From the CIHS Video Series “Ten Minutes at a Time”

Series 2: Project ManagementAdvanced Project Management for Behavioral Health Electronic Health Records (EHRs) From the CIHS Video Series “Ten Minutes at a Time” 9/2013

Module 8: Three Basic Types of Information Technology Networks for EHRs. Overview • Five key terms • Two related to EHR implementation • Three related to information technology • Three basic models of IT architecture for implementing Electronic Health Records (EHRs) • Software-as-a-Service (SaaS), Client-Server, Web-based (Active Server Pages (ASP) in the MS .NET Framework) • Pros and cons associated with each type • No model is superior to another • Must assess requirements and resources to identify the solution that best fits your needs

Introduction • Using an Electronic Health Record requires an electronic network • Will determine the bulk of start-up costs and long-term costs • Electronic networks need four basic parts: • Computers that people can use to enter and to access stored information and to access services – for example, using a printer. These are called personal computers or terminals. • Computer “servers” that manage access • Computers that store information in a format that makes it retrievable • Software applications that allow the various devices to interact, ensuring access by authorized users and protection from unauthorized users. • How these parts are set up to work together is the “Information Technology Architecture” • EHRs are usually designed to work exclusively in one of three types of IT architectures

Two Key Terms - EHRs • Configurable –Software can be modified to a degree, as long as the modifications do not affect “core” functionality. For example, fields can be added to an existing screen, field labels may be changed, new screens can be added • Customizable – Software can be modified to a greater extent, including those parts of the software that are related to “core” functionality.

Three Key Terms - IT • Information Technology Architecture - How the gap is bridged between the person who needs to use the software and access the patient data, and the patient data and software/hardware itself. • Server – A powerful computer or device that manages network resources. Different types of servers include database servers (respond to database queries), file servers (place to store and access files), print servers (manage the traffic among the different computers accessing the office printers) and Web servers. • Client – Computer workstation or personal computer (PC), • initiates contact with the server(s)

Model 1 • Pure “Client-Server:”Customer buys connectivity, hardware, IT staff to manage it and space for housing (“hosting”) it; pays licensing and maintenance fees for software application; can set up remote access using special types of connections; EHR business or developer support is an important component. Sometimes called “2-Tiered Architecture.” No access to the Internet. EHR Business Organization “A” uses “dumb” terminals that are only good for communicating with the computer • Examples • Systems with mainframe computers (instead of PCs) • Often found in hospitals Provides licensed copy of application, maintenance of software and ongoing customer service Network servers do all of the computing work Remote access requires special technology like Citrix, MS Terminal Services

Client-Server - Some Pros /Cons • PROs • Much greater flexibility for customization – core software can be developed or existing software can be modified (at a cost) to the customer’s specifications • Fast access to the data - vitally important in some health care settings • Better control over the data • CONs • Significant upfront costs for hardware and software; also requires IT staff with skill sets that may be expensive and/or hard to find • Many costs and risks devolve to the customer. Developer is only responsible for the software application, assistance with initial installation and configuration per the agreement / contract • Requires top-notch products and customer support - may be expensive and/or of low quality • Changes / updates can be surprisingly expensive

Model 2 • Pure “Software as a Service” (SaaS, sometimes“Cloud” computing) • All hardware and software is housed (“hosted”) and managed by the EHR company; developed specifically for access via the Internet using any kind of browser; usually subscription-service model (i.e., number of users = cost); “core” application is shared, the organization’s configuration and data are not; EHR business is 100% responsible for system (includes data, connectivity, hardware, software, staffing, etc.) Examples – “Salesforce,” (customer relationship management) “Sharepoint” (document sharing and management) “GoToWebinar” (“thin-client” for video and teleconferencing) Organization “A” Uses a PC and Internet in the office EHR Business Subscription allows access to software and data over the Internet from any location Software Server Database Server Organization “B” “A” data “B” data Uses PC and Internet from a remote area

“Software as a Service” Some Pros/Cons • PROs • Minimal start up costs and lower, predictable ongoing costs, scalable to number of users; can change to a different system quickly and easily • Lower level of all types of risk, including for project implementation; faster start-up, guaranteed functionality, more likely to “Go Live” as scheduled • Customer interface supports fast adoption; relatively easy to master learning curve; software updates transparent to customer • CONs • Customizations are not feasible and additional functionality requires a pool of customers who share the costs of development among themselves (new functionality is available to all of the EHR customers) • Slower, since data storage and retrieval rely on the Web • For a large organization with many end-users, costs may actually be higher over a period of time than some alternatives

Model 3 • Web-based (Active Server Pages (ASP).NET):Developed by Microsoft. Adds flexibility to the client-server model for dynamic Internet access that resembles the Software as a Service model; usually the customer (but sometimes the EHR business) hosts the hardware and software necessary to use the EHR. Sometimes called 3 or multi-tiered architecture. • Presentation Tier • User Interface • User Interface Logic • Translates tasks and results to something the user can understand • Data Tier • Information is stored and retrieved from database or file system • Passed to Logic Tier for processing • Logic Tier • Coordinates application • Processes commands • Makes logical decisions • Moves and processes data

Web-based Some Pros/Cons • PROs • Better flexibility on configuration and customization than SaaS – software can be configured using Web-based services; “customizations” are at least possible • May support better access to patient data for reporting and research • Supports unified information technology approach within the organization • Allows easy access using the Internet • CONs • Model still carries a significant upfront cost and long-term commitment; requires an IT staff with the appropriate skill sets and very good customer service • Slower than pure client-server due to interaction with the Web (although Web-services and improved, dedicated broadband access can make this less apparent to the end-user) • May require additional subscription fees if EHR business provides hosting services for the customer’s servers and database.

Summary • There may be some variation in how products are configured and sold, but three types of models dominate the market itself • Software-as-a-Service (SaaS) • Client-server • Active Server Pages (ASP) in the .NET Framework • Each model has advantages and disadvantages. Initial determinants are • What best matches your business requirements? • How much can your organization afford? • How much flexibility does your business really need?

We Have Solutions for Integrating Primary and Behavioral Healthcare Contact CIHS for all types of primary and behavioral health care integration technical assistance and training needs 1701 K Street NW, Ste 400 Washington DC 20006 Web: www.integration.samhsa.gov Email: integration@thenationalcouncil.org Phone: 202-684-7457 Prepared and presented by Colleen O’Donnell, MSW, PMP, CHTS-IM for the Center for Integrated Health Solutions

From the CIHS Video Series “Ten Minutes at a Time”