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Overview of Hospital Information Systems Architecture

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On Configurations and Varieties

[By Brent Metfessel MD MIS]

Dr. Metfessel

Hospitals can use a variety of configurations for HIS implementation depending on business needs and budgetary constraints.

Staffing needed for these systems can range from a few full-time equivalents (FTEs) per 100 beds for very basic off-site processing systems to 15 or more FTEs per 100 beds for sophisticated systems that attempt to combine several architectures into one system (e.g., combination of client-server systems with mainframe processing). Resource use and customizability tend to vary in tandem; the greater the flexibility of the system to meet unique user needs, the greater the cost outlay for capital and/or additional FTEs.


Relationship of Resource Use and Customizability Based on System Architecture Selected

Values range from one (low) to four (high) stars
Architecture Hospital resource use Customizability
Off-site processing * *
Turnkey systems ** **
Mainframe systems *** ***
Client-server *** ****


The Possibilities

The basic system architecture possibilities are as follows:

Off-site (remote) processing: In this case the hospital contracts with a vendor external to the hospital. The hospital sends data over to the vendor site where the actual processing takes place. When processing is complete, the vendor sends the data back to the hospital, usually in electronic form.

Turnkey systems: A vendor provides the hospital with systems that are “pre-packaged” so that hospital-based system development is minimal. Limited customization of the system is possible using systems analysts or programmers.

Mainframe systems: Most applicable to large hospitals, this configuration is highly centralized. A large and powerful computer performs basically all the information processing for the institution and connects to multiple terminals that communicate with the mainframe to display the information at the user sites. Hospital IT departments usually use in-house programmers to modify the core operating systems or applications programs such as billing and scheduling programs.

eHR diagram

Client-server systems: In this configuration one or more “repository” computers exist, known as “servers,” that store large amounts of data and perform limited processing. Communicating with the server(s) are client workstations that perform much of the data processing and often have graphical user interfaces (GUIs) for ease of use. Both customizability and resource use is high, depending on the desired sophistication.

Many clinical information systems that process data directly related to patient care use this configuration.  For instance, the Veterans Health Administration, which has implemented what is likely the largest integrated healthcare information system in the United States, uses client-server architecture.  Known as the Veterans Health Information Systems and Technology Architecture (VistA), this system provides technology infrastructure to about 1,300 care facilities, including hospitals and medical centers, outpatient facilities, and long-term care centers.  VistA utilizes a client-server architecture that links together workstations and personal computers using software that is accessed via a graphical user interface.

Overall, for hospitals that have the financial and manpower resources for a significant investment in IT, client-server architectures are the fastest-growing and typically the most preferred of the system architectures, due in large part to their local adaptability and flexibility to meet changing hospital and medical center needs.

Broad Categories

The above architectures are broad categories.  Modifications and combinations of the above also exist, such as the use of client-server technology with mainframe systems and the addition of wireless technology, smart phones, laptop PCs and tablets,  and various personal digital assistants (PDAs) to supplement the core computing functionality.

In considering the optimal architecture for a hospital, management needs to take into account factors such as size of the institution, desired sophistication of the application, IT budget, and anticipated level of user community involvement.



Another important aspect of HIS is the need for integration.  Often, different hospital departments have their own stand-alone systems — such as a Laboratory Information System (LIS) and pharmacy systems — that do not communicate with each other.  Duplicate data may be kept in separate systems, creating additional work to enter the data multiple times.

In an integrated system, each departmental system communicates with the other systems through either a centralized or decentralized. A computerized physician order entry (CPOE) system, for example, would be much less effective if it did not communicate electronically with the pharmacy system that would process the medication orders.

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NOTES: Resource use refers to the need for FTEs and hospital capital expenditure. Customizability refers to the ability for users to alter the system structure or function to meet the unique needs of the institution.

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4 Responses

  1. HI-TECH Act Structure Driven

    The way your practice and physician organization HIS is structured should greatly influence your adoption, especially given the way the HI-TECH Act is incentivizing you. For example:

    Practice size. The larger your practice, the more it can absorb the sometime large changes that are required to completely automate your business. If you’re in a practice with fewer than 10 physicians you are likely to see more disruption in your business than if you have more than 10 physicians because access to capital, credit, and the ability for your organization to manage change is usually better.

    Ownership and Compensation. If your practice is owned by another organization or if you are employed by another organization then you should be more willing to automate because you’ll be able to get more help and spread your risk across multiple organizations. If you’re a salaried physician, you should be quicker to adopt since you’re not likely to feel pain in the reduced patient flow scenarios that often accompany installation of new technologies.

    Specialty. Primary care practices should be slower to adopt because they are generalists and software and systems are geared more for specialists. If you follow the same rules and procedures and processes across most of your physician population (like many specialties) then installing and using an EMR doesn’t disrupt you as much as if you have wide and varied patient populations and workflows.



  2. EHRs in the news

    Insurance evolution, data breach of patients’ emails and paper prescriptions to be outlawed in NY.

    “Dental insurance isn’t what it used to be, say East Amherst dentistry partners – [Drs. Mark S. Wendling and David Rice at East Amherst Dental Center] will help assemble the paperwork needed to file insurance claims, but patients are required to file the claims themselves. There are too many insurance companies, with too wide a range of reimbursement plans, for a small business to address, Rice and Wendling said. The partners said they have chosen to focus on ‘patient-based care,’ instead of operate an ‘insurance-based’ office.” By Scott Scanlon, News Refresh Editor, January 24, 2015.

    Dr. Wendling tells News Refresh: “Over the course of time, insurance companies have not kept up with cost of living or changes in the industry, so generally speaking when you deal with them, you’re still dealing with the same numbers that you may have seen in the ‘70s and the ‘80s, and it’s just not that way anymore.” (more)



    “Rep. Gosar introduces legislation to restore competition in the health insurance market – Gosar: ‘The government should not be picking winners or losers and the insurance industry should also have to comply with federal anti-trust laws.’” By Steven D. Smith, Prescott News, January 23, 2015 .

    “WASHINGTON, D.C. – Today, U.S. Congressman Paul A. Gosar, D.D.S. (AZ-04) released the following statement after introducing The Competitive Health Insurance Reform Act of 2015, H.R. 494, legislation that would amend the McCarran-Ferguson Act which exempted the health insurance industry from anti-trust laws: ‘My legislation seeks to restore competition among health insurance companies and correct a historical error that allowed for an exemption from federal anti-trust and unfair competition laws. Over the decades, and rapidly since the passage of Obamacare, the health insurance market has expanded into one of the least transparent and most anti-competitive industries in the United States.’” (more)



    “St. Peter’s Health Partners warns of possible breach of patient data – Albany, NY – St. Peter’s Health Partners is warning of a possible data breach in its email system, following the theft of a manager’s cellphone. Emails on the cellphone may have included patient information related to appointment schedules at St. Peter’s Health Partner’s Medical Associates, a large doctors’ practice. By Times Union, January 23, 2015.

    Times Union: “The emails did not include any other medical record information or data related to inpatient hospital treatment or emergency department care, the health system emphasized.” (more)



    “NY Docs Press for E-Script Delay – Handwritten prescriptions will soon be illegal in New York. The Medical Society of the State of New York (MSSNY) and 18 national and NY State medical organizations are trying to delay for a year the onset of a law that would eliminate handwritten prescriptions and drastically restrict prescribers from phoning them in.” By Gale Scott for Healthcare Professionals Network, January 23, 2015.

    Scott: “The measure, due to take effect March 27, would require electronic prescriptions for all medications—not just for controlled substances but antibiotics, allergy medications or anything else that requires a prescription.” (more)


    Darrell K. Pruitt DDS


  3. What is an IP address?

    At its core, an IP address is an online unique identifier. Every computer has its own IP address, and it is through this naming system that computers can connect with each other and share data.

    A standard IP address (using what’s known as the IPv4 protocol) contains four individual numbers separated by a decimal.



  4. Survey: 50% of PCPs Say Health IT Has a Positive Impact

    Kaiser Family Foundation and the Commonwealth Fund recently conducted a survey on primary care provider attitudes toward healthcare changes and trends. Here are some key findings from the report:

    • Half of physicians and 64% of NPs/PAs say health IT has made a positive impact.
    • 1 in 3 physicians and 40% of NPs/PAs say medical homes are having a positive impact on quality of care.
    • 10% say the impact of medical homes has been negative.
    • Physicians were more likely to view ACOs as having a negative (26%) rather than positive (14%) impact.
    • 38% of physicians and half of NPs/PAs were not sure of ACOs’ effect on quality of care.
    • Among the 29% of physicians participating in an ACO, 30% say ACOs are having a positive impact.

    Source: Kaiser Family Foundation, August 5, 2015


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