathology, microbiology, etc.
care providers. Thus drug interaction information was available only to phar-
macists and their staffs, not directly to doctors and nurses. Clinical informa-
tion systems were labeled as such because they were utilized in areas that
supported clinical activities, not because they were intended for use prima-
rily by clinicians. Of all the systems that fall under the rubric of clinical in-
formation systems, only a few are designed primarily for use by health care
providers: intensive care unit systems (ICU), picture archiving and commu-
nications systems (PACS), computerized physician order entry systems
(CPOE), and the EHR.
The modern era of clinical information systems is being driven by con-

cerns of quality, patient safety, and cost, in addition to secondaiy business
and operational issues (3). Today emphasis has shifted toward providing in-
formation systems that support providers during the process of care, result-
ing in the advent of CPOE systems and a much higher profile for EHRs (4).
CPOE systems provide an integrated view of orders and results (medica-
tions, radiology, laboratory) along with decision support functions (drug in-
teractions, duplicate requests, clinical protocols, etc.) and are most often
seen in hospital settings. These are complex provider-centric applications

WHAT IS THE ELECTRONIC HEALTH RECORD? 5
and constitute one of the fundamental building blocks of a hospital-based
EHR. However, they have not yet achieved wide acceptance: fewer than 7%
of American hospitals have fully functioning CPOE systems (1,5).
The EHR is the goal towards which clinical information systems have
been evolving since their inception. Even so, EHR systems remain uncom-
mon in many practice settings. Fewer than 3% of American hospitals have
robust EHR systems (1), while fewer than 15% of physicians use EHRs on
a regular basis (6,7).
The Electronic Health Record Concept
The growing interest in EHRs has been paralleled by an increase in the
number of attempts at defining what they are. When perusing publications
concerned with EHRs and associated technologies, one is quickly struck by
the number of terms used to describe them. Over the years EHRs have been
referred to by a number of terms: electronic medical record, electronic pa-
tient record, electronic health record, computer-stored patient record, am-
bulatory medical record, and computer-based medical record.
Unfortunately, the definitions are conceptual and do little in the way of pro-
viding a technical, engineering, or scientific view of EHRs that could be
used for either designing systems or reviewing products.
In 1991 the Institute of Medicine (IOM) published a landmark report,
"The Computer-Based Patient Record: An Essential Technology for Health
Care" (8), which focused attention on important EHR concepts. One of its
more valuable contributions was in the area of terminology. It defines the
computer-based patient record (CPR) as an "electronic patient record that
resides in a system designed to support users through availability of com-
plete and accurate data, practitioner reminders and alerts, clinical deci-
sion support systems, links to bodies of medical knowledge, and other
aids" (8).
Further amplification was later provided by one of the report's editors,
Richard Dick, PhD, who describes the CPR as "a representation of all of a
patient's data that one would find in the paper-based record, but in a coded
and structured, machined-readable form." Dick further notes that, "Clinical
documentation is completed via computer and is coded within the patient's
CPR. Stored data are indexed with sufficient detail to support retrieval for
patient care delivery, management, and analysis" (9). Regarding the features
of EHRs and EPRs, Dick writes:
The EMR and EPR, which are in fact reasonably synonymous, are electronic,
machine-readable versions of much of the data found in paper-based records,
comprising both structured and unstructured patient data from disparate,
computerized ancillary systems and document-imaging systems. Clinical
documentation may originate in either paper records or computerized data;
however, the data are not comprehensively coded. One might consider the
EMR or EPR as transitional between the paper-based record and the CPR. (9)
The perspective offered by Dick relates the CPR, EPR, and EMR along a
continuum based on, among other factors, the level of granularity of stored
data. A true CPR requires that every data item be uniquely coded and indi-
vidually searchable; an EPR/EMR does not. EPR/EMR systems only require
that the data be in electronic form.
The CPR report, while providing a conceptual framework for discussion

of electronic record systems, proved to be less useful when evaluating real
world products. That task fell to "Key Capabilities of EHR Systems," a re-
port published by the Institute of Medicine in 2003 (10). Building on the
work of the 1991 report, it offered a more practical definition of EHRs. The
report states:
An EHR system includes: 1) longitudinal collection of electronic health

information for and about persons, where health information is defined as
information pertaining to the health of an individual or a health care provider
to an individual; 2) immediate electronic access to person- and population-
level information by authorized, and only authorized, users; 3) provision of
knowledge and decision-support that enhances the quality, safety, and
efficiency of patient care; and 4) support for efficient processes for health
care delivery.
This definition of an EHR system encompasses all of the concepts and
functionality proposed originally for the CPR; thus, we will use "EHR sys-
tem" (EHR) as the official term for this text.
The 2003 report identified eight core areas for which EHR systems should
provide supporting features/functions (Table 1-2) while recognizing four ba-

sic types of EHR care settings (hospitals, nursing homes, ambulatory care,
community-personal health record). The functionalities identified to support
Table 1-2
i ■ Core Functional Areas Identified by the 2003 IOM Report
♦ Health information and data
♦ Patient support
♦ Results management
♦ Electronic communication and connectivity
♦ Decision-support management
♦ Reporting and population health

♦ Order entry/management
♦ Administrative processes
these eight core areas were further expanded and developed by Health
Level 7 organization (HL7) into a standard by which commercially available
products could be evaluated and eventually certified by the Certification

Commission for Health Information Technology (CCHIT) (11). The 2003 re-
port acknowledges that EHR technology develops incrementally and that for
a given setting or a particular product, EHR features and functions will vaiy
over time. Therefore, many products will have advanced features in some
areas while being relatively deficient in others: today's EHR products are
seen as the progenitors of tomorrow's comprehensive EHR systems.
Introduction to Electronic Health Record Systems
Early efforts at building what became EHRs began in the 1960s with the
COSTAR system, developed by Barnett at the Laboratory of Computer Sci-
ence at Massachusetts General Hospital (12). Subsequent efforts at Duke

University (13) and the Regenstrief Institute at Indiana University Medical
Center (14) have all given rise to robust EHR systems that contain data for
thousands of patients. While there is no formal model or standard architec-

ture for EHR systems, these pioneering systems provided a basic model for
current hospital-based and ambulatory EHR systems that has been emulated
by current products.
Inpatient EHR Systems
Whereas EHR systems offer similar features and functions across care set-
tings, they differ significantly in how that functionality is assembled.

EHR systems that support hospitals and integrated delivery systems are
virtual systems created by pooling and sharing data between many compo-
nent systems (15,16). Outpatient systems are usually self-contained applica-

tions in which all functions are built on top of a single, shared database.
The ability of an EHR system to support advanced features such as decision
support, sophisticated reporting, and coded data entry is determined by the
level of integration of its component systems. Two levels of integration are

common: presentation and data level (15,17,18).
System Integration
Presentation Integration
At the presentation level, users are able to view data from all connected
systems through a common interface (15,17,18). The user may access a sin-
gle terminal to review patient information. Systems like this are quite use-
ful, but they are limited when users wish to do more that simple data
retrieval. These systems only seem to be one coherent system because a

single interface is required to interact with all of its components. Much of
the enthusiasm for Intranets and Web browsers are due to their ability to
support, with relative ease, presentation-level system integration (19,20).
A major downside to presentation-level integration is the lack of query
capability across all systems. For example, it would not be possible to ask
a question such as "find all patients with a diagnosis of congestive heart
failure who are not taking an ACE inhibitor" because the patients' problem
lists and medication records reside on two different computer systems. The
billing system may hold the diagnosis codes, while the pharmacy system
holds the medication profile. For a system to qualify as an EHR, some de-
gree of data-level integration must be present.
Data Integration
Data integration is required for true EHR functionality and is more difficult
to attain (21-23). Each component system may have its own data model and
naming conventions for data elements. Data-level integration requires that
all system components use a consistent scheme for coding data elements
and that a mechanism be present for movement of data between systems

(from components to the central system). In the case of a hospital or inte-
grated delivery network (IDN), the central system is usually a large data-
base called a clinical data repository (CDR) (15,16,24).

The CDR acts as the major information source for the entire EHR system
(Chapter 4). The simplest CDR implementations rely solely on laboratory,
radiology, pharmacy, ADT, and other standard department systems as infor-

mation sources (1,2). Achieving true EHR functionality requires adding to
this basic CDR environment CPOE, advanced reporting, PACS, clinical doc-
umentation, clinical decision support capability, and other provider-centric

information technologies (1,2).
The goal of the CDR is to provide a common pool of data that all appli-
cations can access. The most frequently used method for populating the
CDR is through the use of interfaces to link each component system. Inter-
faces are special software programs that move data between systems. Data
that reside in component systems designed by different vendors use pro-

prietary data models; therefore, similarly named data elements from differ-
ent systems may have characteristics that prevent them from being
interchangeable. Simple messaging interfaces alone cannot resolve the

deeper semantic problems present by data from disparate systems (25,26).
The problems that arise in reconciling terms, data elements, and data for-
mats between component systems require additional applications, such as

clinical data dictionaries, in order to provide time data-level integration. The
costs and issues associated with implementating interoperability between
systems, such as the lack of widely accepted data standards, create major
barriers to EHR adoption for many hospitals (2,27).
Legacy systems (older systems currently in place) represent a special

problem for EHR implementation for hospitals and IDNs. These older sys-
tems often cannot be easily replaced and so must become part of newer
systems, thereby hampering data-level integration. In many instances,
presentation-level integration is all that is possible for legacy systems.
A second approach to providing a common data pool is through the use
of an integrated system that relies on a single, shared database that is used

for storage by all components and applications (see Unified Database sec-
tion, below).
The EHR is one instance in which ambulatory practice sites are in a

much better position to implement new technologies than their often
wealthier inpatient cousins. Ambulatory care sites are simpler work envi-
ronments with fewer specialized information management needs. Integra-
tion issues are usually limited to practice management systems, laboratory
interfaces, and office machines (e.g., EKG).
Real-World Electronic Health Record Models
Interfaced Systems: Best-of-Breed
The classic architecture for inpatient EHRs is based on the use of interfaces
and is often referred to as the best-of-breed approach (so named because
departmental managers bought the best component system that they could
afford at the time) (28-30). Best-of-breed (Fig. 1-1) is the natural growth
path to EHR functionality for most hospitals because it makes use of what-
ever component systems the hospital has in place. Most hospitals begin the
Stroke Pharmacy Laboratory ADT MPI
INTERFACES
Tt
S V
Clinical Data Dictionary
V V
Clinical Data Repository
Nursing Clinician Other

CPOE
Documentation Documentation Applications
Figure 1-1 Best-of-Breed (interfaced) EHR.

journey to EHR functionality with the presence of a CDR that integrates data
from departmental systems (laboratory, radiology and medication) and al-
lows providers to access information from a single workstation (results

viewing). Populating the clinical data repository, and by extension the EHR,
using the best-of-breed approach results in the data integration issues dis-
cussed previously (Table 1-3). Once this foundation has been laid, ad-
vanced functionality is added over time in the form of CPOE, clinical
documentation, electronic medication administration, and PACS (1,2).
Integrated Systems: Unified Database
At the other end of the spectrum are fully integrated, unified database sys-
tems (17,21,29,30)- The term "unified database" will be used to denote sys-
tems that share a single underlying database to avoid confusion with the
term "single source," which indicates that all systems were purchased from
the same vendor. Systems from the same vendor do not necessarily share
the same underlying database. Thus, single source does not automatically
imply that systems are fully integrated at the data level.
Unified database systems are labeled as such because all components
share a single (unified) database (Figure 1-2), eliminating the need for a
separate CDR. This approach to EHR design minimizes or potentially elim-
inates the need for interfaces by providing true data-level integration. Uni-
fied database systems may be deployed using fewer hardware resources

and simpler configurations than best-of-breed systems, making it less dif-
Tahle 1-3
i1 1 EHR Integration Models

i
Best-of-Breed: Unified Database:

Interfaced Hybrid Integrated
Advantages Build system Build system Single vendor.

"as-you-go". "as-you-go". No interfaces
Select from best products Fewer vendors than required (or veiy
available. best-of-breed. few).
Data integration less Complete data
costly than best-of integration.
breed. Back-up/availability
Back-up/availability best.
better.
Disadvantages Costly to get good data Multiple interfaces Tied to one vendor
integration. required. (may have less
Many interfaces required. Manage multiple desirable
Manage multiple vendors. applications in
vendors. some areas).
Back-up/availability
more difficult.
Radiology Pharmacy Laboratory ADT MPI
Clinical Data Repository (shared database)
Nursing Clinician Other

CPOE
Documentation Documentation Applications
Figure 1-2 Unified Database (integrated) EHR.
ficult to provide high-availability deployments (less time spent with the

system unavailable to users) that are easier to set up, maintain, and back
up. The unified database approach to achieving EHR functionality is grow-
ing in inpatient environments, although it is the norm in physician offices
(Figure 1-3).
One impediment to having a unified database EHR is that all compo-
nents must be purchased from the same vendor. Because most hospitals
start with a few ancillary systems and build from there, in many settings go-
ing with a unified database architecture would require getting rid of many
current systems. As a result, most hospitals develop hybrid architectures

that exist along a continuum between best-of-breed and unified database
(see Table 1-3). The marketplace reflects the newness of the unified data-
base product in that no vendors currently offer an inpatient EHR on a uni-
fied database platform that includes all required components.
Electronic Health Record Advanced Features
and Functions
Computerized Physician Order Entry

and Decision Support
Computerized physician order entiy (CPOE) is an application that allows
physicians to enter orders for medications, laboratory tests, procedures, and

imaging studies (31,32). CPOE is usually the next major component added
Laboratory Interface Office Equipment Interface
Database Files
Application User Interface
Figure 1-3 Office-Based EHR.

to inpatient EHRs once the CDR is fully functional. Decision support is a

key component of CPOE functionality. Basic decision support is usually im-
plemented as alerts and reminders such as drug interactions or warnings for

order duplications (e.g., ordering a chest x-ray when a current one is ex-
tant) and is usually implemented in stages. Advanced decision support fea-
tures include support for protocols, advanced drug-related alerts, and aid
in drug selection.
Clinical Documentation
Full charting capabilities for nurses and clinicians are a major advancement
for inpatient EHRs. Documentation runs the gamut from vital signs and
basic nursing assessments to advanced systems that support structured
data entry for clinicians. Nursing information systems have been around
for quite a while but have not always been fully integrated with other sys-
tems. Clinician documentation functionality remains uncommon in most
hospitals (1,2).
Picture Archiving and Communications Systems
Radiology information systems provide access to reports of imaging stud-

ies. Gaining access to the actual image requires access to picture archiving
and communications systems (PACS) functionality. PACS began as stand-

alone applications that were available either to radiologists or to limited ar-
eas of the hospital. Through the CDR, PACS functionality is made accessible
as part of the EHR. PACS may be integrated at any stage of EHR evolution
(33,34).
Electronic Medication Administration Records
Ensuring that the correct patient receives the proper medication is a major
safety issue. Electronic medication administration records (eMAR) applica-
tions use wrist bands with bar codes to identify patients and to check the
medication to be administered against the information in pharmacy records.
This helps to prevent errors related to patient identity as well as to ensure
that the proper dosage and drug are administered. eMAR is often integrated
with CPOE in advanced EHR environments (35,36).
Ambulatory Electronic Health Record Systems
EHR systems designed for physicians' offices represent the simplest archi-
tecture consisting of three basic components: the database management
system, user interface, and external interfaces (Figure 1-3). All are con-
tained in one (unified) database and accessed through a common inter-
face. Care must be taken when reviewing products to avoid systems that
simply replicate the functions and content of paper-based records. This de-
sign is still seen in products that rely mainly on document imaging for stor-
age of key chart documents (e.g., progress notes, lab reports). The ultimate
value of an EHR requires, as emphasized by the IOM, discrete data that
can be used for analysis or by other components of the EHR to support

patient care and decision-making. EHRs offering the required level of func-
tionality are evidenced by data formats that permit laboratory results, prob-
lem lists, medication lists and other common record data to exist as coded
data elements. Ambulatory EHR products have begun to differentiate
themselves based on ancillary components that support advanced popula-
tion health features, as well as improved data exchange/interoperability
features.
Major Ancillary Components of Outpatient Systems
Disease Registries and Preventive Medicine
Taking care of patients with chronic illnesses requires managing data from
a wide variety of sources over a period of years. Disease registry features
that support managing a select population such as specialized recall func-
tions, disease-based templates, flowsheets, and specialized reporting func-
tions are becoming more common in outpatient EHRs (37,38).

Data formats that support discrete elements along with more sophisti-
cated report writers are being added to systems due to pressures from qual-
ity concerns such as pay-for-performance programs (39). These new
features encourage "systems" thinking on the part of clinicians who use
these tools to review the efficacy with which they manage their patients at
the population level. They provide the analyzable data required to be able
to audit the practice's adherence to internal and external clinical policies
and guidelines.
Two-Way Laboratory Interfaces
Downloads of laboratory results have been available for a while. Second-

generation systems are now extending their external interface features with
uplinks to clinical labs as well. Removal of the need for paper when order-
ing labs aids in practice efficiency, reduces costs, and paves the way for ad-
ditional decision support functionality.
E-Prescribing
Typical EHR medication features include medication lists and prescription
writers with automatic checks for allergies and drug interactions and drug
information. E-prescribing promises to add new features that promote
patient safety and practice efficiency. E-prescribing services may be embed-
ded in an EHR or provided as a stand-alone product. The most important
advance of e-prescribing over previous electronic prescription writing ap-

plications is the presence of a mechanism for standardized electronic data
interchange (40). With an accepted standard, all EHR and e-prescribing
vendors can create applications that can share and use the same data. This
makes it possible to have access to formularies from third-party payers,

share medication histories between providers, and securely submit pre-
scriptions to any pharmacy that participates. These features are making

their way into second-generation EHRs systems but not without a few
glitches. A national study conducted in 2006 found on-going problems with
e-prescribing services (41).
Electronic Health Record Supporting Technologies
Databases
Databases are the key technology underlying all EHR systems. Databases
can store data in large blocks (documents or images) or as discrete items

(numbers or single words). Modern database systems may hold billions of
data items and manage thousands of transactions per second. A database
may reside on a single computer (the server) or multiple computers. Data
repositories, warehouses, and EHRs are special types of database programs

(see Chapter 4). Database management systems are software programs that
provide the functions required to manipulate the information stored in
databases (e.g., database creation, reporting, design). The internal structure

or organization of a database is referred to as a "schema." There are no
standards for schema design for EHRs; consequently, EHR products built
using the same database management systems may have different schemas.
This creates difficulties when attempting to move from one EHR product to
another. The CCHIT certification process focuses on functional issues

(whether features are present and work appropriately); they do not address
database-related matters.
Delivery Models
Most EHRs are deployed on computers that reside in physicians' practices

and use a central computer (server) to house the main database, which is
accessed using workstations (client): this is referred to as a client/server
model. Using this model, practices must have access to technical expertise
(e.g., systems administrators) to maintain their computer systems. Over the
last 3 years, with the rise of the Internet and high-speed connections, the
"application service provider" (ASP) model for EHR deployments has be-
come more popular. In the ASP model, the EHR resides on a central com-
puter housed by a hosting company (usually the EHR vendor) and is ac-
cessed via the Internet. The ASP model is less expensive to deploy because
the practice does not have to buy a server and maintain it. The advantages
of each deployment model are listed in Table 1-4.
Data Input Technologies
Data entiy is a major EHR implementation issue. The traditional means of
interacting with computers, the keyboard, is not the most efficient method
for many EHR users. The two alternatives that have received the most at-
tention are pen- and voice-based input.
Pen-based input relies on a device that may be used primarily like a
mouse as a pointing device, or it may be used to "write" on the computer

screen much like a real pen. In the latter case, what is written may be cap-
tured as "electronic ink" and look like a handwritten note or the computer
may attempt to interpret what has been written (handwriting recognition)
and covert it to typed text prior to storing it in the EHR. Success with hand-
writing recognition is limited when large amounts of data are to be entered.
Table 1-4
ASP vs Client/Server
asp Client Server
Cost Cheaper to start up Large upfront expenditure

Subscription: cost ongoing Set price
Maintenance included in Maintenance is a separate fee
subscription price
Hardware Workstations with browsers Workstation connected to server
Support Needs For EHR system only EHR and server hardware
Minimal need for information Requires greater information
technology support staff technology support staff
Access Method Broadband connection (if Local access (computers are

connection is down, EHR is directly connected)
unavailable) Server workload may affect
Speed may be slow due to bad response time
connection or many users Remote access to server may
accessing same server create security risk
Secure remote access from
anywhere
Customization Minimal customization possible Customization possible
Security Internet access risks Server security breachs possible

Backups not under user control Back-ups under user control
Vendor bankruptcy could result Vendor bankruptcy results in
in data loss unsupported system but no
data loss
However, electronic ink is popular for drawing diagrams or other notations.
The introduction of tablet PCs (computers designed to support pen-based
input), which are supported by many EHR systems, are making pen-based
input a workable solution (42).
Voice-recognition technology has progressed significantly over the past
few years. Voice-recognition systems are now available that can handle
continuous speech (no unnatural pauses between words) with relatively

few errors. They are also much more affordable. Voice recognition has yet
to be widely adopted as an EHR data entry mechanism. However, the tech-

nology is sufficiently mature to warrant an evaluation (43,44). In concert
with templates or other structured entiy formats, it can be very effective
(see Chapter 3).
Networking
Local Area Networks (LAN) are groups of computers linked together to per-
mit communication and sharing of resources. LAN technology makes com-
puting more affordable because it permits a build-it-as-you-need-it

approach to purchasing and installing both hardware and software. The
main computer on a LAN is referred to as the server. Depending upon the
amount of computing power required, a server may be a fast personal com-

puter with extra memory or a special computer designed just for this pur-
pose. In either case, a server for a small office can be purchased for a few
thousand dollars.
Wireless computer capability is also changing the networking equation.

Wireless networks rely on radio frequency transmissions to communicate.
One great feature of using wireless technology is that users are not tied to
one location. No more wonying about wiring schemes and which rooms
should have terminals. The cost of wireless technology is decreasing while
becoming more powerful. It is worthy of consideration when setting your

networking strategy. One caveat: wireless networks may be security risks if
not properly set up. Have your wireless network set up by a professional
and then tested for security vulnerabilities.
Internet technologies also provide a cost-effective means for sharing ap-

plications. Applications designed for use with Internet protocols may be
open to the public (Web site) or permit access only to a limited group of
computers or people (intranet). Intranets are used to provide EHR applica-

tions (ASP), as well as common office applications such as word processors
and spreadsheets, making intranet applications viable alternatives to LAN-

based, client/server arrangements.
User Authentication
Maintaining the security of the information stored in an EHR is of the ut-

most importance. The standard mechanism in most EHRs for restricting ac-
cess to sensitive information is passwords. Passwords can be quite effective

if guarded properly. However, they can easily be forgotten or stolen. A
newer approach to identifying users is via the use of biologic markers
(45,46). Fingerprint and iris scanning technologies are already enjoying

fairly widespread use in number of fields. Voice and face recognition sys-
tems are also available. Biometric identification is superior to passwords in
two ways: they cannot be forgotten or stolen. Some laptops come with bio-
metric access built in. The role of biometric identification for EHR security
has yet to be fully determined (47).
Standardization
One of the most exciting developments in recent years is the drive to de-
velop a set of national standards for EHRs and interoperability. HL7 pub-
lished its initial EHR functional model, which contains nearly 1000 criteria
organized into about 130 areas. A subset of this group is being used to de-
fine a "legal" EHR (48). The Healthcare Information Technology Standards

Panel is tackling the issue of interoperability by defining formats for infor-
mation exchange based on currently available standards. The work of this

group may make the long-held dream of easily sharing health information
between computer systems a reality (49). Only time will tell.
Summary
Over the past 40 to 50 years clinical systems have undergone significant evo-
lution. The EHR is the ultimate goal of those who see the value of informa-
tion systems in the care of patients. However, much remains to be done in
the areas of data exchange/interoperability, data entry, user interfaces, data-
base design, and security before the full benefits of EHRs can be realized.
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2
Computer Hardware and
Enabling Technologies
Daniel C. Davis, Jr., MD
Nowhere is the phrase "form follows function" more important than
in the selection of computer hardware for the clinical practice. Hard-
ware selection (form) is determined by software and workflow

(function). In the office computer system, the physical components of the
system should be determined by the functions of the system. The physical

components of the office system include the equipment (the hardware),
how the hardware is linked together (the network), and the physical loca-
tions of the equipment within the office. An understanding of fundamental

computing concepts and the basic parts of a computer will help determine
how well different hardware components will support workflow functions
in the office.
Six major topics are addressed in this chapter about computer hardware
and enabling technologies:
1. Basic concepts about computer hardware
2. Hardware technologies and applications
3. Merging technologies in issues
4. Other hardware issues, privacy, and portability
3. Protecting computer equipment and data
6. Choreographing the doctor-patient-computer interaction
Basic Concepts about Computer Hardware
Computers are nothing more than sophisticated calculating machines

that perform mathematical operations using a binary number system.
21
Understanding basic concepts about computers will help in planning the
medical office computer system.
The conceptual computer has four parts:
1. Input: data that are fed to the computer
2. The computer itself, which is often called the processor
3. A program that tells the computer how to mathematically manipu-

late the input
4. Output, which are data presented to the user or another computer
program
Input data can be fed to the computer from many sources and in many
forms. The input data, whether words or numbers, are translated by the
computer into a machine code that the computers can understand. This
code is actually a binary math system consisting of just Ts and O's that can
represent a vast array of numbers, letters, words, and concepts. A string of

input data might look like "00000001" and "00000010", which are binary
code for the numbers 1 and 2.
The processor receives the binary input data and performs mathemati-
cal operations on the input data under the direction of a set of instructions
called a program. For example, a program might instruct the processor to
add "00000001" to "00000010" to get "00000011", the binary equivalent of
1 + 2 = 3.
The computer program is a set of instructions, or Riles, that dictate
what the processor should do with the input data.
Once the processor has manipulated the input data according to the pro-
gram instructions, the processor spits out the result data, which is called
output. This output comes from the processor in the form of binary code.
In our trivial example of "add 1 + 2", the output is "00000011". The binary
output is then translated into a format useable by humans, by another pro-
gram, or by another computer. In our example, "00000011" translates to the
numeral 3.
Parts of the Basic Computer
The computer system in the medical office will consist of one or more per-
sonal computers (PCs) connected by a network. The basic computer in this
network contains six components:
1. Central Processing Unit (CPU)
2. Random Access Memory (RAM)
3. Storage memory
Exploring the Variety of Random
Documents with Different Content
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A Guide for Clinicians

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American College of Physicians Philadelphia

Copyright © 2008 by the American College of Physicians. All rights reserved. No

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Electronic health records : a guide for clinicians and administrators / editor,

This is to all those people who have made my life possible:

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Janice, my wife, for her love and support

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Medical Education Queen's Medical Center

University of Alabama at Honolulu

Birmingham Clinical Associate Professor of

Group (NMPG) Thomas K. Houston, MD, MPH

Chicago, IL Associate Professor of Medicine

Birmingham, AL JohnJ. Janas III, MD

Adjunct Clinical Associate Professor Merida L. Johns, PhD

Chief Medical Officer Terri Thompson Mallett, Esquire

NextGen Healthcare Information Administrative Law Judge

Systems, Inc. District of Columbia Government

Naveen Maram, MD, MSHI, MPH Ashwin B. Philar, MSEE

Medical Vocabulary Engineer McKesson Senior Software Engineer

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Much has changed in the world of electronic health records (EHRs)

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viewpoint is reflected by the 2005 creation of the federal-level Office of