PowerPoint Presentation

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

Welcome to the SAMHSA-HRSA Center for Integrated Health Solutions video series Ten Minutes at a Time. This is Series 2 on Project Management. Modules 6-10 in this series focuses on advanced project management in the implementation of Behavioral Health EHRs. It can be used by PBHCI grantees to support meeting the HIT-related grant expectations. It can also be used by any Behavioral Health Provider who is interested in integrated primary and behavioral health care, meeting the standards for Meaningful Use, and/or implementing or upgrading an Electronic Health Record System. 1Module 8: Three Basic Types of Information Technology Networks for EHRs. OverviewFive key termsTwo related to EHR implementationThree 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 typeNo model is superior to anotherMust assess requirements and resources to identify the solution that best fits your needs

This is Module 8: Three Types of Information Technology Networks for Electronic Health Records. We will begin by looking at five key terms two related to EHRs themselves and three related to information technology. Then we will review the three basic models for information technology architecture, explaining the differences and similarities between Software as a Service, Client Server and Web-based. We will also review the pros and cons related to each approach. Understand that there is no approach that is intrinsically superior to another. The best approach is the one that meets your organizations requirements, within your budget. The goal of this module is to help you to know what to expect when you begin to evaluate different EHRs or consider upgrading your current system.

2IntroductionUsing an Electronic Health Record requires an electronic networkWill 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 accessComputers that store information in a format that makes it retrievableSoftware 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 ArchitectureEHRs are usually designed to work exclusively in one of three types of IT architectures

Lets start with a brief introduction. Electronic Health Records need an electronic network to operate. The type of network will determine the bulk of the start up and also the long term costs. This network requires computers that are a good fit for the software, computer servers to manage the flow of information and information access, computers for storing information in a way that makes it easily accessible, and the software applications needed to run the electronic network. The different ways that these components can be made to work together is called the information technology architecture. Most software is designed to work exclusively on one of three basic types of IT architecture. If you understand what you need and can afford, you can more easily narrow down the field of selections. 3Two Key Terms - EHRsConfigurable 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.

For the purposes of this discussion, the terms configurable and customizable concern the alterations that can be made to the software in order to accommodate the customer. Configuration refers to superficial changes that make the software more user-friendly for the customer. It is usually an expected part of the software implementation process and is not associated with an extra cost. You can think of it as being similar to selecting the paint, carpets and curtains for a new house that youve already paid for.

When the change concerns the core functionality of the EHR, it is considered a customization. This is more like taking down a section of the house itself to put up a new addition. Since it is an expensive and time consuming process that carries significant project risk, customizations are usually only requested when the EHR is missing functionality that the customer has to have to move forward. 4Three Key Terms - ITInformation 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)

Information Technology Architecture describes how the gaps are bridged between the person who needs to use the EHR and the EHR itself. Servers are computers that use software but they are much more powerful than the average home computer, with much faster and bigger hard drives and more memory. They are called servers because they serve up information and allow the user to access resources on a network examples of network resources include printers, files, and databases. When there is more than one computer accessing these resources, they help manage the traffic and ensure that resources are shared. The client is the computer workstation, the personal computer or PC that is used to transmit commands to the network, and that the network servers respond to. In case you are wondering, in this discussion PC retains its original meaning. It does not refer to operating systems, just to a personal computer workstation.5Model 1Pure 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.

Organization A uses dumb terminals that are only good for communicating with the computerProvides licensed copy of application, maintenance of software and ongoing customer service

Remote access requires special technology like Citrix, MS Terminal ServicesEHR BusinessExamples

Systems with mainframe computers (instead of PCs)

Often found in hospitals

Network servers do all of the computing work

We will start with the first model that emerged, the pure client-server model. In this model, the customer assumes all of the responsibilities and costs for the system with the exception of software development and maintenance. The EHR business retains that responsibility. They license the software to the customer, and charge for maintenance. This type of EHR business model requires strong customer support and is not scalable to the size of the business. For example, if there are 100 employees using the software, and 10 are laid off tomorrow, there is no change in the cost of the hardware that is used or in the software licensing and maintenance fees.

The client may not even be a PC the client server IT architecture often uses dumb computer terminals that do not run any software other than that necessary for communicating with the servers. Although it may sound dated, this model is still in use and is very well suited for certain types of work. It may be found in places like hospitals that need very large, very fast systems.

6Client-Server - Some Pros /ConsPROsMuch greater flexibility for customization core software can be developed or existing software can be modified (at a cost) to the customers specifications Fast access to the data - vitally important in some health care settingsBetter control over the dataCONsSignificant upfront costs for hardware and software; also requires IT staff with skill sets that may be expensive and/or hard to findMany costs and risks devolve to the customer. Developer is only responsible for the software application, assistance with initial installation and configuration per the agreement / contractRequires top-notch products and customer support - may be expensive and/or of low qualityChanges / updates can be surprisingly expensive

In some ways, the client-server model offers a certain amount of flexibility. The software applications that run on it can be developed just for the customer, designed to their requirements and specifications. There is also increased access to and control over the data. It requires special connections to access the Internet, so it cant easily communicate with external systems, but that also makes the system faster and much less vulnerable to Web-based attacks. All of this comes at considerable cost and project risk. The customer must know in advance what they need, and be able to communicate the necessary requirements. The customer builds and pays for the IT infrastructure that will support the use of the software, and they hire, train and then must retain the staff to run the in-house part of the system. Since software is usually only well understood by the developer or team of developers, customer service must be of the highest caliber. This can be difficult to ensure. Because it is essentially built from scratch, it is prone to project delays and unexpected expenses. 7Model 2Pure Software as a Service (SaaS, sometimesCloud 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 organizations configuration and data are not; EHR business is 100% responsible for system (includes data, connectivity, hardware, software, staffing, etc.)

Organization BDatabase ServerSoftware ServerExamples

Salesforce, (customer relationship management)

Sharepoint (document sharing and management)

GoToWebinar(thin-client for video and teleconferencing)EHR BusinessSubscription allows access to software and data over the Internet from any location

Organization AB dataA dataUses a PC and Internet in the office Uses PC and Internet from a remote area

The Software as a Service (or SaaS) model is becoming more and more common, as fast access to the internet becomes available, demand increases, and the type of technology necessary to provide this service becomes more affordable and available. In this model, EHR businesses assume the responsibility and associated costs for developing the software application and housing the network servers. The customer usually only needs access to the Internet and a subscription to the service. The software application is shared by all customers, but the respective databases are separate and secure. The interface is configured according to the individual customers specifications. In the subscription model, costs are scalable that is, they are directly proportional to the number of users who need access. This model is also able to take advantage of certain Web-based technologies that add flexibility and improve speed. Examples are plug-ins like the Flash media player, and thin clients for Active Server Pages They allow the active Web server to provide Web pages to the client using the common language of the Internet. 8PROsMinimal 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 scheduledCustomer interface supports fast adoption; relatively easy to master learning curve; software updates transparent to customer

CONsCustomizations 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 WebFor a large organization with many end-users, costs may actually be higher over a period of time than some alternativesSoftware as a Service Some Pros/Cons

The SaaS model is gaining momentum in the IT marketplace in general. In addition to low start-up costs, it offers sophisticated features that a single customer usually could not afford on their own. The customer can count on relatively simple implementations that dont carry a high level of risk. Because so many customers are using the same software, the version that your organization sees can be configured, but the software will not be customized unless there is a pool of customers who all require the same functionality. In that case, these customers bear the costs for development which is then made available to the entire customer base. Reliance on the Internet sometimes makes it slower than the client-server model. 9Model 3Web-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 InterfaceUser Interface Logic Translates tasks and results to something the user can understandLogic Tier Coordinates applicationProcesses commandsMakes logical decisionsMoves and processes dataData Tier Information is stored and retrieved from database or file systemPassed to Logic Tier for processing

Active Server Pages or ASP for the .NET Framework is basically the client-server model with some aspects of SaaS added on. These are often called Web-based software applications. The customer may assume most of the responsibilities and costs for the system just as they would in the client server model. The EHR business maintains and updates the software. The customers pay licensing and maintenance fees, or a per-user subscription fee, or even some combination of both. 10Web-based Some Pros/ConsPROsBetter flexibility on configuration and customization than SaaS software can be configured using Web-based services; customizations are at least possibleMay support better access to patient data for reporting and researchSupports unified information technology approach within the organizationAllows easy access using the Internet

CONsModel still carries a significant upfront cost and long-term commitment; requires an IT staff with the appropriate skill sets and very good customer serviceSlower 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 customers servers and database.

Because of its Internet connectivity, the Web-based model offers many options. The software application may be customizable. Dynamic Web-pages make it possible to use a wide range of Web-services to increase flexibility and access. All businesses need to have a strategy for implementing technology, and using Web-based EHRs improves the organizations ability to develop a unified approach to their IT portfolio this can make business processes simpler and less expensive to implement.

But like the client-server model, it carries significant upfront costs and a long term commitment, a solid IT staff and very good customer support. Because it is Web-based, it also has the disadvantage of being slower than pure client-server and it is more challenging to secure the data. It is also almost as prone to running into difficulties with time, cost and scope as the client-server model.11SummaryThere may be some variation in how products are configured and sold, but three types of models dominate the market itselfSoftware-as-a-Service (SaaS)Client-serverActive Server Pages (ASP) in the .NET Framework

Each model has advantages and disadvantages. Initial determinants areWhat best matches your business requirements? How much can your organization afford?How much flexibility does your business really need?

So, here are the important things to keep in mind. Of the three basic types of information technology architecture, the most significant considerations are start up costs and the resources needed to implement, manage and maintain the system over time. The next most significant consideration is your business requirements and how well the EHR can meet them. You must know what your organization needs and can afford before you can start shopping. Module 9 talks about how to identify these requirements. 12We 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.govEmail:integration@thenationalcouncil.orgPhone:202-684-7457

Prepared and presented by Colleen ODonnell, MSW, PMP, CHTS-IM for the Center for Integrated Health Solutions

Our thanks go to SAMHSA and to HRSA for providing support to the Center for Integrated Health Solutions (CIHS) for this and many other forms of training and technical assistance related to the integration of primary and behavioral health care. Please visit our web site at www.integration.samhsa.gov, email us at integration@thenationalcouncil.org, or just pick up the phone and give us a call at 202-684-7457.

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