Home Uncategorized Week 2 Disscussion Again

Uncategorized

Week 2 Disscussion Again

Prior to beginning work on this discussion forum,

Read Chapters 5, 7 ,8 , and 9 of Health Informatics: An Interprofessional Approach.
Analyze the Wire diagram of healthcare supply chain information systems in Chapter 7 of your text (Figure 7.5).

Using the scenario below respond to the discussion question provided to you by your instructor. Based on your Ashford University major of study (Health and Human Services) analyze benefits, risks, and operational issues associated with these informatics systems and exchange of data in these settings. Evalute the role of the HL7 (Health Level Seven standard as discussed in Chapter 5 of your text) interface standard in data exchange between these informatics systems. Specifically, analyze your response from the standpoint of the Wire diagram of healthcare supply chain information systems in Chapter 7 of your text (Figure 7.5).

Scenario

As health consumers flow through the processes of being evaluated for a surgical procedure, (i.e., being admitted to the hospital, having surgery, recovering post operatively in the hospital and discharged to recover at home) there are a variety of informatics systems, processes, and data involved. These informatics systems exchange data with each other using computer programs called system interfaces. In order to provide care to customers as part of the surgical flow process, numerous informatics systems that share data must be utilized for both clinical and administrative functions.

Initial Post: Your initial post should be a minimum of 350 words. Utilize a minimum of three unique credible or scholarly sources (excluding the textbook or other course provided resources) cited in APA format, as outlined in the Ashford Writing Center’s

Citing Within Your Paper (Links to an external site.)

resource. Keep in mind that scholarly sources include peer-reviewed articles and non-commercial websites. Review the Ashford University Library’s

Scholarly, Peer-Reviewed, and Other Credible Sources (Links to an external site.)

tip sheet for more information about sources. Multiple pages from the same scholarly website will be counted as one scholarly source.

The sophistication in automating this process has in-
creased tremendously since the late 1990s. Applications
now include electronic catalogs; information systems such
as enterprise resource planning (ERP) systems from vendors
such as Infor (www.infor.com) or McKesson (www.
mckesson.com); warehousing and inventory control systems
from vendors such as TECSYS (www.tecsys.com) and
Manhattan (www.manh.com); exchanges from vendors such
as Global Health Exchange (GHX) (www.ghx.com); and inte-
gration with other systems such as clinical, revenue manage-
ment, and finance. An innovative technology in this area is
radio frequency identification (RFID); more information
can be found at www.advantech-inc.com/index.html.

With increased automation, these systems have improved
supply chain performance and management in healthcare,
with more innovations expected in the future. The healthcare
supply chain is an untapped resource of financial savings and
revenue enhancement opportunities.23 Recognizing these
opportunities, HIMSS advocated for more improvements in
a white paper titled Healthcare ERP and SCM Information
Systems: Strategies and Solutions. HIMSS indicated that
ERP systems will be tools for quality and safety because they
integrate capabilities such as procure-to-pay, order-to-cash,
and financial reporting cycles. These functions should help
institutions match needed materials with care in a more
timely and cost-effective manner.24

Integrated Applications in Supply Chain Management
The importance of these ERP and SCM systems should be
apparent, including the technology associated with them, such
as bar code scanners and electronic medication cabinets (e.g.,

Pyxis [www.carefusion.com/our-products/medication-and-
supply-management/medication-and-supply-management-
technologies/pyxis-medication-technologies/pyxis-medst

tion-system] and Omnicell [www.omnicell.com]). The basic
components of an integrated healthcare supply chain system
include the following:

• Supply item master file: A list of all items used in the
delivery of care for a healthcare organization that can be
requested by healthcare service providers and man-
agers. This file typically contains between 30,000 and
100,000 items. Fig. 7.4 shows a supply-item master file.

• Charge description master file: A list of all prices for
services (e.g., Diagnosis-Related Groups [DRGs],
HCPCS, and CPT) or goods provided to patients that
serves as the basis for billing.

• Vendor master file: A list of all manufacturers or dis-
tributors (vendors) that provide the materials needed
for the healthcare organization along with the associated
contract terms and prices for specific items. This file
typically contains 200 to 500 different vendors or
suppliers.

• Transaction history file: A running log of all material
transactions of the healthcare organization. In a com-
puterized system, it is a running list of all supplies
and materials being used to deliver care or manage
the operations of the institution.

These four files must be integrated to support the operations
and management of the supply chain. The integration neces-
sary in the modern healthcare organization is illustrated in
Fig. 7.5 as a diagram of interfaces across supply chain, clinical,
and financial systems.25

FIG 7.4 Extract sample of a supply item master file. (Dr. Jerry Ledlow, personal files.

)

122 UNIT 2 Information Systems and Applications for the Delivery of Healthcare

Persona
l use on

ly, do no
t reprodu

ce.

2020-09
-04

shayna.
rocourt@

student.
ashford.

edu

Persona
l use on
ly, do no
t reprodu
ce.
2020-09
-04
shayna.
rocourt@
student.
ashford.

edu

Persona
l use on
ly, do no
t reprodu
ce.
2020-09
-04
shayna.
rocourt@
student.
ashford.
edu
Persona
l use on
ly, do no
t reprodu
ce.
2020-09
-04
shayna.
rocourt@
student.
ashford.
edu
Persona
l use on
ly, do no
t reprodu
ce.
2020-09
-04
shayna.
rocourt@
student.
ashford.
edu
Persona
l use on
ly, do no
t reprodu
ce.
2020-09
-04
shayna.
rocourt@
student.
ashford.
edu
Persona
l use on
ly, do no
t reprodu
ce.
2020-09
-04
shayna.
rocourt@
student.
ashford.
edu

http://www.infor.com/

http://www.mckesson.com/

http://www.tecsys.com/

http://www.manh.com/

http://www.ghx.com/

http://www.advantech-inc.com/index.html

https://platform.virdocs.com/rscontent/epub/582951/1629902/OEBPS/xhtml/page-152.xhtml?#spNone

http://www.carefusion.com/our-products/medication-and-supply-management/medication-and-supply-management-technologies/pyxis-medication-technologies/pyxis-medstation-system

http://www.omnicell.com/

https://platform.virdocs.com/rscontent/epub/582951/1629902/OEBPS/xhtml/page-152.xhtml?#spNone

Supply Cost Capture
As a survey of supply chain progress26 demonstrates, “In
all industries, not just healthcare, three out of four chief
executive officers consider their supply chains to be essen-
tial to gaining competitive advantage within their mar-
kets.”27,p.2According to Moore, if the trend in the
cost of the healthcare supply chain continues to grow at
the current rate, supply chain could equal labor cost
in annual operating expenses for hospitals and health sys-
tems between 2020 and 2025.28 Clearly, maximizing effi-
ciency of the healthcare supply chain is an increasing
concern.

Consider supply charge capture events in which patient-
specific supplies are ordered for the care of that patient and
the items are then billed separately to the patient. “Every year,
hospitals lose millions of dollars when items used in
the course of a patient’s care somehow slip through the

system without ever being charged or reimbursed.”29, p. 1

Point-of-use technology, or capturing charges when supplies
or materials are used, allows healthcare institutions to increase
productivity, increase accountability, and reduce downtime
through improvements in their internal supply chain. Auto-
mated dispensing machines for medications or supplies can
be used to decentralize store operations, capture charges, and
bring supplies and materials to employees without compromis-
ing security and accountability.30 These systems, if integrated
with a solid business process, can enhance efficiency and effec-
tiveness of the healthcare supply chain.

Strategic factors associated with supply success and
enhancement are important as well. These include the
following27:

• Information system usefulness, electronic purchasing,
and integration

• Leadership supply chain expertise

Location & tracking data

Lo
ca

io
n

ra
ck

in
g

da
ta

Location
data

Vendor confirmation data

O
rd

er
c

on
fir

m
at

io
n
da
ta

V
en

do
r

co
nf

irm
at

io
n
da
ta

Vendor
confirmations

Star AR/
revenue

RxOBOT
APRS

Omnicel

Pharmacy
ordering
system

TBD

Cerner
pharmnet

Cerner millenniumInfor Lawson

Cerner surginet

Cerner procure

Lawson RSS
users

Cathlab(SPR)
TouchScan

Mezzia

TECSYS

RecTrac

PacTrac

Requisitioning

Inventory
control

Purchasing

Receiving

Invoice
matching

Accounts
payable

General ledger

POU Patient
charging

system TBD
Vendor catalog

GHX

V
en
do
r

ca
ta

lo
g

da
ta

Receipt data

R
ec

ei
pt

d
at

A
dv

an
ce

s
hi

p
no

tic
e

Receipt data
R
ec
ei
pt
d
at
a

Payment data
General ledger transactions

Purchase order data

P
ur

ch
as

e
or

de
r

da
ta

Purchase
orders

Vendor
invoice

Requisitions

R
eq

ui
si

tio
ns

Requisition data

R
eq
ui
si

tio
n

da
ta
R
eq
ui
si
tio
n
da
ta
R
eq
ui
si
tio
n
da
ta

Requisition data (Order

R
eq
ui
si
tio
n
da
ta

(
PA

R
u

sa
ge

)
R
eq
ui
si
tio
ns

(
O

rd
er

D
is

pe
ns

ed
g

oo
ds

d
at
a

Dispensed goods data

P
at

ie
nt

c
ha

rg
e

da
ta
P
at
ie
nt
c
ha
rg
e
da
ta

A
D

T
A
D
T

ADT

Item data

Item data
Item data

(for pref cards)

Invoice
data

Ite
m

d
at
a
Ite
m
d
at
a
Ite
m
d
at
a
Ite
m
d
at
a

Delivery data

FIG 7.5 Wire diagram of healthcare supply chain information systems. (Dr. Jerry Ledlow, personal
files.)

123CHAPTER 7 Administrative Applications Supporting Healthcare Delivery

https://platform.virdocs.com/rscontent/epub/582951/1629902/OEBPS/xhtml/page-153.xhtml?#spNone

• Supply chain expenditures
• Provider level of collaboration
• Nurse and clinical staff level of collaboration
• Leadership team’s political and social capital
• Capital funds availability

This section has provided a high-level overview of technology
in materials management. Box 7.2 details specific consider-
ations for automating SCM and materials management.31

Human Resources Information Systems
Human resources information systems (HRISs) leverage the
power of IT to manage human resources. They integrate
“software, hardware, support functions and system policies
and procedures into an automated process designed to sup-
port the strategic and operational activities of the human
resources department and managers throughout the organi-
zation.”32, p. 58 The authors distinguish between operational,
tactical, and strategic HRISs. Operational HRISs collect and
report data about employees and the personnel infrastructure
to support routine and repetitive decision making while meet-
ing the requirements of government regulations. Tactical
HRISs support the design of the personnel infrastructure
and decisions about the recruitment, training, and compensa-
tion of persons filling jobs in the organization. Strategic
HRISs support activities with a longer horizon such as work-
force planning and labor negotiations. In contrast, Targowski
and Deshpande state that generic HRISs typically include
the following subsystems defined by function: recruitment
and selection from among candidates; administration
of personnel processes; time, labor, and knowledge

management; training and career development; administra-
tion of compensation and benefits for active workers and
pensions for retirees; payroll interface; performance
evaluation; transitioning and outplacement; labor relations;
organization management; and health and safety.33

Human Resources Information Systems
as a Competitive Advantage
Khatri argues that the management of human resources in
healthcare organizations is a central function because the
healthcare and administrative services delivered are based
on the knowledge of staff delivering these services.34 Human
resources management should focus on employee training,
as well as developing and refining the work systems to improve
the work climate and the quality of service to customers.
Although healthcareorganizations shouldinclude the effective
management of human resources as part of strategic planning,
most fail to do so.Khatri offers three reasonswhy many health-
care organizations do not employ optimal human resource
practices. First, he argues that the responsibilities and activities
of human resources personnel are institutionalized and under-
valued in many healthcare organizations. Second, the provider
culture of healthcare focuses on the clinical delivery of care
with less attention paid to the effective management of
resources. Finally, lack of expertise and low skills in the human
resource function have limited the ability of human resource
managers to engage effectively in strategic and operational
planning. Khatri’s premise is that improving human resource
capabilities should help human resource managers engage
more effectively in managing human resources.34

BOX 7.2 Process Standardization

Process Standardization in Conjunction with Utilization
of an Information System
• Develop standard (or more standardized) processes for:

• Item master and charge description master maintenance
and synchronization

• Supply stock selection, reduction, compression, and
management

• Supply charge item capture (accurate and timely)
• Accountability measures for Central Supply and clinical

units
• Standardize clinical/floor stocked supplies replenishment

processes
• Daily reconciliation of pharmaceuticals and medical/surgical

supply items, especially supply charge capture items
• Taking into consideration:

• Clinical unit needs
• Physical layout variations may require modification to an

accepted standard
• The business process must be efficient before a technolog-

ical solution can be integrated into the process
• “ One-size” solution will not fit all

Process Standardization in Process Improvement:
Balancing Trade-Offs
• Competing goals exist between various stakeholder groups;

trade-offs will be required to find the proper balance that best
meets all needs

• Clinician Goals
• Does not impede caregivers or patient care delivery
• Minimize rework
• Right supplies, right place, right time

• Supply Chain Managers/Central Supply Goals
• Improve accuracy for supplies consumed
• Improve timeliness for supply consumption
• Efficient use of labor

• Revenue and Cost Avoidance Goals
• Procure and acquire material wisely with contracted compli-

ance goals
• Efficient management of materials considering utilization

rates, preferences, expiration dates and Food and Drug
Administration requirements

• Reduce number of supply charge capture items
• Improve accuracy for charge capture
• Improve timeliness for charge capture
• Improve charge capture rate

From Ledlow JR, Stephens JH, Fowler HH. Sticker shock: an exploration of supply charge capture outcomes. Hosp Topics. 2011;89(1):9. Reprinted
by permission of the publisher (Taylor & Francis Ltd, http://www.tandf.co.uk/journals).

124 UNIT 2 Information Systems and Applications for the Delivery of Healthcare

https://platform.virdocs.com/rscontent/epub/582951/1629902/OEBPS/xhtml/page-154.xhtml?#spNone

http://www.tandf.co.uk/journals

rules that must be changed by recompiling code, or the logic
may be based on machine-learning algorithms that dynami-
cally update as new information is processed by the system.

Data services may be used by the CDS system to access
clinical data in the repository. Sometimes these data are auto-
matically sent to the CDS system by a “data drive” mechanism
that automatically triggers a feed to the CDS system whenever
data are stored in the repository. Clinical applications also
may supply data directly to the CDS system for real-time deci-
sion support; for instance, when a clinician is in the process of
performing an action and needs assistance from the CDS sys-
tem before making a final judgment. Quite often, even if data
are automatically sent to the CDS system through a data drive
mechanism or directly from an application, the rules to pro-
cess the data require additional information from the repos-
itory. In this case, the CDS system may use data access
services to retrieve the needed repository data.

The CDS system may need a queuing mechanism to support
rulesthatwillbetriggeredlater.Forexample,aruleprocessedon
a lab result might trigger anoutputthat says to waitfor a new lab
value in 24 hours before making a final recommendation to the
clinician. If another lab result is not found within 24 hours, the
rule will provide a different output recommendation, such as
“order a new lab X.” Another use for the queue is to support
“stateful” clinical protocols, that is, protocols that remember
the state ofthe patient from a previous point intimeand use this
information to make recommendations later.

Once a rule is run, the output result must be communi-
cated to the appropriate recipients. The CDS system might
store a decision support result in the data repository if the rule
was triggered without direct user input so that a clinician can
see the result later. There might also be a mechanism for noti-
fying a specific user of a result through e-mail, text message,
or other communication pathway. When accessing the CDS
system directly from a clinical application, the CDS system
must have a method for communicating its results back
to the application, usually through a service or application
programming interface (API). CDS systems are explained
in additional detail in Chapter 10.

SYSTEM INTEGRATION AND
INTEROPERABILITY
The EHR is often only one piece of a larger health information
system environment within a healthcare enterprise. In fact,
larger institutions may run two or more EHRs. Because no
single EHR today can provide all of the functionality needed
in most healthcare facilities, the ability to share information
between systems is necessary. Departmental and ancillary
systems for the lab, pharmacy, radiology, registration, and
billing, for example, must be able to pass information to
and receive information from the EHR. Integrating these sys-
tems is typically the responsibility of an interface engine (IE)
(see the “Interface Engine” section). The different methods
for storing and communicating data used by health informa-
tion systems now necessitate interoperability standards to
ensure proper communication.

Interface Engine
Older intersystem communication methodologies used point-
to-point connections to allow different systems to share data
and information; that is, a specialized interface was created
between one system (A) and another system (B). The inter-
face between systems A and B only knew how to translate
between these two systems and could not be used to “talk”
to another system. This method is fine if there are few systems
in the network. However, as the number of systems grows, the
number of connections multiplies rapidly. For a network with
N systems where all of the systems are interconnected, there
are N (N 1)/2 connections; for example, a network with
six systems would have 6 (6 1)/2 ¼ 15 connections. Each
system in the network must individually expose N 1 inter-
faces to be fully interconnected with all other systems in the
network. In practice, this means that for a network with 6
systems and 15 connections, 30 interfaces must be main-
tained. If a system in the network is replaced, all of its
N 1 interfaces must be replaced, too.

Because of the cost and complexity of point-to-point inter-
faces, modern information systems often employ an interface
engine(IE).An IEallows each network data sourcetohave one
outbound interface that can then be connected to any receiving
system on the network. The IE is able to queue the messages
from a data source, transform the messages to the proper for-
mat for the receiving systems, and then transmit the messages
toappropriate systems.Acknowledgment andreturn messages
also can be routed as appropriate by the IE.

IEs use proprietary software or standard programming
languages such as Java to write routines for translating one
system’s data message model into another system’s model.
Most of today’s IEs support standard messaging interfaces
such as HL7 and X12. The IE must also translate terminology
between systems because, quite often, systems will use differ-
ent vocabularies or coding methods to represent comparable
concepts. Sophisticated IEs will use external sources such as a
standard data dictionary to provide the necessary terminology
translation services. This allows the IE to remain up to date on
the latest coding conventions and translations for the systems
on the network.

The following scenario explains how an IE could be used to
integrate an EHR with various ancillary systems. At the begin-
ning of a clinical encounter, the patient is registered in the
facility’s registration system. The collected demographic
information and encounter identifiers are transmitted by
the registration system to the IE, which then transforms
and forwards this information to the EHR and the LIS.
During the patient’s visit, the physician uses the EHR to order
a laboratory test. The lab order message is appended with the
correct patient identifiers and routed through the IE to the
LIS. The EHR uses a proprietary coding system for lab tests
that the physician orders; these are mapped to LOINC codes
that the LIS uses. When the lab completes processing of the
test, the lab results are returned by the LIS to the EHR via
the IE. The IE also branches LIS administrative information
for the test to the facility’s billing system for reimbursement
purposes.

81CHAPTER 5 Technical Infrastructure to Support Healthcare

Person
al use o

nly, do
not repr

oduce.

2020-09
-04

shayna
.rocourt

@stude
nt.ashfo

rd.edu

Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo

rd.edu

Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu

https://platform.virdocs.com/rscontent/epub/582951/1629902/OEBPS/xhtml/page-111.xhtml?#spNone

This scenario describes a somewhat simple network of five
interfaces. In reality, the registration system may be tied to
many more systems that need demographic and patient iden-
tifier information. The EHR will provide order messages not
only to an LIS but also to departmental systems for radiology,
pharmacy, and nutrition, for example. Each department
system’s results may need to be routed to several receiving
systems for storage, processing, and reporting; the EHR will
typically need an inbound interface from each of these diag-
nostic systems. The effect when one or more of the systems on
the network is replaced must be considered. An IE greatly
improves the ability to address this complicated network
environment in an efficient and usually less costly manner.

Interoperability Standards
System and data sharing or interoperability has long been a
problem for EHRs. Most EHRs and departmental and ancil-
lary systems have been written using proprietary program-
ming and data storage schema. This has made it difficult to
share data between systems. When trying to connect two
systems, integrators must first agree on a common exchange
mechanism and message format (called syntactic interopera-
bility). Then, to ensure that the data passed between the two
systems are understandable by the receiving system, the
content of the message must be mapped to a comparable
and comprehensible model and terminology in the receiving
system (called semantic interoperability).

Some of the most widely used clinical messaging standards
are produced by the HL7 organization.19 Virtually all major
clinical information systems in the United States support
at least part of the HL7 version 2.x message standard,
providing a common method for connecting EHRs and
departmental and ancillary systems. The version 2.x standard
specifies the format for messages but does not specify a stan-
dard for the content. The HL7 version 3 standard uses a much
more formal specification to define messages, and it is based
on the Reference Information Model (RIM). The RIM and the
Clinical Document Architecture (CDA) can be used to ensure
better semantic interoperability between systems. Version 3,
initially published in 2005, is not as widely implemented in
clinical information systems in the United States as is version
2.x because of its added complexity and significant implemen-
tation costs. Most clinical interface engines support the HL7
standards.

Many national and international terminology standards
have been developed to support the exchange of clinical data
and promote the semantic interoperability of systems. Most of
these standards were started around a specific clinical domain
but may have been expanded to cover additional domains as
the terminology was adopted. For example, LOINC was orig-
inally developed to describe clinical laboratory data, but it has
been expanded to cover other clinical observations such as
vital signs. SNOMED CT was originally developed as a
nomenclature for pathology. It has been extended to become
a highly comprehensive terminology for use in a wide variety
of applications, including EHRs. Other terminology stan-
dards include ICD-9 and ICD-10, Current Procedural

Terminology (CPT), RxNorm, and nursing terminologies
such as Nursing Interventions Classification (NIC), Nursing
Outcomes Classification (NOC), and North American
Nursing Diagnosis Association (NANDA). For additional
information on terminology standards, refer to Chapter 22.

NETWORKING SYSTEMS
In the previous section, we discussed system interoperability
within the walls of a single institution. However, there is a
growing desire and need to share patient information between
institutions for quality, financial, and regulatory purposes. In
fact, sections of the Meaningful Use criteria in the 2009 Health
Information Technology for Economic and Clinical Health
(HITECH) Act specifically call for sharing of clinical data
between healthcare providers and with public health organiza-
tions.11 Various organizational models for sharing data have
been developed at the local, regional, and national level.

Regional Health Information Organization,
Health Information Exchanges, and Health
Information Organizations
One of the earliest models for a data sharing network was the
regional health information organization (RHIO).An
RHIO is typically characterized as a quasi-public, nonprofit
organization whose goal is to share data within a region.
RHIOs were quite often started with grant or public funding.
Health information exchanges (HIEs) followed RHIOs, and
they are differentiated from them by having an anchor
provider organization and, usually, by being started because
of financial incentives. The anchor organization often pro-
vides a data-sharing mechanism to affiliated providers. In
practice, the operating characteristics of RHIOs and HIEs
may be quite similar, and the distinctions are only in the
terminology used.

Health information organizations (HIOs) are the latest
models, and they support the 2009 HITECH Act mandate
for health information sharing between EHRs. The role of
the HIO is to facilitate data exchange according to nationally
recognized standards. This may mean that the HIO only pro-
vides guidance to the organizations in an information
exchange network or that the HIO assumes the technical
responsibility for providing the exchange mechanism.

To facilitate data sharing, the information exchange net-
work is designed as either a centralized or a distributed data
architecture (although hybrids of the two are also sometimes
deployed). In the centralized model, the participants on the
networks push their data to a central repository housed in
one location. Organizations then retrieve data from the repos-
itory as needed. In a distributed model, the network partici-
pants keep their data and provide a mechanism to answer
requests for specific data. In either model, the network must
provide the ability to match patients between organizations
correctly. Without this matching functionality, the network
participants are unable to share information accurately.

82 UNIT 1 Foundational Information in Health Informatics

Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu

https://platform.virdocs.com/rscontent/epub/582951/1629902/OEBPS/xhtml/page-112.xhtml?#spNone

The network may use a global MPI that can map patient
identifiers between organizations. In addition, to provide syn-
tactic and semantic interoperability of the data, the network
participants must agree on standards for information
exchange. These standards may be similar to those discussed
in the previous section on interoperability standards. Last, the
exchange network must provide appropriate security mecha-
nisms to authenticate and authorize appropriate use, prevent
unwanted access, and accommodate necessary auditing and
logging policies.

To connect to the information exchange network, partic-
ipants may simply treat the network as another interface on
their local IEs. This allows participants to use existing
methods for sharing data, particularly if a centralized model
is used and data are pushed to the central repository. In the
case where a distributed model is used and participants must
accept ad hoc, asynchronous data requests, some additional
effort may be required to effect data sharing. Another model
for linking to the exchange network is to provide a service
layer that accepts ad hoc requests for data. The data request
services are accessible by network participants, often in the
same way that web pages are made available as URLs on
the World Wide Web. This method is becoming more popu-
lar and is particularly advantageous in the distributed
exchange model because it better supports pulling data from
an organization as it is needed.

eHealth Exchange
The Office of the National Coordinator (ONC) for Health
Information Technology facilitated the development of a
national “ network of networks” whose purpose was to enable
healthcare provider organizations and consumers to share
information across local information exchange networks.
The eHealth Exchange (formerly known as the Nationwide
Health Information Network [NwHIN]) created a set of pol-
icies and national standards that allows trusted exchange of
health information over the internet.20 The effort is now man-
aged by a nonprofit industry coalition called The Sequoia
Project (formerly HealtheWay). The Exchange includes orga-
nizations from all 50 states and four federal agencies (Depart-
ment of Defense [DoD], Veterans Health Affairs [VHA],
Health and Human Services [HHS], and Social Security
Administration [SSA]) and allows sending and requesting
health information from participating organizations. An ini-
tial implementation of the information exchange architecture
called CONNECT was demonstrated in 2008, with participa-
tion by various public and private entities,21 and it includes
components for core services (e.g., locating patients, request-
ing documents, and authentication), enterprise services (e.g.,
MPI, consumer preferences management, and audit log), and
a client framework (application components for building test
and user interfaces to CONNECT). A simplified implementa-
tion of the exchange architecture called Direct allows two
organizations to share medical information through common
methods, such as e-mail-like protocols.22 These methods
require a provider directory to ensure secure, point-to-point
routing of messages.

ONC has developed a Shared Nationwide Interoperability
Roadmap23 that gives further direction for the technical
andoperationalinfrastructure thatmustbedevelopedtoadvance
true system-wide interoperability. This Roadmap addresses
not only data syntax and semantic standards but also identity
resolution, data security, access authorization, directories,
and resource locators. Most recently, ONC released an Interop-
erability Standards Advisory, whose purpose is to “coordinate
the identification, assessment, and determination of the ‘best
available’ interoperability standards and implementation
specifications…[to meet] clinical health IT interoperability
needs.”24 Readers may view the entire document at: www.
healthit.gov/sites/default/files/2016-interoperability-standards-
advisory-final-508 . New material from the ONC’s Standard
Advisory panel may be viewed at: www.healthit.gov/providers-
professionals/standards-interoperability or by browsing for
“interoperability standards,” inputting the current year and
“ONC.”

OTHER INFRASTRUCTURE MODELS
The previous sections on the EHR component model and sys-
tem integration focused on technical infrastructure that may
be deployed locally within an organization. Other models
exist that can also supply this infrastructure, but from sources
outside an organization’s walls.

Application Service Provider
Rather than purchasing and installing an EHR, some institu-
tions opt to partner with an application service provider
(ASP) for their clinical application needs. An ASP is a com-
pany that hosts an EHR or departmental system solution for a
healthcare enterprise and provides access to the application
via a secure network. Users of the application are usually
unaware that they are connecting to a vendor’s offsite
computing facilities. An ASP model relieves the healthcare
enterprise from having to host and support the technical
components of the EHR, which may lead to lower capital
infrastructure costs. This obviously helps smaller facilities
that lack funding for a complete IT shop, but it also may
be financially beneficial for larger facilities because of the
economies of scale that an ASP vendor can provide over many
customers.

On the contrary, the ASP model implies some loss of
control of the EHR. ASP customers must be content with
their data being stored at the vendor’s offsite location.
They must also accept that versions of application soft-
ware, functionality, configurations, and levels of support
typically will be what the majority of the other ASP cus-
tomers are using. Last, it may be more difficult to integrate
with other IT systems at the local site because the ASP
vendor may not support interfaces for a healthcare enter-
prise’s entire portfolio of departmental and ancillary sys-
tems. Interfaces may be more difficult to develop and
maintain because the ASP vendor controls its half of each

83CHAPTER 5 Technical Infrastructure to Support Healthcare

Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu

https://platform.virdocs.com/rscontent/epub/582951/1629902/OEBPS/xhtml/page-113.xhtml?#spNone

http://www.healthit.gov/sites/default/files/2016-interoperability-standards-advisory-final-508

http://www.healthit.gov/providers-professionals/standards-interoperability

https://platform.virdocs.com/rscontent/epub/582951/1629902/OEBPS/xhtml/page-113.xhtml?#spNone

interface and may not prioritize projects in sync with the
customer’s needs.

Cloud Computing
A growing trend in IT is the concept of cloud computing.
Although the term cloud computing is somewhat new, the
basic idea behind it goes back decades. It can be traced to early
suggestions that computing would someday be like other pub-
lic utilities, and IT consumers would plug into networks of
applications and physical resources in the same way that elec-
tricity and phone lines are accessed. Computing resources
would be supplied by either public organizations or a few pri-
vate enterprises and shared by the consumer community.

The term cloud was attached to this concept because early
networking diagrams enclosed these “public” computing
resources within a figure of a cloud to represent resources out-
side of an organization’s physical walls and because of the
ability for these resources to change location without affecting
the consumer’s ability to access them. Although we often still
consider clouds as being available in a public space (i.e., acces-
sible by many consuming individuals and organizations), a
cloud may also be private (i.e., deployed within the walls of
single organization for use by that organization’s various enti-
ties). Cloud computing can be separated into three models:
software as a service (SaaS), infrastructure as a service (IaaS),
and platform as a service (PaaS).25

In the SaaS model, service providers run applications (ser-
vices) at one or more locations and make these applications
available to consumers. Consumers connect to the services
through a cloud client, often something as simple as a web
browser. This eliminates the need for consumers to host and
support the applications themselves. The SaaS provider can
also use economies of scale to provide multiple servers and sites
that host applications, potentially increasing the efficiency, per-
formance, and reliability of the applications. SaaS applications
may be as simple as a service that provides a single function,
such as Google Maps, or an application that covers an entire
set of workflow requirements. The ASP model described in
the previous section may be considered a type of SaaS. In clin-
ical computing, SaaS might be used to provide an entire EHR or
EHR function (e.g., scheduling and lab results review from a lab
services provider) or more focused functions within an EHR
application such as drug-drug interaction checking during
the ordering process, information retrieval for clinical descrip-
tions of diagnoses and abnormal lab results, or terminology
mapping between coding systems.26

The most utility-like example of cloud computing is IaaS.
In this model, the cloud provider makes computing machin-
ery available to consumers from large pools of resources. The
IaaS provider can scale the computing resources to the needs
of the consumer. This practice has become simpler with the
growing use of virtual machines, which can be installed as
multiple instances on physical hardware and simulate most
of the characteristics of an operating system and its environ-
ment. The consumer is responsible for deploying the operat-
ing system, applications, databases, and tools, for example,
and then supporting those installed assets. Users may connect

to the assets deployed on the IaaS resources through the inter-
net or via a virtual private network. The IaaS provider can
help organizations to lessen the cost of ownership of physical
resources and offload the need to employ local technical
personnel to maintain equipment.

The PaaS model is a simplification of the IaaS model, in
which the cloud provider deploys an entire platform for run-
ning the customer’s computing needs. This may include the
operating system, application server, web server, and data-
base, for example. The consumer then installs or develops
software on the resources provided. The PaaS provider sup-
ports the computing resources supplied by its cloud, while
the cloud user supports the assets built on top of it.

CURRENT CHALLENGES
Even though most of the technologies discussed so far have
existed for decades, many technical challenges and barriers
remain for implementation in the clinical environment. For
the EHR repository, primary challenges remain around the
robustness of storage architectures. With transitions to
patient-centered longitudinal records, the size and content
scope of the repository has grown considerably. Additionally,
as new data types are added to the EHR to capture information
aboutclinicalencountersandpatienthealththatismoredetailed
(particularlytomeettheexpandingrequirementsofMeaningful
Use),therepositorymustbeabletohandlenewinformationthat
was not anticipated in its original design. These facts demand
that the database and storage mechanisms be flexible.

Databases must be able to scale in size to accommodate
large amounts of online data. As they grow in size, they must
retain performance characteristics that do not slow down the
workflow of the clinical environment. Some database archi-
tectures and their storage services require new designs and
recompilations as new data types are added. Some are not
designed for the volumes of information that may be stored.
Careful consideration of repository architecture must be per-
formed before system selection to ensure that the system will
meet the ongoing needs of the healthcare organization.
Consider that patient data will have a lifetime measured in
decades, whereas the technology will be enhanced or replaced
on a 5- to 10-year, or less, life span. There must be a graceful
way to transition the data in the repository to new technology
without loss of information.

Data integration and interoperability remain the most dif-
ficult challenges in health information systems. The lack of
standards, or the lack of implementation of standards, is a sig-
nificant barrier. Expanding federal requirements around data
exchange are forcing EHR vendors to abandon proprietary
data architectures and adopt accepted standards for many
types of data, but considerable work still needs to be accom-
plished to ensure semantic interoperability of data. This issue,
coupled with older, outdated repository architectures, may
leave some health IT vendors, and, therefore, their customers,
without a path forward for their systems.

Some underlying system architectures make the EHR com-
ponent model described earlier in the chapter difficult,

84 UNIT 1 Foundational Information in Health Informatics

Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu

https://platform.virdocs.com/rscontent/epub/582951/1629902/OEBPS/xhtml/page-114.xhtml?#spNone

impractical, or impossible to implement. Component APIs
and services may be inflexible and require considerable effort
to add new components, particularly if a different develop-
ment group or vendor supplies those components. This issue
reflects a lack of system integration standards (to accompany
the lack of data integration standards discussed previously).
Because of this, quite often, a health IT vendor must supply
all pieces of the component model, locking customers into
a single solution that may lack the needed robustness in
one or more of the components.

Finally, one of the most vexing challenges for health IT has
been the ability for clinical applications to integrate well with
clinical workflow. Informatics professionals address these
workflow issues during system analysis and usability activities
to improve application adoption by clinicians. Additional
information for understanding usability activities is included
in Chapter 21. Still, a thorough analysis and usability assess-
ment may not ensure acceptance in all environments. Some
amount of application adaptability is often necessary to tailor
the system to specific settings and for specific individuals. On
the contrary, allowing for application customization at the
facility, department, and user level may be quite difficult to
accomplish and support (depending on the system architec-
ture and technical abilities of the application support staff),
and it can lead to nonstandard implementations that may
prove costly to operate and maintain. Upgrades to nonstan-
dard and highly tailored applications can also be extremely
challenging. How well application providers support custom-
ization is an important consideration in system selection. It
can have significant consequences on overall clinical IT sys-
tems infrastructure. Too little customization may mean that
multiple applications must be added to the infrastructure to
address the specific needs of each department or unit. More
liberal customization, besides adding user complexity, may
force larger manual and automated governance structures
on the organization to ensure that individual solutions still
support organizational policies and goals. In either case, the
underlying technology of the clinical applications has a pro-
found effect on the ability of users to do customization. In
some cases, a programmer must change or add source code
to make local adaptations. In other cases, tools supplied with
the application allow configuration changes that can be incor-
porated more easily and quickly in the application, but obvi-
ously with limits to the scope of customization.

CONCLUSION AND FUTURE DIRECTIONS
The technical infrastructure of a health information system
includes several key components that are unique to the
healthcare environment. A sound understanding of the attri-
butes of these components, as well as how they interact, is
essential for a successful system implementation that sup-
ports the needs of the clinician users. No single off-the-shelf
system today can support all needs of the healthcare environ-
ment. Therefore it is critical that the technical architecture be
capable of supporting multiple system connections and data
interoperability. More functionality will also become available

from third-party vendors, and infrastructures should be
designed to support linking these capabilities directly to the
clinical workflow. It should also be expected that the desire,
and requirement, to share data outside an institution’s walls
would expand. The informatics role will continue to grow
as the need to understand new technologies, as well as how
they can be combined with existing systems and exploited
in the healthcare environment, gains heightened importance.

Many new technologies are being explored or contem-
plated for health IT infrastructure. Most of these technologies
are not new to other industries; healthcare has been much
slower to adopt IT in general. In some cases, these technolo-
gies have been implemented in organizations that possess
strong informatics experience and/or financial resources,
but they have not been employed more widely. Certainly,
the increasingly technology-savvy clinicians practicing at
healthcare institutions are demanding functionality that looks
more like what they use daily in web-based applications,
smartphones, and tablet computers.

Mobile Apps
The growing use of mobile electronic devices has resulted in
an explosion of smarter technologies for operating systems,
user interfaces, and applications. Apple advertised more than
1.5 million apps available for its iPhone and iPad as of July
2015. Google advertises 1.6 million apps for its Android
operating system, which is used in smartphones and tablets.
Over 165,000 of the available mobile apps can be categorized
as mobile health (mHealth) applications, and that number is
growing (see Chapter 15 for detailed information). The apps
range from personal health and fitness, to medical reference
materials, to radiology image and diagnostic results viewers,
to robust clinical documentation tools.

A valuable aspect of these apps is that they are easily
installed on a user’s device. They are typically much cheaper
than applications that run on laptop and desktop computers.
The ability to “carry” the app anywhere the user goes and
remain connected to an institution’s network (through a
cellular or wireless network) is appealing to clinicians who
roam to several locations throughout their workday. The
volume, ease of installation, and low cost of apps can provide
a much more “ democratic” user voice in the selection of apps
that are most useful or appealing to the user. The lightweight
nature of mobile apps and the use of common user interface
and application programming interface standards may make
it easier for healthcare institutions to develop their own apps,
customized to local needs.

There are challenges, however, to the use of mobile apps in
the healthcare setting. First, the small screen factor of mobile
devices limits the amount of information that may be dis-
played or collected. This can mean scrolling or paging
through many screens to eventually get to the information
needed by the clinician. It also may be easier to miss impor-
tant information on the screen because of the smaller font and
image sizes. Wireless networking may be another challenge
for healthcare institutions. The increasing number of mobile
devices in a healthcare facility, coupled with the “chatty”

85CHAPTER 5 Technical Infrastructure to Support Healthcare

Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu

https://platform.virdocs.com/rscontent/epub/582951/1629902/OEBPS/xhtml/page-115.xhtml?#spNone

nature of many mobile apps, may overwhelm a hospital or
clinic network. Organizations may need to develop support
for virtual private networks to accommodate users who wish
to use their mobile devices and apps outside the institution’s
walls. IT departments also must be able to handle devices
brought into a facility by clinicians who are not employed
by the organization, leading to potentially significant support
and security issues. Finally, although the “democratization” of
apps referred to earlier may seem at first blush to be a positive
trait, a healthcare institution must be concerned with the sup-
port, data, process standardization, and security issues that
may ensue. If clinicians are free to choose any app (e.g., for
charting vital signs or ordering), will those apps be able to
access and store data in the institution’s required format,
run decision support rules required for patient safety and
quality reporting, and share information with co-workers
and referral partners?

Service-Oriented Architecture
There has been much hype for years in the IT industry in gen-
eral about service-oriented architecture (SOA), and health-
care has certainly been an active topic area in the discussion.
SOA can be described as an architecture design pattern in
which services are business oriented, loosely coupled with
other services and system components, vendor and platform
independent, message based, and encapsulated with internal
architecture and program flow that are hidden from the service
user. SOA services are most evident today as web-based (URL)
services that are accessed through Hypertext Transfer Protocol
(HTTP). Extensible Markup Language (XML) and JavaScript
Object Notation (JSON) are commonly used as the message
formats. The interface to a web service, including its allowed
input parameters and return data, is often described using
the Web Services Description Language (WSDL).27 SOA fits
in the SaaS category of cloud computing, but it has much more
highly defined design and implementation patterns.

What this means to IT is potentially a more decentralized
approach to system design in which solution providers con-
centrate on specific aspects of a business need. System archi-
tects can pull together many business services to meet the
larger application needs of the organization without having
to worry about the complexity inside the service code. Reuse
is a key benefit of SOA because services may be used by dif-
ferent consumers for a variety of applications. Because the
services are loosely coupled with each other and with other
aspects of the service user’s system, service code may be chan-
ged and enhanced without necessarily having to change other
aspects of the overall consuming system. Changes can easily
be communicated to service users through updates in a
service’s WSDL.

The SOA design philosophy has been researched in health-
care for a number of years. A joint effort by HL7 and the Object
Management Group (OMG) to develop standards for health-
care services has resulted in the Healthcare Services Specifica-
tion Project (HSSP).28,29 HSSP has been investigating several
health IT functional areas that could become the building
blocks for EHR services. One example is CDS.30 By exposing

CDS services over the web, users would be able to access
CDS content from a variety of sources without having to main-
tain the content locally. Other areas being pursued by HSSP
include services for terminology mediation and clinical data
access and update.

Because no single vendor product can meet all needs of a
healthcare enterprise, vendors and market segments (e.g.,
pharmacy fulfillment and HIE) are also incorporating SOA
principles in their architectures in order to more easily and
quickly provide functionality to users. Whether a major
EHR product will ever be entirely composed of SOA services
supplied by third-party providers is an open question, but it is
likely that health IT infrastructures will provide increased
support for services as standards continue to emerge and ser-
vice providers become more numerous and relevant to the
healthcare community.

One emerging technology that is capturing the attention of
the provider, vendor, and standards communities is Fast
Healthcare Interoperability Resources (FHIR).31 Currently a
draft HL7 standard, FHIR combines features from HL7 v2,
v3, and CDA with a foundation in existing web messaging
standards such as HTTP, XML, JSON, and REST (represen-
tational state transfer). As its name implies, it is designed to
provide a faster path to system interoperability. The common
building blocks of FHIR are called “Resources.” Resources
describe a specific type of exchange, which includes the type
of information being exchanged (e.g., patient demographics,
conditions, and medications) and the type of interaction (e.g.,
search, read, and update). The ease of use of the standard has
encouraged several major electronic medical record (EMR)
vendors to begin building FHIR interfaces to their systems,
demonstrating a long-sought desire for open, nonproprietary
services that others may use to access data and build third-
party applications.

Open Source Software
Open source software (OSS) can be defined as software whose
source code is made available to users, who then may be able
to examine, change, and even redistribute the code according
to the software’s open source license. OSS is often developed
in a public forum in which many programmers from different
organizations, or acting as independent agents, contribute to
the code base. There is typically a central code repository
where all contributors place their updates and where users
can download the latest versions of code or compiled objects.
Users may also keep a list of bug reports and feature requests.
Open source advocates believe that OSS may be more secure,
bug-free, interoperable, and relevant to specific user needs
than proprietary (vendor) software is because a more hetero-
geneous group of individuals with varying uses for the soft-
ware has direct access to the source code. Some noted
examples of OSS are the Apache HTTP web server, the Linux
and Android operating systems, the Eclipse software develop-
ment platform, the Mozilla Firefox web browser, and the
OpenOffice software suite.

Several examples of OSS exist in the healthcare arena. EHR
applications include OpenMRS, a multi-institution project

86 UNIT 1 Foundational Information in Health Informatics

Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu

https://platform.virdocs.com/rscontent/epub/582951/1629902/OEBPS/xhtml/page-116.xhtml?#spNone

led by the Regenstrief Institute and Partners In Health, a
Boston-based philanthropic organization,32 and OpenEHR,
an ONC-certified ambulatory EHR.33 The U.S. Department
of Veterans Affairs is seeking to develop an open source ver-
sion of its VistA EHR.34 The openEHR Foundation is devel-
oping open clinical archetypes (standard data models) to
promote sharable and computable information.35 Open
source, standards-based CDS tools and resources are being
developed as part of OpenCDS.36,37 Mirth Connect is an
OSS IE that is built for HL7 integration.38 Apelon provides
its terminology engine, Distributed Terminology System
(DTS), as an open source platform39; 3 M Health Information
Systems has announced that it has made its health data dic-
tionary available through open source.40,41 FHIR (described
above) is another example of OSS. These examples, and the
many more in development or production, point to a future
health IT infrastructure environment with wider clinician col-
laboration and less expensive software licensing costs. How-
ever, organizations need to be aware that “ open source” does
not mean free; they must budget for local customization,
implementation, training, support, and hardware costs.

SMART
Through its Strategic Health IT Advanced Research Projects
(SHARP), the ONC funded the Harvard-based Substitutable
Medical Applications, Reusable Technologies (SMART) Plat-
forms project.42 The goal of SMART is to provide a health IT
platformbasedoncoreservicesthatallowsappstobesubstituted
easily. Inspired by the boom in mobile apps for cell phones and
tablets, researchers have developed an application ecosystem in
which data can be accessed easily and presented to apps con-
structed for specific purposes. The apps can be bundled to pro-
vide an entire health IT solution. Institutions can decide which
apps their “containers” will deploy for their clinicians based on
local needs and specific app aspects such as security capabilities.
The API is open source, allowing anyone to develop new appli-
cations, which can then be provided to the user community as
open or closed source code. A government-funded effort ini-
tially, it will be interesting to see whether the SMART platform
will be adopted widely by the healthcare provider and vendor
community or if a similar effort may compete with SMART.
A recent initiative with FHIR, SMART on FHIR43,hascom-
bined the open application technology of SMART with the
open-exchange standard in FHIR, to provide interesting new
possibilities for health application development.

REFERENCES
1. Clayton PD, Narus SP, Huff SM, et al. Building a comprehensive

clinical information system from components: the approach at
Intermountain Health Care. Methods Inf Med. 2003;42(1):1–7.

2. Gostin L. Health care information and the protection of personal
privacy: ethical and legal considerations. Ann Intern Med.
1997;127(8 Pt 2):683–690.

3. Marietti C. The eyes have it: CCOW (Clinical Context Object
Workgroup) brings both cooperation and competition together
to tackle visual integration. Healthc Inform. 1998;15(6):39.

4. Berger RG, Baba J. The realities of implementation of Clinical
Context Object Workgroup (CCOW) standards for integration
of vendor disparate clinical software in a large medical center.
Int J Med Inform. 2009;78(6):386–390.

5. Cimino JJ, Li J, Bakken S, Patel VL. Theoretical, empirical and
practical approaches to resolving the unmet information needs
of clinical information system users. Proc AMIA Symp.
2002;170–174.

6. Reichert JC, Glasgow M, Narus SP, Clayton PD. Using
LOINC to link an EMR to the pertinent paragraph in a
structured reference knowledge base. Proc AMIA Symp.
2002;652–656.

7. Cimino JJ, Li J. Sharing Infobuttons to resolve clinicians’
information needs. AMIA Annu Symp Proc. 2003;815.

8. Collins S, Bakken S, Cimino JJ, Currie L. A methodology for
meeting context-specific information needs related to nursing
orders. AMIA Annu Symp Proc. 2007;155–159.

9. Del Fiol G, Huser V, Strasberg HR, Maviglia SM, Curtis C,
Cimino JJ. Implementations of the HL7 context-aware
knowledge retrieval (“Infobutton”) standard: challenges,
strengths, limitations, and uptake. J Biomed Inform. 2012;45
(4):726–735.

10. Weir CR, Nebeker JJ, Hicken BL, Campo R, Drews F, Lebar B. A
cognitive task analysis of information management strategies in
a computerized provider order entry environment. J Am Med
Inform Assoc. 2007;14(1):65–75.

11. Centers for Medicare & Medicaid Services (CMS). Electronic
Health Records (EHR) Incentive Programs; 2015. https://www.
cms.gov/Regulations-and-Guidance/Legislation/
EHRIncentivePrograms/index.html?redirect¼ /
ehrincentiveprograms.

12. Anderson C, Sensmeier J. Alliance for nursing informatics
provides key elements for “ Meaningful Use” dialogue. Comput
Inform Nurs. 2009;27(4):266–267.

13. Forrey AW, McDonald CJ, DeMoor G, et al. Logical Observation
Identifier Names and Codes (LOINC) database: a public use set
of codes and names for electronic reporting of clinical laboratory
test results. Clin Chem. 1996;42(1):81–90.

14. Huff SM, Rocha RA, McDonald CJ, et al. Development of the
Logical Observation Identifier Names and Codes (LOINC)
vocabulary. J Am Med Inform Assoc. 1998;5(3):276–292.

15. Logical Observation Identifier Names and Codes (LOINC).
Regenstrief Institute; 2015. http://loinc.org.

16. Sittig DF, Wright A, Simonaitis L, et al. The state of the art in
clinical knowledge management: an inventory of tools and
techniques. Int J Med Inform. 2010;79(1):44–57.

17. Hulse NC, Rocha RA, Del Fiol G, Bradshaw RL, Hanna TP,
Roemer LK. KAT: a flexible XML-based knowledge authoring
environment. J Am Med Inform Assoc. 2005;12(4):418–430.

18. Rocha RA, Bradshaw RL, Bigelow SM, et al. Towards ubiquitous
peer review strategies to sustain and enhance a clinical
knowledge management framework. AMIA Annu Symp Proc.
2006;654–658.

19. Health Level Seven International (HL7). http://www.hl7.org;
2015.

20. eHealth Exchange. The Sequoia Project; 2015. http://
sequoiaproject.org/ehealth-exchange/.

21. CONNECT Community Portal. http://www.connectopensource.
org/; 2015.

22. The Direct Project. http://wiki.directproject.org; 2015.
23. Office of the National Coordinator for Health Information

Technology. Connecting Health and Care for the Nation:

87CHAPTER 5 Technical Infrastructure to Support Healthcare

Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu
Person
al use o
nly, do
not repr
oduce.
2020-09
-04
shayna
.rocourt
@stude
nt.ashfo
rd.edu

https://platform.virdocs.com/rscontent/epub/582951/1629902/OEBPS/xhtml/page-117.xhtml?#spNone

https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms

http://loinc.org/

http://www.hl7.org/

http://sequoiaproject.org/ehealth-exchange/

http://www.connectopensource.org/

http://wiki.directproject.org/

Turn in your highest-quality paper
Get a qualified writer to help you with

“ Week 2 Disscussion Again ”

Get high-quality paper

NEW! AI matching with writer

Hire a Writer

Client Reviews

4.9

Sitejabber

4.6

Trustpilot

4.8

Our Guarantees

100% Confidentiality

Information about customers is confidential and never disclosed to third parties.

Original Writing

We complete all papers from scratch. You can get a plagiarism report.

Timely Delivery

No missed deadlines – 97% of assignments are completed in time.

Money Back

If you're confident that a writer didn't follow your order details, ask for a refund.

New to Your Trusted Assignment Help Service? Sign up & Save

Calculate the price of your order

Type of paper needed:

Pages:

You will get a personal manager and a discount.

Academic level:

We'll send you the first draft for approval by at

Total price:

$0.00

Power up Your Academic Success with the
Team of Professionals. We’ve Got Your Back.

Power up Your Study Success with Experts We’ve Got Your Back.

Order Now Order Now