EHR+Information+Automation+Functionality

Dr. Sanghee Oh, PhD
The primary issues deterring medical facilities from integrating EHR systems can be traced to their immense upfront and installation costs as well as lack of efficiency. Not resolving these issues means EHR adoption rates could drop in the coming years as medical facilities fail to see the feasibility of possessing one. A recent study published by Watchdog showed that 45% of medical respondents stated patient care productivity decreased with their EHR’s, one doctor claimed their daily patient work load dropped down by 8 (Beseth, 2015). High upfront costs can also be seen in the most popular EHR systems. In 2012, the D-H medical center in New Hampshire paid Epic $80 million dollars to integrate their EHR into the facility with expectations of low operating performance based on the shear cost of the installation (Moukheiber, 2012 ). The CIO of Valley View Hospital located in Colorado stated that his facility would face upfront costs of $80,000 not including the $10,000 annual fee (Millard, 2013). He then elaborated how the support service failed to fix issues appropriately, which often caused delays in treatment. The EHR experience of Valley View Hospital can be seen numerous times across other medical facilities in the U.S. In turn, this generates a stigma where medical facilities will dismiss EHR systems and identify them as a problem more than a solution. An EHR survey published in 2014 showed 70% of respondents claiming their EHR investment was not worth the cost with as little as 24% of physicians not supporting them (Murphy, 2014). The evidence is transparent and abundant that a re-engineering of EHR integration is needed that possesses a reasonable low installation cost and has the efficiency to increase the productivity and care of patients.
 * Problem Statement/Evidence **

Implementing EHRs is not a new idea. Hospitals and clinics have stumbled across the same way of thinking as we discussed earlier years ago, and companies like Cerner, GE, and Epic have been taking full advantage of the demand. GE health EHRs implore features that make it easy to integrate with already installed systems and are compatible with many forms of legacy hardware. A weakness General Electric has would be the fact that you cannot host their solution locally. Therefore you are forced to pay their monthly hosting and maintenance fees. Cerner has been around the longest (Earl, 2015) and started off as an information technology company in 1979 under the name PGI and Associates. Leveraging their long time in the business, they have been able to perfect certain technologies that big infrastructures prefer (such as hospitals), and cheapen their costs, making their service as a whole sometimes cheaper than other EHRs. Epic EHRs are used by over 40 percent of the medical field and are known for being best in KLAS. Although they don’t advertise or market they are still widely used because of many satisfied customers. Epic’s software is quickly installed, intuitive to use, and highly interoperable with other Epic (Jayanthi, 2015) software - giving it a solution somewhat akin to Microsoft office. Taking inspiration from all of these companies we have decided to take the very best parts of these EHRs and Make our own, calling it Hygeia.
 * Market Research/Existing Solutions **


 * Potential Solutions **

// 1. Lower Installation/Upfront Costs // A EHR web based application has the potential for being integrated without the need for high installation or upfront costs. The application can be hosted on a vendors cloud server and accessed by the customer through the internet. This not only reduces the installation costs, but also the expenditure for hardware upgrades as the application will be designed and upgraded on site. Annual maintenance costs will also witness a decrease since the application is hosted by the vendor. Medical facilities would only be required to pay for connection to the EHR and other minor upgrades to establish a stable connection.

// 2. Increased Flexibility & Reliability // Integrating a web based EHR will also increase the flexibility and reliability of the system. Because the application is being hosted by the vendors cloud database, the customer just needs a stable internet connection in order to access the EHR. Medical personnel will now have the freedom to access the EHR from any browser they feel comfortable with, whether it’s Firefox or Safari. Not only does this give the customer browser flexibility, but also gives the HIT sector the opportunity to better choose computer systems that fit the hospital like Windows or Linux. Web based EHR applications also possess a higher degree of reliability than standard EHRs. The majority of applications that have to be installed on computers requires them to be manually upgraded. This upgrading process is troublesome for hospitals because normal users aren’t given the permissions to upgrade and may have to wait for an administrator or IT technician to perform the task. Web applications do away with this process by upgrading the web application on the cloud server. This means that once the web application has been updated on the server, the changes on the user end will be universal and instantaneous. National access is another major component to the reliability of a web based EHR. In a situation where a patient is sick in another state and the doctors need access to his medical records. The doctors can easily acquire them through the web based EHR because the patient’s information will be hosted on a cloud server.

// 3. Automation Testing // Web based applications possess the additive benefit of being tested through automation. Programs such as Selenium and TestNG allow software engineers to design efficient testing suites that run automatically (Hilman, 2011). Unlike manual testing which is often slower and prone to error, automation testing suites can be executed numerous times with little to no malfunction. These testing suites can be used to help increase the web applications efficiency as well as ensure the application is secure and free of any security holes.

// 4. Integration of Cloud Computing // Today, the revolution of cloud computing is increasing with more and more businesses seeing the advantages of storing information in this manner. To begin, cloud computing offers a solution to centralizing data. In the event of database failures, cloud computing offers escape routes that normal databasing storing can’t provide (Balding, 2008). For example, cloud databases can easily have the information backed up on a mirror database in event of a crash. In addition, the centralizing aspect of cloud computing databases makes it easier to access information when needed to. When it comes to security and fraud, cloud computing databases contain the flexibility needed to produce higher levels of encryption to protect information. In the EHR industry, this section is critical since most of the information that’s handled on daily basis is patient information which is protected under HIPAA.

// 5. Document Scanner Implementation // Another addition to our application that would help improve the efficiency of both the EHR and medical field is a paper to digital document converter. The idea is that the majority of health facilities are overloaded with medical files and folders on patients that takes up space and decreases the speed of workflow. In addition, this creates an additional barrier for medical facilities to integrate EHRs since a lot of time would have to be spent manually entering the patients information into the computer. To solve this, a scanner could be engineered that would convert the patients hand written information into a text file that could then be organized and uploaded to the cloud database. Handwriting recognition algorithms have been studied and researched extensively with the rise of mobile phones and neural networks. These neural networks are fed "training" examples, such as various ways letters are written in the English alphabet. The more training examples that are given to the neural network, the more efficient it will be at recognizing and correctly converting the patients handwritten information (Nielson, 2015). With an accurate handwriting recognition network, documents can be digitized in a fraction of the time it would take doing it manually saving time and boosting productivity in the medical facility.

High installation costs in conjunction with feasibility issues creates a difficult atmosphere for medical facilities to adopt EHRs. Today, personal healthcare is becoming more and more popular as technology continues to build the bridge between people and their healthcare providers. This is why it’s crucial that an EHR system is produced that is reason-ability priced and functions up to the standards of a medical facility. In addition, the EHR system produced must be constructed with the idea that the technology used is both current and compatible. Recently, the company HITConsultant produced a survey in which the results showed that multiple medical facilities have begun transitioning to electronic forms of medical records ( Callahan, 2010) . The web based EHR being produced has the potential to not only solve these issues with cost, but also be an application up to date with a cloud server capability . Health information can easily be entered, stored, and retrieved on the hospital local database and backed up on the cloud server. <span style="color: #2a2a2a; font-family: 'Times New Roman',serif; font-size: 16px;">A web based EHR may also be the solution for EHR integration in rural areas. Technology implementation in non-urban areas is often difficult due to increased distances and aging populations. Since the EHR will be hosted on the web, a stable internet connection is the only thing required for medical facilities to access the application, which can really help the EHR extend its use. In addition, the lower installation costs means smaller medical institutions can integrate the EHR into their network.
 * <span style="font-family: 'Times New Roman',serif; font-size: 16px;">Reason for the Solution **


 * <span style="font-family: 'Times New Roman',serif; font-size: 16px;">Templates/Final Solution **

<span style="font-family: 'Times New Roman',serif; font-size: 16px;">Figure 1.1: Block diagram displays how cloud server would connect to medical clients

<span style="font-family: 'Times New Roman',serif; font-size: 16px;"> Figure 1.2: Example of the homepage for the Hygeia EHR Web Application



<span style="font-family: 'Times New Roman',serif; font-size: 16px;"> Figure 1.3: Template of the doctor user interface, Census tab opened



<span style="font-family: 'Times New Roman',serif; font-size: 16px;"> Figure 1.4: Template of the nursing user interface, Patient Lab Results tab opened



<span style="font-family: 'Times New Roman',serif; font-size: 16px;"> Figure 1.5: Template of patient user interface, medical team tab opened complete with doctor bio



<span style="font-family: 'Times New Roman',serif; font-size: 16px;">Figure 1.6: Document scanner template, scanning input on left & digitized text on the right

<span style="color: #000000; font-family: 'Times New Roman',serif; font-size: 16px;">Hygeia is an EHR web application that’s fully accessible over the internet. One of the greatest advantages of this application is that it’s hosted on a cloud database. This hosting method helps eliminate the kinds of ridiculous installation costs associated with standard software installation packages. In addition, manual installations would be eliminated since any updates to the application would be witnessed instantaneously on the cloud-based server. Subsequently, because this is a web application that’s hosted on a cloud server, it includes cloud databasing which is an efficient step forward to enhance database security by simply increasing the amount of failsafe procedures such as mirror databasing. Another big advantage is that the web application can undergo automation web testing meaning that checking for bugs within the application would be faster and more effective. Furthermore, since the tests could be run almost daily, the web application is more secure and less prone to security breaches.The feasibility of the design was also focused on creating an efficient tablet layout. The idea was to create a simple interface that could easily fit proportionally on a typical iPad tablet and reduce any amount of scrolling. To combat this, a system of tabs was designed so that the user could easily access the needed information without having to click through links or scroll down a page. This would also make migrations from computers to tablets easy for the user since the layout would be similar in layout.
 * <span style="color: #000000; font-family: 'Times New Roman',serif; font-size: 16px;">Feasibility of Solution **

<span style="color: #000000; font-family: 'Times New Roman',serif; font-size: 16px;">The utilization of web applications can have a very positive impact on healthcare. It has the ability to cut out busy paperwork or digitizing patient information so it’s organized and quickly accessible to minimize human error. However, developing a successful and efficient web application can take an extensive amount of time and energy. Creating an idea for an application can be fleeting, but when ensuring meaningful use and meeting HIPAA requirements it can take a lot of time. The web application also has to be certified and the certification process time can vary, although it is possible to get temporary certification while the program is being tested. When planning for the application it was important to take into account the main tasks that this particular application would accomplish and what tasks it would eliminate or make easier. Hygeia would help a patient with Internet access communicate more quickly and efficiently with their particular health care team, while also allowing their health care team to communicate with each other.
 * <span style="color: #000000; font-family: 'Times New Roman',serif; font-size: 16px;">Timeline and Future Plans **

<span style="color: #000000; font-family: 'Times New Roman',serif; font-size: 16px;">A pressing issue for many web applications is the slow installation and a very slow update process. One of the benefits of Hygeia is to completely eliminate that time a patient can spend updating the software. All updates and installations are handled at a vendor level. Overall the process for creation and development was increased for the sole purpose of decreasing the amount of time the patient has to spend on the application. This web application is particularly efficient when utilized as a follow up tool for patients. For example, if a patient had blood work done in a hospital lab, the nurse could upload the results using the document scanner. The patient could login and view their results almost instantly or message the physician with any questions. Hygeia can also be very useful for physicians and nurses. For primary care physicians note dictation is a vital portion of their work. Hygeia can keep track of every patient's needs and store them in an organized and secure location. For example, a physician can scan their or the nurse's manual notes about a patient and with the use of handwriting recognition technology they can digitize the documents so they can be easily referred back to. A web application such as this one leaves indefinite possibilities for updates and improvements. Because the upgrades are made at a vendor level this application has the unique ability to work on the upgrades while the patients are using the application. A user assessment aspect of the web application is in place so that the users can be actively involved in the software upgrades. The user can help implement quality improvement.

<span style="color: #000000; font-family: 'Times New Roman',serif; font-size: 16px;">For the future, more research and energy will be devoted to the integration of the cloud database with the application itself. In order for a functional EHR to be constructed the application must run smoothly from the user level to the back end level. This means that any information that’s transmitted and captured by the EHR must be properly stored in the database. Also, security testing of the database would be a major field of focus, especially since the HIPAA guidelines must be upheld. This would be achieved by the team composing automation tests with Selenium that would test the stress, load, and functionality of the program. The results from these tests will work to expose the areas of the application that need to be patched up and improved.

<span style="color: #000000; font-family: 'Times New Roman',serif; font-size: 16px;">The work was divided proportionally in four parts for the four team members. Kristian Hogue was the project manager. After we came up with the idea for the project, Kristian put the group together for discussions and we were all assigned the work that was due for the project. He also helped each member with the details of the work they were assigned and basically captained the team. Joy Willis was part of the application design. She did a lot of work in the area of making the application look presentable and also helped in making templates for the presentation. Jarai Howard was the market researcher and also helped with the application design. He helped a lot with the outside information such as research about what companies are doing in the actual world and helped us understand the market in a better way. Deep Chovatia was the database manager. He designed the database template and the database schematic. He also did research on how to make the database secure from data leaks and other threats.
 * <span style="color: #000000; font-family: 'Times New Roman',serif; font-size: 16px;">Teamwork roles **


 * <span style="color: #000000; font-family: 'Times New Roman',serif; font-size: 16px;">Meeting minutes/Timeline **

//<span style="color: #000000; font-family: 'Times New Roman',serif; font-size: 16px;">September 21, 2015 – The topic of the project was decided upon and team roles were assigned as well as overall objectives for each member. (20 min) //

//<span style="color: #000000; font-family: 'Times New Roman',serif; font-size: 16px;">October 25, 2015 – Presentation template was discussed as well as application prototypes created. It was decided that the application should function properly for both internet and tablet users since medical facilities are integrating tablets with their agendas. (45 min) //

//<span style="color: #000000; font-family: 'Times New Roman',serif; font-size: 16px;">October 29, 2015 – Application prototypes were adjusted, final touches were put on the presentation. Database schematic was decided to be included in the presentation since the cloud computing database was a significant component to the application. (20 min) //

//<span style="color: #000000; font-family: 'Times New Roman',serif; font-size: 16px;">November 2, 2015 – Agreement was made that the presentation would include separate but similar portals for doctors, nurses, and patients. In addition, a prototype for the document scanner interface was created. (40 min) //

//<span style="color: #000000; font-family: 'Times New Roman',serif; font-size: 16px;">November 7th, 2015 – Reviews were gathered from classmates //

//<span style="color: #000000; font-family: 'Times New Roman',serif; font-size: 16px;">November 10th, 2015 – Follow up report was written outlining the classmate’s feedback that included what needed improvement the most. It was determined that the patient portal must be more efficient and database security explained further. (55 min) //

//<span style="color: #000000; font-family: 'Times New Roman',serif; font-size: 16px;">November 28th, 2015 – Prototypes for all portals were updated that met the standards of the student’s feedback. This included clearer pictures, intricate colors, increased efficiency, and better layout. Database security was also improved by researching what techniques like encryption and database mirroring would be appropriate for our system. (120 min) //

//<span style="color: #000000; font-family: 'Times New Roman',serif; font-size: 16px;">November 30th, 2015 – The layout of the final presentation was discussed, which included what prototypes would be involved, speaking roles, and which member would compose what specific slide. (60 min) //

//<span style="color: #000000; font-family: 'Times New Roman',serif; font-size: 16px;">December 1st, 2015 – Final presentation was given to the class, included problem statement, market research, Database security outlining, portal prototypes, document scanner prototype, and learning experiences. //


 * <span style="color: #000000; font-family: 'Times New Roman',serif; font-size: 16px;">References **

<span style="color: #000000; font-family: 'Times New Roman',serif; font-size: 13.3333px;">Balding, C. (n.d). Assessing the Security Benefits of Cloud Computing. Retrieved 5 Dec. 2015, from <span style="color: #1155cc; font-family: 'Times New Roman',serif; font-size: 13.3333px;">[]

<span style="font-family: 'Times New Roman',serif; font-size: 13.3333px;">Beseth, Karen. "Doctors Say Obamacare’s Electronic Health Record Mandate Is Too Costly, Results in Worse Care." //Watchdog Arena//. Watchdog, 20 Feb. 2015. Web. 8 Dec. 2015. <http://watchdog.org/201170/obamacare-doctors-electronic-health-record/>.

<span style="color: #000000; font-family: 'Times New Roman',serif; font-size: 13.3333px;">Callahan, Daniel. "Framing the Issue." //Health Care Costs and Medical Technology//. Retrieved 5 Dec. 2015, from <span style="color: #1155cc; font-family: 'Times New Roman',serif; font-size: 13.3333px;">[]

<span style="color: #000000; font-family: 'Times New Roman',serif; font-size: 13.3333px;">Earl, Elizabeth. "Epic vs. Cerner: 9 Key Comparisons." //Epic vs. Cerner: 9 Key Comparisons//. Beckers Hospital Review, 13 Apr. 2015. Web. 7 Dec. 2015. <span style="font-family: 'Times New Roman',serif; font-size: 13.3333px;">Hilman, A. (2011, May 26). The Benefits of Automated Testing and Deployment. Retrieved 5 Dec. 2015, from []

<span style="color: #000000; font-family: 'Times New Roman',serif; font-size: 13.3333px;">Jayanthi, Akanksha. "50 Things to Know about Epic and Judy Faulkner." //50 Things to Know about Epic and Judy Faulkner//. Berkers Hospial Review, 22 June 2015. Web. 7 Dec. 2015<span style="color: #000000; font-family: 'Arial',sans-serif;">.

<span style="font-family: 'Times New Roman',serif; font-size: 13.3333px;">Milliard, M. (2013, December 27). Epic Install Proves More Expensive. Retrieved December 5, 2015, from []

<span style="font-family: 'Times New Roman',serif; font-size: 13.3333px;">Moukheiber, Zina. "The Staggering Cost Of An Epic Electronic Health Record Might Not Be Worth It." //The Staggering Cost Of An Epic Electronic Health Record Might Not Be Worth It//. Forbes, 18 June 2012. Web. 4 Dec. 2015. []>.

<span style="font-family: 'Times New Roman',serif; font-size: 13.3333px;">Murphy, K. (2014, February 10). What has Physicians so Dissatisfied with their EHR systems? Retrieved December 4, 2015, from []

<span style="font-family: 'Times New Roman',serif; font-size: 13.3333px;">Nielson, Michael. "Chapter 1: Using Neural Nets to Recognize Handwritten Digits." //Neural Networks and Deep Learning//. Determination Press, 1 Aug. 2015. Web. 6 Dec. 2015. <http://neuralnetworksanddeeplearning.com/chap1.html>.

<span style="color: #000000; font-family: 'Times New Roman',serif; font-size: 13.3333px;">HealthIT.gov. (n.d.). Retrieved December 4, 2015, from <span style="color: #1155cc; font-family: 'Times New Roman',serif; font-size: 13.3333px;">[]