HCA 521 Health Care Technologies And IT Infrastructure Exercises

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Fundamentals of Information
Systems
LEARNING OUTCOMES
H
After completing this chapter, you
I should be able to:
䊏
Understand fundamental G
concepts of computers
䊏
Discriminate between hardware and software
G
䊏
Define computer input and output
S
䊏
Discuss components of a database
䊏
Compare different types of
, computer data and explain relational data
䊏
䊏
䊏
Describe different types of computer networks
Understand how a wireless network functions
S
Understand how interoperability standards help disparate systems
H
exchange data
A
ACRONYMS USED IN CHAPTER
4
N
I
Acronyms are used extensively in both medicine and computers. The following
C
acronyms are used in this chapter.
ASCII
American Standard Code Q
for
LAN
Local-Area Network
Information Interchange U
LED
Light Emitting Diode
BLOB
Binary Large Object
MDS
Minimum Data Set
A
CAT
Computerized Axial Tomography
MRI
CCOW
Clinical Context Object Workgroup
CD
1
Computer Output to Laser
1Disk
Central Processing Unit
0
Digital Imaging and Communication
5
in Medicine
Digital Video Disk
T
Health Information Management
S
PACS OR PAC SYSTEM Picture Archiving
and Communication System
COLD
CPU
DICOM
DVD
HIM
Compact Disk
Magnetic Resonance Imaging
PDA
Personal Digital Assistant
PDF
Portable Document Format
PET
Positron Emission Tomography
POP3
Post Office Protocol, Version 3
RAID
Redundant Array of Independent Disks
RAM
Random Access Memory
Health Information System
RIS
Radiology Information System
HL7
Health Level 7
SAN
Storage Area Network
HTTP
Hypertext Transfer Protocol
SMTP
Simple Mail Transfer Protocol
IMAP
Internet Message Access Protocol
SSL
Secured Socket Layer
I/O
Input/Output
TCP/IP
Transmission Control
Protocol/Internet Protocol
TIFF
Tagged Image File Format
HIS
ISP
Internet Service Provider
JPEG
Joint Photographic Experts Group
74
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
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VPN
Virtual Private Network
WAN
Wide-Area Network
VOIP
Voice-Over-Internet Protocol
WI-FI
Wireless Fidelity
75
The Technology behind Health Systems
As a student of this course you probably already use computers, but depending on your previous
computer experience and previous courses you have taken, you may or may not understand them.
The purpose of this chapter is to familiarize you with some of the terminology and concepts that
make a computer work and that make dozens of computers work together as a health information
H
system (HIS).
Computer systems are generally discussed in terms of
I two components: hardware and
software.
G
Hardware
G
Hardware refers to the components you can physically see and touch: the computer, circuit
S
boards, computer chips, monitor screen, keyboard, mouse, cables, wires, printers, and so forth.
, later), the switches, routers, netWhen multiple computers are connected in a network (discussed
work cards, and cabling that connect them are also referred to as the hardware. Let’s look at some
specific types of hardware.
S
CPU
The central processing unit (CPU) is sometimes referred to as the computer’s brain. It is
H
usually a single chip, which controls the flow of information to and from other parts of the
A
computer. It often adds, subtracts, modifies, and otherwise “processes”
the information passing
through it according to instructions from the software.
N
MEMORY AND STORAGE Computers can hold vast quantities
I of information, but only a little of
it is in the CPU at any one time. Information not currently being processed is stored elsewhere.
Some of the places where it is stored include optical disksC
(CD or DVD), the hard drive, and
computer memory chips. In most cases, the computer can both
Qread the information stored on the
device and write (save) information back to the device.
U
Random access memory (RAM) chips keep information in electronic circuits, which operate
at or near the same speed as the CPU. This provides the CPUAwith the ability to access the infor-
mation it needs very quickly such that the CPU can read and write information to RAM almost
continuously. However, RAM information is only in memory while the computer is turned on.
1 memory chips hold only a certain
When the computer is turned off, the memory is cleared. Also,
quantity of information; anything more than the chip can hold
1 must be stored elsewhere.
Hard drives store information magnetically on disks that spin at high speeds inside a sealed
0 magnet, the information stored
unit. Unless the disk becomes damaged or exposed to a strong
there is stable, and is retained even when the power is turned 5
off. Hard drives can store vast quantities of information and are the computer’s principal storage device. The CPU can both save and
T drives are very fast, they are conretrieve information from the hard drive. Though modern hard
siderably slower than the purely electronic circuits of RAM S
memory.
Figure 4-1 allows you to identify many of the hardware components discussed in this section. Because it generates intense amounts of heat, the CPU is covered by metal fins (heat sink)
and a fan. The actual CPU is not visible in the picture.
Optical disks, such as CD-ROMs or DVDs, use lasers to burn information for long-term storage. The CPU can read and write optical disks just as it can hard drives, although an optical disk
transfers information slower than does a hard drive. The advantage of an optical disk is that the
storage is permanent. The disk is not affected by magnetism, has an extremely long life span, and
can be removed from the computer when not needed. Although each disk has a fixed capacity, an
unlimited number of disks can be used, making optical disks ideal for archiving records that are
not frequently accessed.
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
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FIGURE 4-1
Interior of
workstation
showing CPU,
RAM, ROM, and
optical and hard
drives.
H
I
G
G
S
,
S
H
A
N
Although certain types of optical disks are reusable, optical disks cannot be written over
accidentally. Optical disks are oftenIused for the transfer and storage of large radiology images.
They are a reliable media for permanent
C record archives.
Read-only memory (ROM) chips are computer chips with electronic circuits that retain inforQ or other parts of the computer can read a ROM chip as
mation when the power is off. The CPU
quickly as a RAM chip, but cannot U
accidentally write over the information stored on the ROM.
This type of memory is usually used to store instructions the computer needs to start up; also
devices within the computer such as A
the hard drive may store information about its configuration
on a ROM chip.
Magnetic tape was used in the early days of computing to actively store and retrieve data.
Today it is used only to back up data1stored on hard drives.
INPUT AND OUTPUT DEVICES
1
How does information get into the computer? Then once the
information is in the computer, how0do you see it? The computer terms for these concepts are
input (putting information in) and output
5 (information coming out of the computer). Sometimes
the abbreviation I/O is used, which simply stands for input/output.
The main devices for inputting T
information into the computer are the keyboard and mouse.
Likewise the most popular output device
S is the monitor or screen. Newer technology such as the
Tablet PC (shown later in Figure 4-3) and touch screens, which are often used in kiosks, combine
these functions, allowing the screen to act as both an input and an output device.
Printers are also output devices. The only output device for early computers was a teletype
printer. Even after monitors came into use as the predominant display technology, business
processes were so oriented toward paper records that most computer information was also
printed, wasting tons of paper that also had to be stored.
In the 21st century businesses and healthcare organizations are increasingly using scanners
to store images of documents instead of storing the paper documents. A scanner is an input device
that looks and works much like a modern office copier, except where a copier prints a copy, a
scanner sends it to a computer as a digital image. The image of the document can be retrieved and
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
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FUNDAMENTALS OF INFORMATION SYSTEMS
displayed on the computer screen or even reprinted whenever it is needed. A small scanner is shown in Figure 4-2.
However, if a document that an organization needs to
keep, such as financial and other reports, was originally
generated by a computer, then there is no need to waste
time and paper printing the computer report, then scanning it back in as a document image. Some systems can
directly create the report as an image file. This process,
sometimes referred to by the acronym COLD (computer
output to laser disk), will be discussed later in this chapter.
Other input devices include microphones and cameras, which can capture sound, digital pictures, and video
to be saved directly in the computer. The monitor screen
and computer speakers are the output devices for these H
types of files. Voice files and document image files can be
converted to computer data using special computer programsI(voice recognition and optical character recognition software, respectively).
G
Tablet PCs (Figure 4-3) and PDAs (personal digital assistants) can receive handwritten input.
G
Using an inkless pen, called a stylus, that will not damage the screen, the user writes on the
S
screen. Handwriting recognition software interprets the handwritten
characters and changes them
into typed letters and numbers, which can then be saved as computer data.
,
Medical images such as x-rays, CAT scans, MRIs, and PET scans are major input sources for
health information systems. These diagnostic devices are able to save images directly from the
medical device that captures them. Other medical devices that
Scan output their information to an
electronic patient chart include ultrasound and electrocardiogram devices and even those that
H
measure vital signs.
So far the input and output methods we have discussed are
A those by which humans and computers interact, but for sheer quantity of data input and output, the greatest volume is the elecN of input and output is conducted
tronic exchange between computers. A small portion of this type
using the memory storage devices we discussed earlier: CD-ROM,
DVD, and portable RAM
I
devices. However, most of the data exchanged between of computers is via networks, which are
C
discussed later in this chapter.
Because our primary method of inputtingQinformation into the computer is
keyboarding, and our primary method of using that information
U is looking at a screen, workers
who use a computer all day can develop various ailments
A
from repeating the same motions, sitting at the same
angle to the monitor, screen glare, and other factors.
Computer ergonomics is the study of the physical effect of
1
human/computer interaction on workers with the goal of
1
minimizing or eliminating problems.
Ergonomics in the healthcare workplace goes beyond 0
the computers. It is applied to the height and shape of
desks, nurses’ stations, wall units, portable carts, and the 5
height at which monitors are mounted. Another consider- T
ation unique to healthcare is the ability to protect the keyboard, mouse, and the screens of portable devices so they S
can be sanitized without damaging the electronics.
Figure 4-4 shows a workstation mounted at a nurses’
station using a bracket that allows the user to adjust the
height and angle of both the monitor and keyboard for
maximum ergonomics.
ERGONOMICS
77
FIGURE 4-2
A scanner captures
an image of a
document.
(Courtesy of Allscripts,
LLC.)
FIGURE 4-3
Clinician using a
tablet PC.
(Courtesy of GE Healthcare.)
Software
The second major component of our discussion is software.
It consists of the logic, programs, and routines that make the
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hardware useful and provide instructions to the computer for processing the information it receives. It is referred to as “soft” because it is
intangible. Unlike hardware, you cannot physically touch it. When
you turn on your computer and when you start a desired program,
those programs are temporarily loaded in the CPU and RAM. When
you close a program those functions disappear.
Our discussion of software will be broadly grouped into two
types: operating system software and application software.
FIGURE 4-4
Ergonomically
mounted
workstation in a
nursing unit.
OPERATING SYSTEMS Operating system software consists of
programs that enable us to work with a computer’s hardware. This
type of software includes functions that allow the CPU and other
control chips to operate the monitor display, memory storage
devices, and input/output devices, including the keyboard and
HYou are probably most familiar with the Windows® or
mouse.
Macintosh
I operating systems; however, in HIS environments you
may also find UNIX®, AIX®, HP-UX®, and LINUX®, which are
G
also operating systems.
An
Goperating system is not simply a single program, but rather
thousands of little functions and programs that perform different
S
operations. Generations of computer science advances have evolved
,
into today’s
operating systems, making it possible for you to click
the mouse, start a program, and see the characters you type appear
on the screen. A few of the layers of this underlying technology
S
are explained
in the later section titled Bits and Bytes—How
Computers
“Think.”
H
In a healthcare facility most of the computers are linked
A software is part of the operating systems just discussed,
together into a network. The networking
but we will learn more about networks
N later in this chapter.
APPLICATION SOFTWARE Applications
I are the software that you use every day. They make the
computer “apply” to the task we need done. A word processor is a good example of application
C between an operating system and application software,
software. To understand the differences
consider this simple example: Let us
Qsay you want to write a paper for class. You click on the
word processor icon on your computer screen and the operating system loads the software into
U
the CPU. You type your paper, spell check it, save it, and print it out.
During your word processing session,
A the operating system handled the many things common to all applications. It captured the signals from the keyboard and mouse, interpreted what
letters they were, and provided those to the application. In contrast, the word processor kept track
1 were spelled correctly, and when it was time to go to the
of how characters formed words, if they
next line and start a new paragraph 1
or a new page. The application allowed you to decide what
font was used and whether or not to center the title of your paper. Meanwhile, with each key0
stroke, the operating system communicated
with your monitor so the characters appeared on
your screen.
5
When you saved your work, the application called on the operating system, which stored it
on the hard disk and kept track of itsTlocation for future retrieval. When you printed your paper,
the application software sent not only
S the text but information about the margins, font changes,
ink color, and so forth. However, it was the operating system that located the printer device, set
up communications with it, regulated how fast the text was sent to it, and kept track of the
printer’s progress.
Unless you choose to become a computer or network technician, almost everything you do
on a computer in an HIM profession will be focused on application software. Examples of HIS
applications include patient registration and scheduling software, electronic health records, clinical
information systems, computerized order entry systems, billing and coding software, document
imaging systems, radiology information systems, and laboratory information systems, as well as
generalized applications such as word processing, spreadsheets, and e-mail. Some of these applications will be discussed in more depth in later chapters.
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Bits and Bytes—How Computers “Think”
1
Computer processor and memory chips contain millions of transistors, each of which act like an
on/off switch. These represent the smallest unit of information in the computer called a bit. Bits
represent the values zero and one. If the transistor switch is off, the bit is zero; if the transistor
switch is on, the bit is one. Imagine that the eight LED lights in Figure 4-5 represent a group of
eight bits. Where the LED is green, the bit is on; where it is off, the LED is not lit.
Look at the number next to each LED in Figure 4-5; notice that each successive number is
twice as large as the one above it. When bits are grouped together, each succeeding bit in the
group represents a number twice as large as the previous bit. From this humble beginning, the
computer forms a binary number system. Binary means made up of two parts, in this case zero
and a designated number.
Eight bits, grouped together, form the basic unit of computing called a byte. Figure 4-5 has
eight bits, therefore it also illustrates one byte. The value of a byte is the cumulative total of its
bits which are “on.” For instance, in Figure 4-5 the LEDs next
H to bits 1 and 64 are on; the other
LEDs represent bits that are “off” or zero. The sum of bits that are “on” represents the value of
I
the byte, which in this figure is 65.
G to do math. For example, to add
Logically, you can see how a computer could use this system
four to this number, turn on the third bit. The sum of the byteGwould then be (1 ⫹ 4 ⫹ 64 ⫽ 69).
However, most of the data we see in the computer consists of letters, words, names, so how do
S
bits become alphabetical?
In 1963 the American Standard Code for Information Interchange
(ASCII) standardized text
,
bytes by assigning a meaning to each possible combination of bits.1 Bytes with values of 1
through 31 are used to control the flow of information in the computer. Bytes with values of 32
through 126 represent printable characters of the alphabet, punctuation,
and numerals. Bytes with
S
values of 128 through 255 are used as for extended characters. As an example, the table shown
H
later in Figure 4-7 lists the values assigned to the alphabet characters
in ASCII. For example, the
value 65 shown in Figure 4-5 equates to the letter “A” in theA
ASCII standard.
Although everything in computer memory is a function of bits being on or off, not everything
N on, the highest number the comis limited to 8-bit bytes. If all of the bits in Figure 4-6 are turned
puter could calculate would be 256. To go beyond this limit,
I data types are defined that use a
larger number of bits. For example, a numeric integer is 16 bits. Integers can be used for whole
C
numbers from –32,767 to 32,767. Long integers use 32 bits to handle larger whole numbers.
Numeric data that has decimal fractions is a data type calledQ
double, which has 64 bits.
2
79
4
8
16
32
64
128
FIGURE 4-5
LED lights
illustrate 8 bits.
1
2
4
8
16
32
64
128
256
FIGURE 4-6
Maximum value of
a byte is 256.
EXTENDING FUNCTIONALITY So it’s all math, right? Well,U
actually that is true. The genius of
modern computer science has been the ability to take the basic
A arithmetic function derived from
turning bits on and off and extend it into all of the possible data types we use today. Take color
for example.
The smallest dot on a computer screen, called a pixel, can
1 be displayed in millions of colors
by using a large number of bits. If the pixel data were one bit, the only colors would be white (bit
1 it can display 256 colors. When
on) or black (bit off)—but define that pixel as eight bits and
image data is defined as true color, it uses 32 bits and suddenly
0 the computer can render all the
nuances of a CAT scan or an MRI.
5 circuits in the scanner capture the
When images are scanned into a medical record, electronic
reflection of each pixel on the page and express it as a numerical
T value. The computer stores these
digits in a file that it recognizes as image data.
S of a doctor dictating a note. A
Similarly, with sound files, a microphone captures the voice
sound card converts the electrical signal into numbers representing the frequency of the sound
wave at each instant. Computer software stores these in a file it recognizes as a sound file.
Even the computer software is really just ones and zeros stored in a type of file that the computer recognizes as program instructions. Virtually, everything in computer processing is a function of handling bits in specific size groups, defined as specific data types.
1
ASCII characters use only seven bits. The eighth bit, called the parity bit, was originally reserved for error checking.
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All that we see and hear from the computer is really just a marvelous expression derived
from binary math. Computer science has built layer upon layer of functionality over these fundamental concepts, so that the user and even the programmer seldom need to think of bits and bytes.
Although an operating system’s “data type” refers to how bits are grouped into logical units,
in application software “data type” refers to how data is used: as a text character, a date, a mathematical value, and so forth. Hereafter, when we refer to a data type, we will be referring to the
application-level definition.
Databases
Thus far we have discussed the operating system and application software in terms of its ability to
store, retrieve, and process information. In computer systems, information that is input is called
data. Data is stored in an arrangement
H defined by the software to make it easy to identify and
retrieve the data later. The structure defined by the application to hold the data is called a database.
I
Healthcare systems typically have numerous
databases.
A database can be structured inG
any of many different ways, but before exploring different
types of databases, let us first discuss some of the key concepts of data.
G
Characters
S
A character is the smallest unit of ,text data. Text characters (sometimes called alphanumeric
characters) are limited to letters, numbers, a space, and punctuation marks as defined in the
ASCII table shown in Figure 4-7. Some application software disallows certain punctuation
marks; other software permits special
Ssymbols such as © to be used as data.
H
Fields separate data into defined units
Athat can be recognized later. For example, when you look
at an envelope, your brain recognizes the street, city, state, and zip code by the way they are sepN
arated and the order in which they appear. Similarly, a database may have separate fields for the
street address, the city, state, and zipI code.
Storing data in defined fields not only allows the application software to retrieve and redisC
play the data in the correct form, but it also allows the software to find and process pieces of data
quickly. For example, having the zipQ
code in its own field would make it possible for the application to sort and print addresses in zipUcode order.
A
Fields
FIGURE 4-7
Decimal values for
alphabet
characters in the
ASCII table.
Alphabet Portion of the ASCII Table (abridged)
Value
Char.
Uppercase
Value
Char.
75
K
1
1
0
5
T
S
Value
Char.
Value
Char.
Value
Char.
86
V
95
e
106
p
87
W
96
f
107
q
88
X
97
g
108
r
89
Y
98
h
109
s
90
Z
99
i
110
t
100
j
111
u
101
k
112
v
65
A
76
L
66
B
77
M
67
C
78
N
68
D
79
O
69
E
80
P
70
F
81
Q
71
G
82
R
91
a
102
l
113
w
72
H
83
S
92
b
103
m
114
x
73
I
84
T
93
c
104
n
115
y
74
J
85
U
94
d
105
o
116
z
Lowercase
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81
Fields not only separate data into logical groups, but define the type of data in the field as
well. Some basic field types are alphanumeric (text), numeric, and dates. Numeric fields are further defined as integers (whole numbers) or decimal numbers such as money.
Field types help the computer display and process the data correctly. For example, to print a
report in chronological order, the computer needs to know that the number in a date field represents year, month, and day. When printing the amount field on the patient bill, the computer needs
to know that the value in the numeric field is monetary and should be printed with two decimal
places.
Records
The next level of a database is a record. Records are made up of a group fields about a specific
thing. For example, an address record may contain the fields for street address, city, state, and zip
code. One record would hold the address data for patient Gloria Green; a separate address record
Hcould have thousands of address
would hold the address data for Rosa Garcia. The database
records for thousands of patients, but each record would have
I the same group of fields, arranged
in the same order.
G type of record can be made up of
A database will have many different types of records. Each
different fields, arranged in a different order, for a different purpose.
We have discussed a record
G
type for a patient’s address, but the database also has a record type for the patient’s insurance
S
information, and yet another record type for the patient’s visit.
Although spreadsheet programs are far simpler than the, databases in healthcare, if you are
familiar with Excel® you may be able to visualize the concepts of fields, records, tables, and files.
For example, Figure 4-8 shows an Excel file containing patient information. Think of rows 2, 3,
and 4 as records of data—one for each patient. Think of the S
columns as fields. Notice how each
record has the same number of fields, even if there is no data. For example, Mr. Baker has no midH
dle name, but the place for the middle name is reserved.
A
N
How are records stored? Some databases are a collection of many separate files, each holding a
I
certain type of record. Other databases store all types of records in one or more large files and
then define tables to group records of the same type together.CSeveral data tables are shown later
in Figure 4-10.
Q
DATA DICTIONARY Figure 4-8 was intended merely to provide a visual concept. A database
U
would not usually have the field names in the data table. Fields and tables are defined elsewhere
in the database or application and are referred to as the data A
dictionary.
Files and Tables
1
1
0
5
T
S
FIGURE 4-8
Excel spreadsheet
of patient
information.
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Patient Info Table
Field Name
Len.
Data Type
Pat_#
12
Integer
Last_Name
22
Alpha
First_Name
15
Alpha
Middle_Name
15
Alpha
Birthdate
10
Date
Patient Address
Field Name
Pat_#
Address
City
State
Zip
Field Name
Pat_#
Encounter_#
Date
Time
Provider_#
Field Name
Provider_#
Last_Name
First_Name
Middle_Name
Credentials
FIGURE 4-9
HLen.
I 12
G25
G25
S2
,
10
S Patient Visits
HLen.
A12
N15
I 10
C5
Q4
U
AProvider Info Table
Len.
112
122
015
515
T10
S
Data Type
Long Integer
Alpha
Alpha
Alpha
Alpha
Data Type
Long Integer
Double
Date
Alpha
Integer
Data Type
Integer
Alpha
Alpha
Alpha
Alpha
Data dictionary tables.
The data dictionary defines the field name, the maximum length of data the field can
hold, and the type of data the field will contain. It also defines the record layout; that is, the
order of the fields in the record. Figure 4-9 illustrates a data dictionary for the tables used in
Figure 4-10.
Figure 4-10 illustrates the data from four different tables. The columns represent the fields,
and the rows represent the records. Each table holds a different kind of data.
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83
Patient Info Table
Pat_#
Last_Name
First_Name
Middle_Name
Birthdate
59301
Garcia
Rosa
Marie
19781229
18889
Green
Gloria
Leigh
19511202
1398
Baker
Harold
19680118
Patient Address Table
Pat_#
Address
City
59301
1301 Paces Ferry Rd
Atlanta
State
Zip
GA
30339-1301
Pat_#
Encounter_#
Date
59301
100875
20071220
HGA
I GA
G
G
STime
, 09:00
59301
111219
20080211
11:15
59301
120547
18889
1398
3529 Cobb Dr
Smyrna
9856 Peachtree Rd
Atlanta
Patient Visits Table
Provider_#
1
2
3
FIGURE 4-10
30080-3529
30305-9856
Provider_#
1
2
S16:30
1
H
Provider Info Table A
Last_Name
First_Name
Credentials
NMiddle_Name
I Carl
Jones
Clive
MD
CAnn
Smith
Marsha
ARNP
Q
Lopez
Roseanne
MD
Data tables for patients, addresses, U
encounters and providers.
A
RELATIONAL DATA
20080601
1
The data dictionary may also indicate the relationship between records in
1 to be very efficient. Long pieces
one table to related records in another. Databases are designed
of information that will be used many times can be stored once, and referenced only by an ID
0
field that takes less space to store. Two examples of this can be found in Figure 4-10:
5
䊏
䊏
The HIS registration system has assigned each patient a unique ID number (stored in the
T do not need the entire name, only
first field). The Patient Address and Patient Visits records
the patient ID. Each time the application reads an address
S or visit record, it can automatically retrieve the patient’s name from the related Patient Info record.
A second example, similar in concept, is that the Patient Visits records do not need to
repeatedly store the full name of the doctor in every encounter record. It is only necessary
to use an ID field that relates to a table of providers in the practice.
Virtually all healthcare information systems use relational databases. Well-designed relational databases store information efficiently, retrieve data very quickly, and expand easily as the
organization’s data grows.
Figure 4-11 illustrates how data from the different database tables in Figure 4-10 is used
when printing a patient statement.
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FIGURE 4-11
Information from
different database
tables is used to
print a patient’s
bill.
P.O. Box 811
Atlanta, GA 30305-0811
PHONE (404) 555-2010
TO
Patient ID 59301
DATE
Patient
May 31, 2010
Rosa Garcia
1301 Paces Ferry Rd
Atlanta, GA 30339-1301
Database
DESCRIPTION
Visit Records
Provider
DOCTOR
AMOUNT
05/16/2010 Extended Office Visit (Est. Patient)
Clive
Jones, MD
70.00
05/23/2010 Brief Office Visit (Est. Patient)
Marsha
Smith,
ARNP
45.00
Address
H
I
G
G
S
,
SUBTOTAL
Patient is responsible for balances not paid by insurance
FIGURE 4-12
Photo of
wildflowers (inset)
enlarged to show
pixels in one
flower.
STATEMENT
GOOD HEALTH ASSOCIATES
BILLED TO
INSURANCE
TOTAL DUE NOW
115.00
115.00
.00
S
H
Images
A
Information stored in a healthcare system is not limited to the ASCII data we have discussed so
far. Images that are used to diagnoseN
the patient such as x-rays, MRIs, and CAT scans as well as
scanned images of paper documents Iare also part of the patient’s record. Images are captured and
stored using different sets of standards. The DICOM (Digital Imaging and Communication in
C images. Typical standards for photographs and scanned
Medicine) standard is used for diagnostic
documents include these three:
Q
䊏 JPEG (Joint Photographic Experts
U Group)
䊏 TIFF (Tagged Image File Format)
A
䊏
PDF (Portable Document Format).
1
1
0
5
T
S
Conceptually, medical image files are made up
of data similar to the photographs you take with
your digital camera, except they are higher quality.
A digital image consists of millions of dots, too
small to see. In Figure 4-12 a portion of a digital
photo is magnified to show the dots.
Whereas the smallest unit of ASCII data is a
character (one byte), the smallest unit of an image is
a pixel. A pixel represents the color, brightness, and
contrast of a single dot in the image as a number. The
amount of detail that can be seen in a digital image is
a factor of the number of pixels (dots) per inch, and
the number of bits used for each pixel. (Pixel size
was discussed in more detail earlier in the Bits and
Bytes—How Computers “Think” section.)
IMAGE STORAGE: FILE OR BLOB
Images can
contain millions of pixels, making the amount of
data enormous. Some of the image standards listed
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85
above permit the data to be compressed for storage and then restored to near original quality for
viewing. Some of the standards keep the image in its original size and do not compress it, making
the file size very large.
Diagnostic and radiology images are typically stored in a Picture Archiving and
Communication System (PACS) or a Radiology Information System (RIS) computer. Some
healthcare systems store images of scanned documents in the same system as the patient’s electronic chart, whereas other systems use a separate computer for document image storage.
Images are binary data, but not ASCII data. Images vary in size, can be very large, and therefore do not fit well in the records and fields of the types of databases we have studied so far. There
are two popular techniques for storing and retrieving images. Both methods use the database to
catalog information about the image such as the patient, date, type of image, and a description. A
field in the catalog record also indicates where the image is located.
In the first method, systems keep images as individual files on a hard drive, CD, or DVD.
The database catalog records include a field containing theHpath (location) to the image files
stored on the disk drive so the image can be accessed when desired.
I
The second method is to set up a portion of the database
to hold binary large objects
(BLOBs). Image data can then be stored directly in the database
(though separate from the
G
data stored in fields). When an application requests the image, the database retrieves the
G
BLOB. The database recognizes that it is not data from a field and passes it on to the requestS
ing application.
Image systems can also store many other types of digital information including audio or
,
video files.
S
H
A a mainframe. Users had screens
In the early days, hospitals had a single giant computer called
and keyboards called terminals, but all of the computer processing
N was done by the mainframe.
Today healthcare organizations of all sizes have hundreds of computers connected together as a
I
network.
Networks allow computers to seamlessly pass information
C to one another and to share
resources such as printers, scanners, application software, and central disk storage. Networks
Q in the operating system. There
require special hardware and software, some of which is included
are several types of networks and many types of network software.
U Here we discuss but a few that
are found in healthcare.
A
Networks
Network Hardware
Networks require a network card for each computer (some newer
1 computers have this built in). A
network router is also required. The router is also sometimes called a hub or switch. It identifies
1
each computer on the network and manages the flow of information
throughout. Network cables,
wires specially manufactured to handle data at high speeds, are
0 run from the router to each computer. (Wireless networking is also used, as discussed in a later section.)
5
T
Clients and Servers
Most healthcare organizations set up networks to allow manyScomputers to share the information
stored in one or more large databases. This is called a client/server configuration. The desktop
computers throughout the facility need only a portion of the software (called the client) and rely
on a main computer (called a server or host) to store, process, and retrieve the data.
Generally, the server is a larger, more powerful computer than the client computers, but its function is passive. That is, it waits for requests from the client, and then serves the requested data to the
client. The client can be a typical desktop computer, a laptop, or a Tablet PC or other portable device.
The client sends requests and waits for replies from the server.
A familiar example of this is e-mail. The application software you use to retrieve, write, and
send e-mail messages is the client. Each time you receive or send a message, your computer is
communicating with an e-mail server.
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H
I
G
G
S
,
S
FIGURE 4-13 Multiple servers
H at a large inpatient facility.
A
N
Each client workstation in a healthcare
facility typically communicates with multiple
servers. Some examples might include
a
registration
server, a clinical information system server
I
(for medical records), image servers, e-mail servers, application servers, and print servers.
C at a large inpatient facility.
Figure 4-13 shows a number of servers
Q
Local-Area Networks
U
Local-area networks (LANs) are computers
that are connected by a network serving just the
organization or facility in which they
A are located. Each computer on the network is called a
node. A LAN allows computers to share printers, files, and other resources in common. The
cables and switches used in a LAN allow for high-speed transfer of information within the net1 and can be designed to keep the data very secure.
work. A LAN can be managed locally
1
0 similar to a LAN except that they cover larger geoWide-area networks (WANs) function
graphic areas. To do so, the WAN 5
typically uses telecommunication lines to connect two or
more LANs into one large private network. The phone company provides a secure connection
that prevents computers not on the T
WAN from accessing it.
For example, a WAN might beSused where a hospital owns several healthcare facilities
Wide-Area Networks
that are miles apart. It would be too expensive for the hospital to run its own wires that distance, so the hospital would lease high-speed telephone lines to connect the LAN at each
facility into one large network. Given permission to do so, any node on the network could
communicate with computers at all of the other facilities as seamlessly as if they were in the
same LAN.
A WAN may not transfer data as quickly as a LAN because the portion of the network
using the phone lines may limit its speed. This is partially because the point at which the LAN
connects to the phone lines can act as a bottleneck when large amounts of data are being sent
over the WAN, and also because the cost of the phone lines will be based on their quality and
capacity. Businesses have to balance the expected normal usage of the WAN with their budget.
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Several types of telecommunications are available for a WAN. The two most prevalent are
leased line, point-to-point connections, or frame relay. Frame relay uses a computer node at the
phone company to securely send the data transparently through the phone circuits to a node near
the other end of the WAN. Frame relay is cheaper for a geographically large WAN because the
business leases a point-to-point connection only as far as the phone company node.
Internet
LANs and WANs are private networks that can be accessed only by the users in that network. In
contrast, the Internet is a worldwide public network that can be accessed by any computer anywhere. Most people know about the Internet because of the services they use on it such as e-mail,
research, games, and web pages; however, it is also used to exchange data.
The Internet was created by interconnecting millions of smaller business, academic, and
government networks. It is a very large network of networks, functionally similar to the other
types of networks we have discussed.
H
I in common. Networks use a
Different types of networks have certain things
protocol or set of rules for how they are to communicate on the network. Networks also assign a
G
unique ID or number to each computer on the network.
Although several standard protocols are in use for variousG
LANs, the entire worldwide Internet
uses one specific protocol: TCP/IP, which stands for Transmission
Control Protocol/Internet
S
Protocol. The TCP/IP protocol is now also commonly used for LANs and WANs.
The difference between the Internet and other networks, is seen in how the Internet works.
When a LAN or WAN is represented in a schematic design, lines connect each node of the network to the hub/switch or router. In contrast, the Internet is represented in the schematic as a
S one side and out to its destination
cloud (as shown in Figure 4-14) because information goes into
without relying on any predefined circuit.
H
To help you understand how this works, let us compare the post office and the phone comA establish an electrical connection
pany. When you make a phone call, the wires and circuits must
PROTOCOLS
N
I
C
Q
U
A
DMZ
Server
Router
Hub/Switch
Firewall
Internet
FIGURE 4-14
Drawing of a
network
configuration.
1
1
0
5
T
S
Wireless
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with the phone of the person you are calling before their phone rings and the call can go through.
When you write a letter, you address the envelope and deposit it in the mailbox. You don’t know
how the post office will transport it or what roads the trucks will take, but in the end it is delivered
to the address on the envelope.
The Internet Protocol encloses data in packets that have an address on them. The packets are
sent through the various networks making up the Internet until they arrive at their address.
Figure 4-14 is a drawing of a LAN configuration. Each workstation is connected to the
router, which is sometimes also called a hub or switch. The black connecting lines represent
cables or wires that are run throughout the facility. Each server is also connected to the router.
Figure 4-14 also shows that the network is connected to the Internet. The Internet is shown
as a cloud. Two components shown at the top of the figure are used to secure the network. The
first is the firewall. This may be a special device, a component of the router, or a dedicated computer. The firewall screens packets coming in from the Internet. The firewall can be set up to limit
connections to only certain networks,
Hcomputers, or TCP/IP ports.
The second level of protection is the server at the top labeled DMZ. This is a computer that
I or be used to send messages out of the network but which
can provide information to the public
cannot be used to access the hospital’s
G internal network from outside.
G
The flexibility
of the Internet protocol and its ability to get
information to and from almost any point
in
a
worldwide
network obviously has a lot of potential
S
for healthcare. Providers can access their patients’ charts, communicate with patients, transmit
,
medical images, and work from anywhere.
However, the Internet is not very secure. The packets
of data pass through many computers and networks on their way to their destination. They can be
copied, opened, and read by anyone with enough technical savvy.
S so we can use the accessibility of the Internet, but protect
How do we secure the information
the information? Two ways of doingH
this are to use a secured socket layer (SSL) or a virtual private network (VPN). Both of these rely on encrypting the transmission. There are other secure
A
transmission schemes not covered here.
SSL adds security to HTTP (Hypertext
N Transfer Protocol) web pages, sending only encoded
data within the packets, and then decrypting it when it is received to display the web page. This
I
prevents anyone intercepting the transmitted
packets from making sense of them. SSL, however,
is limited to the type of things you can
C do on a web page.
Some providers and organizations want to run software that is on their network computers
Q
from home or elsewhere. As we discussed earlier, the most secure method would be a point-toU However, if that is not possible or if the provider is not
point connection to the hospital’s network.
always accessing the network from the same location, a VPN may be used.
A
The VPN uses the Internet to transport packets of data, but it has its own software that
encrypts and decrypts the packets between the sending and receiving systems. The VPN also verifies the identity of the person signing
1 on, ensuring access only to those who are permitted to use
the system. A VPN is not limited to web pages and may be used to secure the data being trans1such as an electronic health record system.
mitted for other application software,
SECURE REMOTE ACCESS
0
5
Remote access today both in and out of the office includes wireless devices that access the netT networks are connected to the LAN through a radio transwork while the user is mobile. Wireless
ceiver called an access point, which S
is actually wired to the router like other network nodes.
Wireless Networks
The portable device has a built-in radio transceiver and a unique ID. When it is near an
access point, it sends packets of data using Wi-Fi, a high radio-frequency. The access point
receives the packets and sends them along on the network. Where there are multiple access
points, the closest point automatically takes over transmissions, as the user walks from one location to another.
Figure 4-15 illustrates the coverage area of an office with multiple access points. The red lines
indicate the wired LAN cables connecting the computers and access points. The overlapping teal
and lavender circles represent the range of radio signals from each access point. The laptop computer in the exam room is communicating with access point 1 due to its proximity. If the laptop were
moved to one of the other exam rooms, access point 2 would automatically take over the connection.
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FUNDAMENTALS OF INFORMATION SYSTEMS
FIGURE 4-15
office.
89
H
I
G
Access points of a wireless network
in a medical
G
S
,
Printers and Reports
S
In addition to sharing files and data, one of the main resources shared on a network are printers.
H
Despite the move toward electronic records, healthcare organizations
are anything but paperless.
There is a frequent need to print orders, reports, and forms throughout
the facility. The ability for
A
a networked computer to send output to a printer that is not directly attached to it has many
N
advantages, including these:
䊏
䊏
䊏
䊏
I
Saves the cost of attaching a printer to every computer.
Saves the desk space attached printers would occupy. C
Allows the use of faster printers with more features thatQ
would be too expensive to buy for
individual workstations.
U
Saves time because, rather than printing a report in one department and carrying it to
A right in the other department.
another, it is possible to sent the output to a printer located
Many larger printers have their own network card, allowing them to be connected directly to
the LAN without being connected to a workstation. However,1printers that are connected to workstations may also be used as network printers if the workstation is configured for this.
1
Report Server
0
Because reports make up a large portion of what is printed,5we will discuss a related topic: the
report server. The advantage of the large relational databases we discussed earlier in this chapter
T purposes. For example, patient
is that they contain a great deal of data that is useful for reporting
records contain information such as the dates the patient was
S seen, the procedures that were
billed, the amount paid by insurance, and the amount outstanding. This data, gathered from all of
the accounts, is then used to produce monthly financial reports, length of stay reports, and billing
and productivity reports, to name just a few.
The report does not exist as organized data. To generate the report, the application software
queries the database and begins collating and sorting data from fields within relevant records
returned from the server. Finally, the organized data is formatted with headings and columns and
sent to the printer as the finished product you see when you look at a report.
When an organization runs a lot of large or complicated reports, the gathering, sorting, and
printing of the reports can impact the performance of the database server. To minimize this, some
applications make use of a report server, a computer that is used only for the generation of
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reports. The database server is still queried for the relevant data records, but that information is
copied temporarily to the report server, which handles the sorting, organizing, and printing of the
report. Because the data in the report server is only a temporary copy, it is deleted when the report
is finished.
Cold
Businesses are required to keep copies of a large number of financial and compliance reports generated every month. Over time these records require a lot of storage space, so many organizations
choose to keep those reports in a computer document imaging system of the type discussed earlier for use with patient records.
Organizations that intend to store reports in a document image system can do so without
printing and then scanning them by using some type of COLD (computer output to laser disk)
software. Rather than printing a paper copy, COLD software captures the printer output and converts it into an image file, exactly asHit would appear on the piece of paper. The file is archived
onto an optical disk (CD or DVD) for permanent storage.
I
Computer systems can also achieve similar results using software other than COLD. One
example you may be familiar with isG
the PDF or Portable Document Format. If you participate in
online banking services, you may be able to download your bank or credit card statement as a
G
PDF file. In these examples, the bank may not be printing the statement you download, but rather
S statement directly into a PDF file.
their computers output an image of your
,
Interoperability Standards
S
The ability of various software systems to communicate with each other and to share data saves
H information in multiple systems. Where group medical
the time and effort of reentering the same
practices often use software from only one or two vendors the ability to share data within the
A
application is assured. However, it is not uncommon for larger organizations such as hospitals to
N by various vendors.
have from 60 to 600 software applications
Whereas the network protocols
I we have discussed so far enable the workstations and
servers to exchange packets of data, nothing in the protocol has defined the content of those
packets. Similarly, the databases weCdiscussed defined the data in fields and records and data
types, but nothing assured that the data
Q in one database could be understood by another application or database.
Uinformation industry has created standards that define the
To solve this problem, the health
exchange of patient and medical data
Abetween applications. To facilitate the interoperability of
diverse systems, vendors who create application software must support and adhere to the standards.
Two concepts important to interoperability of healthcare systems are data elements and HL7.
1
1
One might confuse the term data elements with fields or records that hold data, but the concept
0 to paper records as well as computer records. Data eleis broader. The term data element applies
ments do not define the layout of the5database, but rather are a broad set of standards that establish what types of information health systems ought to keep. For example the patient’s address is
T
one of the standard data elements. However,
we see in Figure 4-10 that the address is divided into
four fields. A different database might
use
six
fields for the address, but it would still be considS
Data Elements
ered one data element.
Including standard data elements in a database design makes it likely that the application
will have data similar to other systems. This not only improves interoperability but provides common elements for system-wide reports.
Data Sets
A data set is a list of data elements collected for a particular purpose. For example, an admission
record would need all the data elements of the patient demographics, insurance information, next
of kin, and so forth. In a paper system, this would be done by making sure the paper form
contained all of the appropriate boxes and that they were filled in correctly.
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In an electronic system, many elements of the data are entered only once, and then assembled into the data set as needed. For example, the patient demographics, insurance information,
and next-of-kin information would be retrieved from the patient registration system without
reentering the data.
Usually a healthcare data set represents the minimum list of data elements that must be collected. Examples of standard data sets in healthcare will be discussed in Chapter 5.
HL7
As you learned in Chapter 2, HL7 stands for Health Level Seven, a nonprofit organization that
developed and maintains the leading messaging standard used to exchange clinical and administrative data between different healthcare computer systems. The acronym is also used as the name
of the standard itself.
HL7 specifications are independent of any application or vendor; therefore, applications that
can send and receive HL7 messages can potentially exchange
Hinformation. If a hospital has one
vendor’s system for registration and another vendor’s radiology system, the simple act of transferring patient information from the admissions office to theIradiology department would not be
easy without HL7.
G
Of course, HL7 goes much further than specifying the communication of patient admission,
G
registration, and discharge information. It includes a wide range of clinical information mesS of orders, lab results, radiology
sages. As such it is the primary standard for the communication
reports, clinical observations such as vital signs, and many other types of clinical data maintained
,
in the patient’s record.
HL7 has been successful because it is very flexible both in its structure as well as its support
for multiple coding standards. Healthcare systems use codes
Sin place of text in many database
fields. Procedure codes, diagnosis codes, lab test codes, and many other types of codes not only save
H there are uniform standard codes
space but ensure accurate interpretation of the data later. Although
for some types of data, multiple code standards are being used
Afor other types of data. Therefore,
when a message is received, the codes and terms used by the other system may not match those used
N message that contain coded data
by the receiver. To overcome this problem, segments of the HL7
also identify what coding standard is being used. A special computer
program called an HL7 transI
lator is used to match the codes in the message with the codes used by the other application. The
translator can also reconcile differences between two systemsC
using different versions of HL7.
Q
U
One of the main challenges in a large HIS department is to maintain the interoperability between
multiple systems. For example, cross-reference tables are used
Ato reconcile differences in the way
Maintaining Interoperability
various systems codify data. One database might assign a unique code to each provider; another
might use the doctor’s Social Security number. As data is exchanged, a table of providers would
1 to provider record in that syshelp each application correctly match the ID for a patient’s doctor
tem. When a new provider joins the practice, not only must 1
that person be added to every database, but to the cross-reference table as well.
0 regularly update their software
This seems complex enough, but application venders also
to new versions. Often the update involves changes to that5application’s database. Every new
version must be tested to ensure that it will not fail. The HIS department must then analyze
T
any proposed database changes to ensure continued compatibility
with the 60 or so other
applications already running on the network. Healthcare organizations
that use multiple venS
dors typically have a separate set of computers used to test software changes without risk to
daily operations.
CCOW
CCOW stands for the Clinical Context Object Workgroup, a subset of HL7. Like HL7 its
acronym is used for the name of the group and the standard that the group developed. The purpose of the standard was to develop a means by which a facility that used applications from
several different vendors for their electronic health record could make it easier for the users.
For example, if one brand of software is used for the chart, but a different one for prescriptions
and yet a third for writing lab orders, clinicians would have to log into three different applications
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and search for the same patient in each application before they could record the encounter
and orders.
When CCOW is implemented, the user logs in once. When the user changes applications, the
user is automatically logged into the new application and the patient, provider, and clinical
encounter are automatically selected. This is called context management.
Although CCOW makes things simpler for the end user, implementation is very difficult.
Each vendor’s application software must be specifically written to enable CCOW, and the HIS
department must set up special servers to handle the CCOW functions. CCOW is usually only
found in inpatient settings, particularly teaching hospitals.
Communication Systems
Thus far we have discussed systemsHused for the patient and business records of a healthcare
organization. Equally important, however,
are the communication systems used by the staff in the
I
healthcare facility.
A REAL-LIFE STORY
G
G
S
,
A Look Behind the Hospital Network
S
H
Craig Gillespie is a network specialist at a large hospital connected
Ato multiple remote facilities.
N
stored on a SAN (storage area network) with a RAID 5 (redunI array of independent disks) with redundant connections all
ur hospital has a variety of computer systems and operating dant
systems linked not only by our internal LAN but also by a high- the
C way through. Should a hard disk become damaged, this type
speed WAN, which connects the main hospital to our downtown of configuration would allow us to swap out a disk drive without
Q bringing the system down.
business office and a couple of our other medical facilities.
even
Our network uses a Cisco backbone and multiple Cisco routers.
U Finally, of course, we regularly back up the systems. Our
Our servers include IBM AS 400s running IBM’s proprietary O/S 400 backup system uses a Robot tape library with eight drives in it.
operating system; IBM P series running AIX; and a number of Intel- A With so many different applications in our facility, there are
By Craig A. Gillespie
O
based servers running Red Hat Linux. Our PACS (Picture Archiving
and Communication System) runs on a Sun system (Unix). The
dietary department is using an application that runs on a Novell
network and a few other applications that run Citrix.
Oracle is the principal database our applications use. As the
amount of data increases, the database grows in size. We usually
have to manually increase the extent of the database about every
five months. This is usually just because of the indexes. Because
I don’t like taking our system down to rebuild indexes, I would
rather grow it a little bit and wait until the system is down for
something else to rebuild them.
From a pure IT point of view, as a system administrator and
database administrator, it doesn’t matter to me what the application is. What matters is how important is it; what are the
response time requirements; and what can I do to make sure
those happen?
There are several things we do. First, a few of our systems are
mirrored. That means the data is constantly written twice to two
different systems, so if one goes down the other has the same
up-to-the-minute data. In addition, the most important are
things we can do to help the teams that support those applications as well. For example, the database, operating system, network, and many of our applications create log records of certain
events, such as user logon, connections, error messages, and so
forth. When an application team identifies certain errors or conditions they need to be alerted to, I use script languages to write
little programs to scan the logs checking for certain things outside of the standard application area. When the scripts find
something, the team can be alerted.
When I talk to people who are interested in what I do I say,
“Why don’t you try a little project at home to see if this kind of
work is for you?” Take an old computer, purchase a copy of Red
Hat Linux (a low–cost, Unix-type operating system), and build a
proxy server or a mail server. This exercise will get you involved
enough to have an understanding of what is going on.
If you’re still interested, then try a little web development and
some degree of programming. You don’t have to write a program, but learn enough to understand what is happening
behind the scenes. These are suggestions to help you find out if
the technology side of IT interests you.
1
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FUNDAMENTALS OF INFORMATION SYSTEMS
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E-Mail Systems
E-mail has become a primary communication tool in all types of businesses. The IT department
has responsibility for the hospital’s e-mail system. These responsibilities include managing a
mail server, assigning user e-mail addresses, managing e-mail record storage, and protecting the
system from viruses and malicious software that can affect workstations, other servers, and the
entire network.
E-mail was used earlier in this chapter as an example of a client/server architecture. The
e-mail program on the workstation is the client, sending and receiving messages to the e-mail
server. The e-mail server is typically set up to communicate through a larger server outside the
network, called a mail host.
Like other components of networks, e-mail systems use a protocol. Several different protocols are available for e-mail. SMTP (Simple Mail Transfer Protocol) is the standard for sending
messages; however, it cannot be used to retrieve messages.
E-mail is retrieved from the mail host using either IMAPH
(Internet Message Access Protocol)
or POP3 (Post Office Protocol, version 3).
I
䊏
䊏
IMAP holds messages on the host server until they are specifically
deleted by the user.
G
POP3 holds messages on the mail host server, deleting them
G from the host server once they
are downloaded.
S
Most healthcare facilities use POP3 to retrieve e-mail from a host server operated by an
, in the hospital’s e-mail server.
Internet service provider (ISP). The downloaded e-mail is stored
The typical hospital user’s e-mail client communicates only with the hospital’s e-mail server,
not the mail host at the ISP. This arrangement helps shield the hospital’s e-mail system from the
S
public Internet.
H
Telecommunications
A
Historically, responsibility for a facility’s phone systems was assigned to engineering, physical
N
plant, or another department. Increasingly, however, telecommunications systems are becoming
I
the responsibility of IT departments. This makes sense for several
reasons:
䊏 The phone switching systems are now computer based, C
requiring IT expertise to manage
them.
Q
䊏 As organizations upgrade the wiring in their facilities, many are eliminating phone wires
U
and opting to use VoIP (Voice-over-Internet Protocol). VoIP uses special phones that provide phone service by sharing the computer network. A
䊏
The increase in wireless devices, including pagers, cordless intercoms, and medical
telemetry devices, is more easily managed by one department than by several.
Chapter 4 Summary
The Technology behind Health Systems
1
1
0
5
T
instructions that enable us to work. Operating
S program
systems and network software control computer hardware,
Computer systems are generally discussed in terms of two
components: hardware and software. Hardware refers to the
components you can physically see and touch: the computer, circuit boards, computer chips, monitor screen, keyboard, mouse, cables, wires, printers, and so forth.
Software refers to the operating system and application programs, which provide instructions to the hardware
to process the information the computer receives and
stores; that is, computer software gives functionality to the
computer hardware, making it useful. Software consists of
input/output devices, and communications with other
computers. Application software allows us to perform specific tasks on a computer such as write a letter, enter a
medical record, view an x-ray, send an e-mail, or order a
medication.
The fundamental unit of modern computing is called a
bit. Bits are grouped together in logical units, the most
common of which is called a byte. There are eight bits
in one byte. Bits have a value of 0 or 1. When they are
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
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CHAPTER 4
grouped together as a byte, the value of the byte can range
from 0 to 256. Computers create alphabet characters by
using the numbers 32 through 128 to represent letters,
numerals, and punctuation marks. This is called the ASCII
table.
The smallest unit of text data is a character. Text
characters (sometimes called alphanumeric characters)
are limited to letters, numbers, a space, and punctuation
marks.
Bits are also grouped into larger units to represent large
numbers, digital images, or other types of data. The smallest
unit of a digital image is called a pixel. Pixels are typically
comprised of 8 to 32 bits, depending on how many colors are
represented by the pixel.
Computer data is information that can be stored and
retrieved. Data and programs are stored on the hard disk,
optical disks, or temporarily in RAM memory chips.
Programs and data are retrieved and processed by a computer chip called the CPU or central processing unit.
Databases
Data is stored on disk drives in files and databases. Databases
store data in defined structures called tables. Tables have
records. The records are made up of fields, which have a
defined field type and format. Examples of field types
include numeric and alphanumeric or text fields. Numeric
fields can be further defined to hold specific types of data
such as money or dates.
Networks
Multiple computers can be linked together into a network. This
allows them to communicate with each other to share files and
information. A computer network consists of hardware such as
cables, network cards, routers or switches, and networking
software, which is sometimes included in the operating system. Wireless networks allow portable devices to communicate
with the network using a radio signal called Wi-Fi. Antennas
called access points are connected to the computer network. As
a user moves throughout the facility, the portable computer
automatically switches to the access point with the strongest
signal, dynamically maintaining the connection to the network.
Printers and Reports
Computer output devices include printers, screens or monitors, and COLD (computer output to laser disk) software.
COLD software converts printer output directly into an
image file, thus bypassing the steps of printing and then
scanning the paper report.
Interoperability Standards
Data
H is input into the computer using a keyboard, mouse,
touch screen, microphone, camera, or scanner. Data can also
Ibe directly transferred from another computer or medical
device. For computers to exchange data, it is necessary for
G
the data to be in a format that both systems understand. In
G
healthcare HL7 is the most prominent interoperability standard used today. (This is different from the HIPAA transacS
tions discussed in Chapter 3 that are used for claims billing,
,reimbursement, and insurance eligibility.)
When a facility uses application software from many
different
vendors for their electronic health records it is necS
essary to use HL7 to maintain interoperability between the
H
various applications. Even with HL7 in place the users may
find
A that they have to sign into several applications to record
the information about one patient. One solution to the probN
lem is to allow the user to sign in and select the patient once,
Ithen to use CCOW to maintain the context while switching
between applications.
C
Q
Communication Systems
U
The communication systems used by the staff in the healthcare facility include e-mail systems and telecommunicaA
tions, which are now often placed in the IT department. One
important advancement in application software is a networking application that allows the computer network to replace
1
the hospital telephone system. The application is called VoIP
1
and eliminates the need for the facility to maintain two dif0
ferent sets of wiring.
5
T
S
Critical Thinking Exercises
1. Look at your personal or home computer (or a school computer if you do not have one
of your own). What operating system is on your computer? Name at least three application programs on the computer.
2. See if you can determine how much RAM is installed in your computer or the school’s
computer. What are the steps you used to determine this?
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
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FUNDAMENTALS OF INFORMATION SYSTEMS
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Testing Your Knowledge of Chapter 4
1. What does the acronym COLD stand for?
2. What part of the computer hardware only retains data
while the computer is on?
3. How many bits are in a byte?
4. Describe the difference between computer hardware
and computer software.
5. What type of data is stored in a PACS?
6. Is a document scanner an input or output device?
7. A character is the smallest unit of text data. What is the
H
smallest unit of image data?
8. A database record can have different types of fields. I
Name three different field types.
G
9. What is the difference between a LAN and a WAN?
10. What is the acronym for the Internet protocol?
11. Name two ways discussed in this chapter for sending
information securely over the Internet.
12. What is the name of the standard by which computers
define alphabetical, numerical, and punctuation
characters?
13. What is the acronym for the software that allows computer networks to be used for telephone systems?
14. What is a BLOB used for?
15. What computer chip is sometimes called the “brains”
of the computer?
G
S
,
S
H
A
N
I
C
Q
U
A
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Comprehensive Evaluation of Chapters 1–4
This comprehensive evaluation will enable you and your
instructor to determine your understanding of the material
covered so far.
1. The hospital emergency department is what kind of
facility?
a. acute
b. subacute
c. inpatient
d. outpatient
2. What type of nurse can diagnose patients and write
orders?
a. triage nurse
b. licensed nurse practitioner
c. licensed vocational nurse
d. doctor’s nurse assistant
3. An inpatient was admitted June 10 and discharged
June 14. What was the LOS?
a. 3 days
b. 4 days
c. 10 days
d. 14 days
4. What does the acronym CIO stand for?
a. computer input/output
b. computer interpreted observation
c. chief information officer
d. chief complaint
5. Which group first established standards for hospital
records?
a. American College of Surgeons
b. American College of Pathologists
c. American Medical Association
d. American Hospital Association
6. A user authorized to view records on a document
image system must be a:
a. Registered Health Information Technician
b. Registered Health Information Administrator
c. registered health nurse
d. none of the above
For each of the following allied health professions, indicate
whether the job is clinical or nonclinical:
7. Clinical application specialist
a. clinical
b. nonclinical
H8. Lab technician
I a. clinical
b. nonclinical
G
G9. Coding specialist
a. clinical
S b. nonclinical
,
10. Cancer registrar
a. clinical
S b. nonclinical
H
11. Diagnosis-related groups are used for:
A a. point of care documentation
N b. Medicare billing and reimbursement
I c. patient assessment
d. decision support
C
12. Which of the following is not one of the four compoQ
nents of the HIPAA Administrative Simplification
U Subsection?
A a. Privacy
b. Security
c. Transactions and Code Sets
d. Conditions of Participation
1
1
13. HIPAA security standards are divided into three
0 categories. Which of the following is not one of those
5 categories?
T a. Physical Safeguards
b. Ambulatory Safeguards
S c. Administrative Safeguards
d. Technical Safeguards
14. Which of the following is a covered entity under
HIPAA?
a. pharmaceutical manufacturers
b. government agencies
c. healthcare providers
d. medical device manufacturers
96
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COMPREHENSIVE EVALUATION OF CHAPTERS 1–4
97
24. Which of the following is not an image file type?
a. ASCII
b. DICOM
c. JPEG
d. TIFF
15. HIPAA requires which of the following to disclose
health records for TPO?
a. signed informed consent form
b. signed patient authorization form
c. patient receipt of privacy policy
d. U.S. government authorization
25. CMS “deemed status” means that Joint Commission
accreditation is deemed to have met CMS condition of
participation requirements.
T. true
F. false
16. HIPAA requires an authorization to release PHI to be
signed by:
a. the patient or personal representative
b. a physician or nurse
c. the medical administrator or office manager
d. a notary public
26. The position of security officer is exclusively found
H only in very large healthcare facilities.
I
T. true
Write the full name represented by each of the following
G F. false
acronyms:
G 27. A pixel is the smallest unit of text data.
17. PHI ________________________________________
S T. true
18. EDI ________________________________________
F. false
,
19. HIM ________________________________________
20. EHR ________________________________________ S
21. What type of the computer memory only retains data
while the computer is on?
a. ROM
b. RAM
c. CPU
d. CRT
22. How many bits are in a byte?
a. Two
b. Four
c. Seven
d. Eight
23. A data dictionary defines:
a. medical terminology
b. field names and position
c. communication standards
d. clinical vocabulary
28. A single database record can have more than one type
of field.
T. true
F. false
H
A 29. Group medical practices are considered ambulatory
N facilities.
T. true
I
C F. false
Q 30. A physical exam must be performed on a patient
within 72 hours of a hospital admission.
U T. true
A F. false
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31. The hospital CEO is in charge of all medical staff.
T. true
F. false
32. Hospitals start a new chart each time a patient is
admitted.
T. true
F. false
Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
Instructions: This assignment must be done in APA format. A minimum word count
for the overall assignment is 1600 words (not including reference portion). A
minimum requirement of 4-6 references (with in-text citations) is required.
Although this assignment is APA format, it must keep the answer and question
format. See details below.
Format for Assignment:
Question: XYZ
Answer: XYZ
Reference: XYZ
Instructor Notes: In professional writing avoid using first person “I” and third
person “we”, as they detract from the quality and turn professional researched
statements into opinions. Instead of “I” use, for example, use “the writer, the
author or the researcher”.
Instructors General Note:
1. Beyond examples and names, give two examples of application of the
data. Who uses it? What does it tell you? How are the data applied?
2. Beyond what is it, how is it applied? Why
3. Beyond naming them, discuss the pros and cons for each. Give
examples from the research where these were breached. Why? Who?
Consequences?
4. Beyond describing the differences explain how each are used in quality
improvement.
5. Please answer these as four, numbered answers
Questions
1. What are data elements? Give two examples of a data element.
2. What is HL7?
3. Name two ways discussed in this chapter for sending information securely
over the Internet.
4. Describe the difference between a data element and a data set.
Reference Book: Gartee, R. (2011). Health information technologyand
management. Upper Saddle River, NJ: Pearson.
Part Two
Instructions: Write an 150 word response to each post. A minimum of one (1)
reference is to be used (with in-text citatation). Be sure to wrote as of your talking
to the person. Please be detailed as possible.
1. Computer networks play a dominant role in transmitting data within a large
corporation and with smaller companies. A network is simply a set of
computers (or terminals) interconnected by transmission paths. These
paths usually take the form of telephone lines; however, as technology has
advanced, other media, such as wireless and infrared transmission have
replaced older technology to send data. A network serves one purpose:
exchange stored data between multiple users, computers, and other
devices (Qureshi & Hartman, 1997).
Companies either have a local area network (LAN) or a wide area network
(WAN) system that allows different users the ability to exchange data in
real time. These networks are used depending on the size and location of
these users. A LAN network would be used by a company that may have
several users in a close geographical location or the same building. These
types of situations would be all the computers and terminals in a small
hospital or physician’s office needing to communicate within that area.
These users transmit the data short distances through ethernet cables
owned by the company. These networks can be faster to run, cheaper to
maintain, and more reliable than WAN networks (Sharp, 1998).
A WAN would be used for companies that have multiple offices or users
over a larger geographical location like nationwide or international users.
This type of network would be needed by a large hospital system that have
different locations in a region. Wide Area Networks are comprised of more
than one LAN in order to connect the multiple users together. WANs can be
set up through internet service providers like AT&T or Xfinity for their
networking needs. These types of networks can be slower due to multiple
issues like upload and download speeds being affected by how busy the
server is (Gartee, 2011). These networks normally cost more than LAN’s
due to the quality of service the company is requesting. This would hit the
financial bottom line more than running their own Ethernet cables for
transmitting data.
2. There are some similarities between LAN and WAN but there are some
distinct differences that set them apart. Lan (local area netwrok) is a group
of computers that are connected together and are usually in the same
building with all the computers on the same server. Devices on a LAN often
use the LAN’s infrastructure to connect to the public internet, but they can
often communicate with each other directly through the LAN quicker than a
WAN network (WAN & Prokopchina, 2014). This can be ideal for companies
that need to send and receive information quickly. (WAN & Prokopchina,
2014). With a LAN, the server is usually under the control of one
administrator who can allow or deny access into the network. One of the
main advantages of the LAN are the speed at which data is transferred
while a downside is the small area that is covered by the LAN (Fiho &
Galvao, 1998).
The WAN network (wide area network) is by name, covers a wide
geographical location and can cover a much wider range than a LAN. The
WAN can be contained to one building over accessible to the public. WANs
are majority too complex to be managed by private administrators, and for
that reason, they usually have a public ownership. The main advantage to
the WAN is the large area that is covered but with the large area and access
by the public, firewalls and other security measures are needed.

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