Week 6 - Discussion ForumRequired ResourcesTextSharpe, N. .docx

Week 6 - Discussion Forum
Required Resources
Text
Sharpe, N. D., De Veaux, R. D., & Velleman, P. F.
(2019). Business statistics (4th ed.). Retrieved from
https://www.vitalsource.com/
· Chapter 24: Decision Making and Risk (Data Description,
Inc.)
Web Page
Walmart. (n.d.). Financial information: Annual reports &
proxies (Links to an external site.). Retrieved from
https://stock.walmart.com/investors/financial-
information/annual-reports-and-proxies/default.aspx
· This web page provides information about Walmart’s financial
information, including access to their annual reports, and will
be useful in your Walmart Expansion Analysis Final Project this
week.
Accessibility Statement does not exist.
Privacy Policy (Links to an external site.)
Recommended Resources
Web Pages
International Labour Organization. (n.d.). ILOSTAT (Links to
an external site.). Retrieved from https://www.ilo.org/ilostat
· This web page provides access to International Labour
Organization databases and may be useful in your Walmart
Expansion Analysis Final Project this week.
The World Bank. (n.d.). DataBank (Links to an external site.).
Retrieved from https://databank.worldbank.org/data/home.aspx
· This web page provides access to World Bank databases and

may be useful in your Walmart Expansion Analysis Final
Project this week.
The World Bank. (n.d.). Doing business data (Links to an
external site.). Retrieved from
http://www.doingbusiness.org/en/data
· This web page provides access to World Bank economic data
and may be useful in your Walmart Expansion Analysis Final
Project this week.
Privacy Policy
Instructions
Prior to beginning work on this discussion forum, read Chapter
24 of your textbook.
Imagine that you are a successful business executive for a toy
company, ChoiceToys. You are tasked to market one of the two
new toys for the upcoming holiday season based on an optimal
decision strategy. As the data analyst, you will be responsible
for providing the expected profit payoff and associated
probabilities.
Part 1 (Due by Day 3)
In your initial post, using the scenario below, you will be acting
as the data executive speaking to a data analyst. You will need
to speak to the data analyst and get more information so you can
develop a decision analysis. Given the information the data
analyst has provided, what more data do you think you need to
create a decision analysis?
Toy 1 is being introduced to the market for the first time by
ChoiceToys with no market competition. ChoiceToys believes
that competitors will not be able to bring a similar toy to the
market for this upcoming holiday season. You are not sure how
the toy will be received by the consumers and there is equal
chance that it will be highly successful, successful, or not

successful. You will need to determine what the expected profit
payoff will be and provide this in your scenario.
Toy 2 has been in the market, is known to consumers, and is in
demand; however, it has two other competitors in the
marketplace. If marketed, ChoiceToys will be one of the three
companies selling this toy in the market in the upcoming
holiday season. You will have to determine the profit payoff for
Toy 2 respectively for a highly successful, successful, and not
successful case. You will also need to determine the probability
that Toy 2 will be highly successful in the market and equal
chances for being successful or not successful in the market.
Part 2 (Due by Day 6)
As a data analyst, you need to use decision analysis techniques
to recommend decision alternatives or optimal decisions based
on expected profit payoff for the upcoming holiday season.
Respond to one of your peers’ initial posts, and complete the
following:
· Identify the sequence of actions you need to take to start this
decision process.
· Explain each sequence and justify why it will help you with
your decision.
· Propose a risk profile for each choice.
Chapter 3: Computer and Network Architectures
Robert Hoyt MD
William Hersh MD

After viewing the presentation, viewers should be able to:
Describe the basic components of computing
Discuss the Internet and World Wide Web
Understand the importance of networks in the field of medicine
Compare and contrast wired and wireless local area networks
(LANs)
Describe the newest wireless broadband networks and their
significance
Learning Objectives
Types:
Microcomputer
Minicomputer
Personal computer (PC) (Desktop)
Supercomputer: mainframe enterprise level
Laptop
Server: robust in terms of speed and memory
Mobile

smartphone
tablet
Computers
Computers recognize the binary digit (bit): 0 and 1
Bits represent everything in a computer: text, images, etc.
8 bits is a byte which can have 256 combinations
Text is represented by 7 bit alphanumeric combinations
(ASCII). For more text characters Unicode is used. For
example, 16 bit UTF means 16 bit
Images are represented by pixels. Each black/white pixel is 1
bit. Images are “memory hogs”, compared to text
Computers and Data
1000 bytes = 1 kilobyte (or 1K)
1000 kilobytes = 1 megabyte (or 1 meg)
1000 megabytes = 1 gigabyte (or 1 gig)
1000 gigabytes = 1 terabyte

1000 terabytes = 1 petabyte
1000 petabytes = 1 exabyte
1000 exabytes = 1 zettabyte
1000 zettabytes = 1 yottabyte = 1024 bytes
Kilobyte to Zettabyte
Central processing unit (CPU): where the computer chip resides
and is related to data processing speed
Memory: random access memory (RAM) is the working memory
that is lost when the computer is turned off.
Auxiliary storage: active storage is where data is stored that is
needed continuously. Archival storage can refer to tape, hard
disks, optical drives or cloud
Input and Output devices: keyboards, mouse, monitors, etc.
Computer Hardware
Software programs instructs the hardware what to do

Application Programming Interfaces (APIs) are a common way
now for computers to react with other programs or apps
Operating systems provide a standardized way for software
programs to perform tasks
Computer Software
C, C++, C# – used in many modern applications
MUMPS – used in many early medical applications, now
renamed to M and with many modern enhancements
BASIC – common in early days of PCs
Python – originated as “scripting” languages for Unix and Web,
but achieving larger-scale use, e.g., in machine learning
applications
Java – attempt to create standard language for Web applications
JavaScript – scripting language for Web browsers
R – emerging important language for statistics and data
analytics
Programming Languages for Computing

Source code is free and shareable. Examples are Linux, Apache,
Mozilla, OpenOffice, etc.
Resources for open source software in healthcare:
https://sourceforge.net/directory/business-
enterprise/enterprise/medhealth
https://en.wikipedia.org/wiki/List_of_open-
source_health_software
Online Registry of Biomedical Informatics Tools (ORBIT) –
https://orbit.nlm.nih.gov/
Open Source Software
Spreadsheets are considered flat files or one dimensional;
unlike relational databases which link tables together for more
robust storage and queries
A database management system (DBMS) is a program that
manages the database
Most common language to query the database is structured
query language (SQL)
There is a trend towards non-relational database systems, like
NoSQL for large “big data”
Database Systems

Note the primary key (Employee ID = 1) in the first table is
linked to the second table (Salary)
SQL Database Schema
The Internet is the largest and arguably most important large
scale international network
The Internet is a global “network-of-networks” using the
Telecommunications Protocol/Internet Protocol stack (TCP/IP)
as the communications standard. The TCP/IP stack allows for
layering of different standards and technologies based on the
participants in an exchange and the payload being exchanged
The Internet began in the late 1960 as a network known as
Advanced Research Projects Agency Network (ARPANET)
capable of tying together universities and research organizations
securely
The Internet and World Wide Web

The World Wide Web (WWW) operates on top of the Internet
and was created by Tim Berners-Lee in 1989
The WWW introduced the web browser, a software program
that allows for connection to web servers over the Internet using
Hypertext Transfer Protocol (HTTP)
Web pages are written using Hypertext Markup Language
(HTML), an implementation of a markup language, or method
for defining formatting of text in a document, which has become
synonymous with the Web
Achieving interoperability on the Internet depends on global use
of standards
Standards exist for the exchange of data, such as HTTP; the
format of data, such as HTML, and the transport of data, such as
TCP/IP
In a TCP/IP network, each device (host) must have an Internet

Protocol (IP) address. IP addresses can be distributed amongst
different tiers of lower layer networks, or “sub-networks”
In order for addressing to function properly in the presence of a
sub-network, the machine must both have an IP address and a
routing prefix or “subnet mask” (example: IP address of
192.168.10.1 and subnet mask of 255.254.254.0) in order for it
to be considered properly addressable by other network nodes
Two versions of IP addressing exists today, IP version 4 (IPv4)
which has been around for more than 40 years
IP version 6 (IPv6) is being used to phase out IPv4 before the
complete depletion of assignable addresses brings the growth of
the Internet to a complete halt
It is useful to think of the Internet as comprised of two main

components, protocols and hardware
Each machine addressable on a network is known as a node
Computers connect to the internet through an Internet Service
Provider (ISP) such as Bell South or AT&T
An electronic request for an IP address is sent via the network
link provided by the one’s ISP to a DNS server
The DNS server then matches the requested domain name and
responds with an IP address
The browser is now capable of sending an HTTP GET request
(again routed through one’s ISP provided link) to the IP address
returned from the DNS request
The browser can now render and display the document defined
by the HTML response on the user’s screen

A message must be sent using small packets of information that
can arrive via different routes, useful when there is web
congestion, and are reassembled back at one’s computer
All traffic sent using TCP/IP (such as phone calls over the
internet (VoIP) and email) are sent using packets
A router is a node which directs the packets on the Internet.
The role of ordering these packets and making sure that they
make it to their intended recipient in the proper structure is one
of the jobs of TCP/IP
The Uniform Resource Locator (URL) is a specified address to a
specific resource (e.g. http://www.google.com); the first part of
the URL is the protocol identifier and the rest is the resource
name
The protocol identifier and the resource name are separated by a
colon and two forward slashes. As an example,
http://uwf.edu/uwfmain/about describes HTTP as the
protocol,“uwf.edu” as the server to which the HTTP request will
be made, and “/uwfmain/about” as the path to the resource
being requested. The most common domains end in .com, .edu,
.org, .net, .mil, .gov and .int

How the Internet Works
Prior to the advent of the Internet, disparate businesses and
health care entities were not able to easily exchange data;
instead data resided on a local PC or server
Now, much of what we do is “is in the cloud”
Web services are task specific applications which are deployed
in a platform independent manner via a series of transactions to
and from other web-aware applications/services over a network
(such as the Internet)
Web services can be broken down into two categories: RESTful
services and SOA services
Web Services

Representational State Transfer (or RESTful) services are
lightweight services which use existing Internet infrastructure
and World Wide Web (WWW) concepts as their backbone
REST is an architecture, not a standard with endless
possibilities as to how REST can be applied to act as a service
bus
Communication with a RESTful service is a relatively quick
process and can utilize any existing content standard for
packaging its messaging. Most commonly, a RESTful service
will use XML or JavaScript Object Notation (JSON) for this
content delivery
RESTful Services
Operation Types (GET, DELETE, POST, PUT). These HTTP
methods can provide four different points of access to a
RESTful service. If a URI or URL identifies an object, the
HTTP operation type defines an accessor method to that object
(e.g. GET a list, POST an update, PUT a new record, DELETE
a purged record)
MIME Type (Multipurpose Internet Mail Extensions) is a means
of communicating the content type used within a message
transferred over the Internet. Typically, in a RESTful service,
this would be XML or JSON, but it could be any other type

RESTful Services
RESTful Operations
SOA is based on SOAP, a protocol standard for interacting with
web services
These services require a set of standards for content and a
service oriented architecture (SOA) stack, a collection of
services
The most common standards used in web services transactions
are HTTP, as the internet protocol, with XML as the delivery
language
Service Oriented Architecture (SOA) Web Services

SOAP (Simple Object Access Protocol): a communication
protocol between applications. It is a XML-based platform
neutral format for the invocation and response of web services
functions over a network
WSDL (Web Services Description Language): a XML document
used to describe and locate web services. A WSDL can inform
a calling application as to the functionality available from a
given service, as well as the structure and types of function
arguments and responses
UDDI (Universal Description, Discovery and Integration): a
directory for storing information about web services, described
by WSDL. UDDI utilizes the SOAP protocol for providing
access to WSDL documents necessary for interacting with
services indexed
Service Oriented Architecture (SOA) Web Services
UDDI provides the service registry (like the yellow pages) and
WSDL describes the services and the requirements for their
interaction
A service requester seeking a web service would search a
service directory for a function that meets a need using a

structured language
Once the service provider is located, a SOAP message can be
sent back and forth between the service requester and service
provider (next slide)
SOA Web Services
SOA Web Services
A conceptual model was created in 1984 to help understand
network architectures
It divides computer-to-computer communication into seven
layers known as the OSI Stack
The Open Systems Interconnection (OSI) Model

Application. This is the layer where applications access
network services. Examples: software for database access,
email and file transfer and the Internet protocols FTP, HTTP
and SMTP
Presentation. This layer translates (formats) the data for the
application layer for the network. Examples: data encryption
and compression
Session. This layer establishes, maintains and terminates
“sessions” between computers
The OSI Model Layers
Transport. This layers deals with error recognition and
recovery and handles message size issues and can send receipt
acknowledgments. The Internet protocol related to this is TCP
Network. This layer is involved with message control,
switching and routing. It translates logical addresses into
physical addresses
Data link. This layer packages data from the physical layer into
frames (special packets) and is responsible for error free from

transfer from one computer (node) to another
Physical. This layer deals with the unstructured raw data
stream from the other layers. Specifically, it encodes data and
decides whether the bits will be sent via a digital or analog
mode and decides if the bits will be transmitted as electrical or
optical signals. This layer is involved with communication with
devices. Examples: USB, Bluetooth and RS-232
A network is a group of computers that are linked together in
order to share information
A network can share patient information as well as provide
internet access for multiple users
Networks can be small, connecting just several computers in a
clinician’s office or very large, connecting computers in an
entire organization in multiple locations

There are several ways to access the internet: dial-up modem,
wireless fidelity (WiFi), a Digital Subscription Line (DSL),
3G/4G telecommunication, cable modem or T1 lines
Networks
Transmission methodTheoretical max speedTypical speed
rangeDial-up modem56 Kbps56 KbpsDSL6 Mbps1.5-8Mbps
downlink/128 Kbps uplinkCable modem30 Mbps3-15 Mbps
downlink/1-3 Mbps uplinkWired Ethernet (Cat 5)1000 Mbps100
MbpsFiber optic cable100 Gbps2.5-40 GbpsT-1 line1.5 Mbps1-
1.5 MbpsWireless 802.11g
Wireless 802.11n54 Mbps
300 Mbps1-20 Mbps
40-115 MbpsWiMax70 Mbps54-70 MbpsLTE60 Mbps8-12
MbpsBluetooth24 Mbps1-24 Mbps3G2.4 Mbps144-384
kbps4G100 Mbps10-70 MbpsSatellite10 Mbps10 Mbps
Data Transfer Rates
Bandwidth is the size of the pipe to transmit packets (a

formatted data unit carried by a packet mode computer network)
Packet loss is an issue because packets may rarely fail to reach
their destination. The IP Transmission Control Protocol (TCP)
makes sure a packet reaches its destination or re-sends it. The
User Datagram Protocol (UDP) does not guarantee delivery and
is used with, for example, live streaming video
End-to-end delay is the latency or delay in receiving a packet.
With fiber optics the latency is minimal
Jitter is the random variation in packet delay and reflects
Internet spikes in activity
Data Transfer Affected By:
Networks are named based on connection method, as well as
configuration or size. As an example, a network can be
connected by fiber optic cable, Ethernet or wireless. Networks
can also be described by different configurations or topologies.
They can be connected to a common backbone or bus, in a star
configuration using a central hub or a ring configuration
Network Types

A PAN is a close proximity network designed to link phones,
computers, PDAs, etc. The most common technology to create
a wireless personal area network or WPAN is Bluetooth (BT)
BT is designed to wirelessly connect an assortment of devices at
a maximum distance of about 300 feet with the most recent
Bluetooth devices (version 5.0). It does have the advantages of
not requiring much power and connecting automatically. It
operates in the 2.4 MHz frequency range
The most common application of Bluetooth today is as a
wireless headset to connect to a mobile phone but wearable
technology (e.g. fitness devices) is a close second
Personal Area Networks (PANs)
Bluetooth can be used to wirelessly connect computers to
keyboards, mice, printers, PDAs and smartphones
Security must be enabled due to the fact that even though the
transmission range is short, hackers have taken advantage of
this common frequency
Bluetooth Smart or Low Energy 5.0 requires less power, has
better battery life and is less expensive. The frequency is the
same but the range is less (about 50 meters)

PANs can also use other standards: Infrared to connect devices
using the IrDA standard, ZigBee networks, Wireless USB and a
body area networks (BANs)
A wireless body area network (WBAN) is also known as a body
sensor network which is gaining importance in healthcare
Another wireless sensor network protocol known as ANT™ is
available for ultra-low power applications. The proprietary
network operates on the 2.4 GHz ISM band
LANs generally refer to linked computers in an office, hospital,
home or close proximity situation
A typical network consists of nodes (computers, printers, etc.),
a connecting technology (wired or wireless) and specialized
equipment such as hubs, routers and switches
LANs can be wired or wireless
Local Area Networks (LANs)

To connect several computers in a home or office scenario, a
hub or a network switch is needed
Routers direct messages between networks and the Internet;
whereas, switches connect computers to one another and prevent
delay
Unlike Hubs that share bandwidth, switches operate at full
bandwidth. Switches are like traffic cops that direct
simultaneous messages in the right direction
Wired LANs
To handle larger enterprise demands Gigabit Ethernet LANs are
available that are based on copper or fiber optics. Cat5e or
Cat6 cables are necessary
Greater bandwidth is necessary for many hospital systems that
now have multiple IT systems, an electronic medical record and
picture archiving and communication systems (PACS)
Typical LAN shown on next slide
Wired LANs

Typical Wired LAN Schema
Phone lines can connect a computer to the internet by using a
dial-up modem. The downside is that the connection is
relatively slow
Digital subscription lines (DSL) also use standard phone lines
that have additional capacity (bandwidth) and are much faster
network connection than dial up
DSL also has the advantage over modems of being able to
access the internet and use the telephone at the same time
Wired LANs

Power lines are another option using standard power outlets to
create a network. PowerPacket® is inexpensive to install and
claims data transfer speeds of 14 Mbps
Ethernet is a network protocol and most networks are connected
by fiber or twisted-pair/copper wire connections. Ethernet
networks are faster, less expensive and more secure than
wireless networks. The most common Ethernet cable is
category 5 (Cat 5, 5e) unshielded twisted pair (UTP)
Wired LANs
Wireless networks are based on the Institute of Electrical and
Electronics Engineers (IEEE) 802.11 standard and operate in the
900 MHz, 2.4 GHz and 5 GHz frequencies
Wireless networks have become much cheaper and easier to
install so many offices and hospitals have opted to go wireless
This allows laptop/tablet PCs and smartphones in exam and
patient rooms to be connected to the local network or internet
without the limitations of hardwiring but it does require a
wireless router and access points
Wireless LANs

802.11ac is the newest standard that can operate at speeds up to
900 Mbps with a frequency of 2.4 and 5 GHz
The network router is usually connected to the Internet by an
Ethernet cable to DSL or a cable modem. Security must be
established using an encryption scheme such as WiFi Protected
Access II (WAP2) encryption
Each device on a network has a unique address (MAC) and
routers can have security lists which only allow known devices
or MACSs into the network
Wireless LANs
Wireless LAN (WLAN)

GANs are networks that connect other networks and have an
unlimited geographic area. The problem with broadband
technology is that it is expensive and the problem with WiFi is
that it may result in spotty coverage
These shortcomings created an initiative known as Worldwide
Interoperability for Microwave Access (WiMax), using the
IEEE 802.16 standard
This 4G network is about 10 times faster than 3G and has
greater capacity which is equally important
Global Area Networks (GANs)
The goal is to be faster than standard WiFi and reach greater
distances, such that it might replace broadband services and
permit widespread wireless access to the internet by PCs or
phones
The introduction of one 4G network (WiMax) was so slow that
major carriers adopted Long Term Evolution (LTE) WiFi
Operating in the 700 MHz range it has maximum download rates
of 100 Mbps and upload rates of 50 Mpbs
There will be a slow roll out of 5 G in 2018
Global Area Networks (GANs)

In this case the home computer is the client and is attached to
the network at work by communicating with a VPN server
associated with that network
The Internet can serve as the means of connection with VPN
working over both wired and wireless LANs
“Tunneling protocols” encrypt data by the sender and decrypt it
at the receiver’s end via a secure tunnel. In addition, the
sender’s and receiver’s network addresses can be encrypted
A physician at home may use a VPN to access the work EHR
Virtual Private Networks (VPNs)
Virtual Private Networks (VPNs)

Informaticians need to understand computer and network
technologies
Clinicians and IT staff must have an excellent understanding of
office networks and the related required security
Wireless networks have become attractive due to faster speeds
and lower costs
Wireless broadband has arrived to provide faster Internet access
for all
Conclusions
Chapter 4: Electronic Health Records
Robert Hoyt MD
Vishnu Mohan MD

After reading this chapter the reader should be able to:
State the definition and history of electronic health records
(EHRs)
Describe the limitations of paper-based health records
Identify the benefits of electronic health records
List the key components of an electronic health record
Describe the ARRA-HITECH programs to support EHRs
Describe the benefits and challenges of computerized order
entry and clinical decision support systems
State the obstacles to purchasing, adopting and implementing an
electronic health record
Enumerate the steps to adopt and implement an EHR
Learning Objectives
2
There is no topic in health informatics as important, yet
controversial, as the electronic health record (EHR)

In spite of fledgling EHRs being around for the past 35-40 years
they are still controversial in the eyes of many
Due to the federal government reimbursement programs for
EHR use by physicians and hospitals, EHRs are now part of the
healthcare landscape
Some of the famous early EHRs are listed on the next slide
Introduction
The Problem Oriented Medical Information System (PROMIS)
American Rheumatism Association Medical Information
System (ARAMIS)
Regenstrief Medical Record System (RMRS)
Summary Time Oriented Record (STOR)
Health Evaluation Through Logical Processing (HELP)
Computer Stored Ambulatory Record (COSTAR)
De-Centralized Hospital Computer Program (DHCP)—
forerunner of VistA (Veterans Health Administration)
Early EHRs

Electronic Health Record: “An electronic record of health-
related information on an individual that conforms to nationally
recognized interoperability standards and that can be created,
managed and consulted by authorized clinicians and staff across
more than one healthcare organization”
While the “experts” can debate the difference between EHR and
EMR, we will not and will stick with EHR throughout the
textbook and slides
Definition
Paper records are severely limited: less legible, more difficult
to retrieve, store and share and unstructured data. Also,
electronic records less likely to be missing and available 24/7
from multiple locations. Paper records do not permit clinical
decision support
Need for improved efficiency and productivity: clinicians are
more productive if charts are available and retrieval of results is
faster. EHR access from home while on call helps productivity
Quality of care and patient safety: the factors already described
in last two bullets plus clinical decision support, quality reports
and secure messaging as part of an EHR
Why do we need EHRs?

Public expectations: EHRs may increase patient satisfaction
through faster results, messaging, patient portals, electronic
patient education, e-prescribing and online scheduling
Governmental expectations: federal government considers EHR
to be transformational and hence why they support
reimbursement for use
7
Financial savings: EHRs may save money by eliminating
transcription and improving coding. Decreased file room
storage and faster chart pulls and info retrieval may result in
cost savings
Technological advances: computers are much faster, the Internet
is more prevalent, wireless and mobile technologies are
ubiquitous; all supporting EHRs
Need for aggregated data: healthcare data must be electronic to
be shared, stored and analyzed. Research depends on large study

populations and data sets which EHRs can provide
Need for integrated data: electronic data permits integration
with health information organizations, data analytics, public
health reporting, artificial intelligence and genomic information
EHR as a transformational tool: select organizations such as the
VA and Kaiser Permanente made huge investments in EHRs to
standardize care and transform delivery and analysis of
healthcare
Need for coordinated care: with an aging population with
multiple physicians and medications, care coordination is
important. Sharing electronically has great potential, but
barriers exist as we point out in the chapter on health
information exchange

Electronic Health Record Key Components
Clinical decision support
Secure messaging
Computerized physician order entry
Practice management
Manage care module
Referral management
Results retrieval
Prior encounter retrieval
Patient reminders
Electronic encounter notes
Multiple input methods
Access via mobile technology
Remote access from home
Electronic prescribing
Integration with images
Integration with physician and patient education
Public health reporting
Quality reports
Problem summary lists

Electronic Health Record Key Components
Ability to scan in data
Evaluation and management help
Ability to graph and track results
Ability to create patient lists
Ability to create registries
Preventive medicine tracking
Privacy/security compliance
Robust backup systems
Ability to generate summaries of care (CCD)
Support for client server or application service provider (ASP)
modes
CPOE is an EHR feature that processes orders for medications,
lab tests, imaging, consults and other diagnostic tests. It is not
the same as electronic prescribing
CPOE has many potential benefits (next slide)
CPOE has the potential to reduce medical errors but the
literature is mixed. Most early studies came from a select
number of academic institutions with home grown EHRs and
large IT departments

Computerized Physician Order Entry (CPOE)
Potential Benefits of CPOE
Koppel et al
Overcomes the issue of illegibility
Fewer errors associated with ordering drugs with similar
names,
More easily integrated with decision support systems than
paper,
Easily linked to drug-drug interaction warning
More likely to identify the prescribing physician,
Able to link to adverse drug event (ADE) reporting systems
Able to avoid medication errors like trailing zeroes
Creates data that is available for analysis
Can point out treatment and drugs of choice
Can reduce under and over-prescribing,
Prescriptions reach the pharmacy quicker

One study suggested cost savings from reduced length of stay,
compared to paper based orders
Some studies have shown improved standardized care with
EHRs, but this is not universal
CPOE is difficult to implement in hospitals because it disrupts
workflow and slows physicians down. They often don’t realize,
however, that CPOE benefits others on the team, such as nurses
and pharmacists
CPOE
With CPOE you can embed a variety of tools to assist in
decision making. Traditionally, this meant medication alerts and
patient reminders. In reality, any software that assists decisions
is a CDSS:
Knowledge support: programs embedded into the EHR that
educate clinicians or patients
Calculators: part of the EHR
Flow charts and graphs: to look at lab or vital sign trends over
time
Clinical Decision Support Systems (CDSSs)

CDSS (continued)
Order sets: inpatient clinical practice guidelines for specific
scenarios (e.g. pneumonia), standardizing care
Reminders: remind clinician or patient about pending tests, etc.
Differential diagnosis: software exists that helps clinicians
analyze symptoms and signs, to arrive at a diagnosis
Lab and Imaging decision support: what tests are indicated and
at what costs?
Public health alerts: primarily infectious disease alerts for new
outbreaks, e.g. MERS virus
Clinical Decision Support Systems (CDSSs)
Currently, the vast majoring of eRx occurs as part of an EHR
and not a standalone program
69% of office-based prescriptions are now electronic
93% of community pharmacies are connected to the Surescripts
network
The next slide lists the potential advantages of eRx over paper-

based prescriptions
Electronic Prescribing (eRx)
eRx Potential Benefits
Legible and complete prescriptions
Abbreviations+ unclear decimal points are avoided
The wait to pick up scripts shorter
Fewer duplicated prescriptions
Better compliance with fewer drugs not filled or picked up
Potential to reduce workload for pharmacists
Timely notification of drug alerts and updates
Ability to check formulary status and copays
Can interface with practice and drug management software
The process is secure and HIPAA compliant
Associated with CDDSs
Digital records improve data analysis of prescribing habits
Batch refills can save time
Better use of generic or preferred drugs

Details about drug allergies
Drug-drug interaction alerts
Formulary alerts to tell you drug is either not recommended or
not reimbursed
Alerts can exist to ask about pregnancy, kidney or liver function
and safety in the elderly
Dosing alerts can arise based on age or size of patient
eRx Clinical Decision Support
Alert fatigue: too many alerts result in deletions, some justified,
others not. Hot topic and area of much future research
Prescribing errors still occur with eRx but they are different;
wrong drug or wrong dose
There are still issues at the pharmacist’s end but these should
improve over time
Still not clear how many adverse drug events are prevented with
eRx; perhaps too soon to know
eRx Challenges

Chronic disease: track e.g. diabetes
Research registries: high volume allows research questions to
be answered
Safety registries: issues reported to e.g. FDA
Public health registries: immunizations, cancer and
biosurveillance
Quality: data could be stored in registry and later forwarded to
e.g. CMS
EHR Registries
Prior to EHR adoption, most medical practices used an
electronic PMS. Now most are part of their EHR
PMSs are essential to run any practice: for billing, dealing with
insurance companies, evaluating physician performance and
practice trends
Typical office workflow is shown in next slide
Practice Management Systems (PMSs)

EHR Adoption
The US has been behind many other “developed” countries up
until the HITECH ACT that included reimbursement for EHRs
Ambulatory EHR adoption (2015): roughly 86% have EHRs, but
some are much more advanced than others. Larger practices
adopt at a higher rate due largely to stronger finances
Inpatient (hospital) EHR adoption (2015): perhaps as many as
96% of US hospitals have EHRs and most are participating in
the Meaningful Use program. Smaller urban and rural hospitals
lag
Just because you own an EHR doesn’t mean you are maximizing
the features and benefits (next slide)

Very Few Practices Have Reached Stage 7 Sophistication
(HIMSS data second quarter 2017
Financial: in spite of government reimbursement, some
practices will gain and some will lose money. What will the
long term annual costs be after reimbursement ends? Will some
stop using EHRs?
Physician resistance: complying with meaningful use has been
onerous and may not result in any immediate and direct benefit
to clinicians and patients
Loss of productivity: there is almost always initial loss of
productivity and if the practice doesn’t change workflow habits
there will be a long term losses as well
EHR Challenges

Workflow changes: everyone must adapt to doing business
differently but some seek strange workarounds
Reduced physician-patient interaction: without careful
forethought and planning, there will be less eye contact and
interaction with patients
Usability issues: some EHRs are not user friendly and require
too many mouse clicks or illogical steps, impeding workflow
Integration with other systems: practices may need to build
expensive interfaces to communicate with HIOs, practice
management systems, etc.
EHR and Meaningful Use Challenges
Lack of interoperability: EHRs are not capable of
communicating with each other without additional technology,
thus an impediment to data sharing
Privacy concerns: hacking into EHRs could result in loss of
privacy for thousands, rather than a single paper chart
Legal: It is not known if EHRs will increase or decrease
malpractice over the long haul
Inadequate proof of benefit: in spite on many published studies,

there is not adequate proof that EHRs improve quality of care
Patient safety and unintended consequences: not only are
studies suggesting improved patient safety mixed, there is
evidence that new medical errors may occur (at least in the
short term) with EHR use. “E-iatrogenesis” means medical
errors due to technology
Situation worsened by alert fatigue, frequent software upgrades,
usability issues, stress to meet meaningful use objectives
Several sentinel failures of major EHRs in large healthcare
systems have highlighted EHR vulnerability
The US federal government (along with the IOM) has opined
that EHRs are an important part of healthcare reform
A program for reimbursement for EHR use by clinicians and
hospitals under Medicare and Medicaid (HITECH Act) was

established in 2009
Clinicians had to: (1) be eligible, (2) register for
reimbursement, (3) use a certified EHR, (4) demonstrate and
prove Meaningful Use, and (5) receive reimbursement.
As of December 2017, $24.8 billion was spent by Medicare and
$12.54 by Medicaid on EHR reimbursement to clinicians
HITECH ACT and EHR Reimbursement
Medicare defines EPs as doctors of medicine or osteopathy,
doctors of dental surgery or dental medicine, doctors of
podiatric medicine, doctors of optometry and chiropractors
Medicaid defines EPs as physicians, nurse practitioners,
certified nurse midwives, dentists and physician assistants
(physician assistants must provide services in a federally
qualified health center or rural health clinic that is led by a
physician assistant). Medicaid physicians must have at least
30% Medicaid volume (20% for pediatricians)
Eligible Professionals (EPs)

The goals of MU are the same as the national goals for HIT: (a)
improve quality, safety, efficiency and reduce health disparities;
(b) engage patients and families; (c) improve care coordination;
(d) ensure adequate privacy and security of personal health
information; (e) improve population and public health
EHRs must be certified by several organizations as capable of
meeting meaningful use objectives
Meaningful Use Goals
Users must meet required core measures and multiple menu
measures (textbook for more details). Quality measures are a
major part of meaningful use
There are penalties for hospitals or EPs that don’t comply with
Medicare Meaningful Use
Meaningful Use

Low cost that includes 3 month free trial
Fully featured and compliant with Meaningful Use
Available as a client or web based (ASP) model
Appeals to small practices, particularly primary care
Small EHR Example
Amazing Charts
Medium priced for medium sized practices of multiple
specialty types
More clinician and patient features to include mobile and a
health information exchange (HIE) solution
Medium EHR Example
eClinicalWorks
Intended for very large practices such as Kaiser-Permanente

Includes every aspect of Meaningful Use and numerous
innovations such as a comprehensive patient portal and several
mobile solutions
Large EHR Example
Epic
Develop an office strategy: why are you considering EHRs? Is
your entire staff onboard? Don’t do it just for reimbursement.
Plan, plan, plan
Do Research: take advantage of courses, books, articles, EHR
survey results, regional extension centers, HIT consultants, etc.
List features: be sure to include inputting methods, backup,
warrantees, mobile presence, etc.
Analyze and re-engineer workflow: consider all processes likely
to change when you transition from paper to electronic
Implementing an EHR Steps

Use project management tools: these will improve your
organization for tasks
Choose client versus ASP model: the web based model will be
easier with less of the need for in house IT support
Practice management system needs: should you purchase a
combination or build an interface?
Survey your hardware and network needs: will you need more
bandwidth? Wireless? How many computer stations and will
they require upgrades?
Develop a vendor strategy: create request for proposals (RFPs)
for vendors to outline all of your needs, to include price,
maintenance, etc. Obtain commitments in writing.
Select a vendor: develop a contract and have it reviewed by
legal
Develop a paper to EHR conversion strategy: it is likely you
will initially run a dual paper and electronic practice. Textbook
discusses this in more detail

Training: you can’t train to much and be sure to discuss the
details with your vendor early on
Implementation: decide whether you will phase in
implementation or have a “go live” date. Be prepared to
decreased productivity for several months and a new glitches
along the way
EHRs are felt to be critical for US healthcare reform
Paper based health records are severely limited
EHR reimbursement has greatly increased US adoption
In spite of many potential benefits of EHRs, multiple challenges
are associated with adoption
Planning, training and strategizing about EHRs is more
important than the actual EHR brand purchased
Conclusions

ALHE Research Paper Rubric
GRADING ITEMS
POSSIBLE POINTS
Was the research paper formatted in APA styling
5
Did topic relate/speak to Information Sharing in today’s HC
system
5
Was the subject communicated in a professional manner and
informative
10
Did evidenced based literature sites support the paper’s content
10
Overall rating
_____/ 30
Week 6 - Discussion 2
Required Resources
Text
Langvardt, A. W., Barnes, A. J., Prenkert, J. D., McCrory, M.
A., & Perry, J. E. (2019). Business law: The ethical, global, and
e-commerce environment (17th ed.). Retrieved from

https://www.vitalsource.com
· Chapter 20: Product Liability
· Chapter 48: The Federal Trade Commission Act and Consumer
Protection Laws
· Chapter 49: Antitrust: The Sherman Act
· Chapter 50: The Clayton Act, the Robinson-Patman Act, and
Antitrust Exemptions and Immunities
Text
· Chapter 47: Administrative Law
Website
United States Consumer Product Safety Commission (Links to
an external site.). (www.cpsc.gov/)
· This website provides information about the United State
Consumer Product Safety Commission and may assist you in
your Final Paper this week.
Accessibility Statement (Links to an external site.)Privacy
Policy
Instructions
Prior to beginning work on this discussion,
· Review Chapter 48 of the course textbook.
Between 1966 and 1975, the Orkin Exterminating Company, the
world’s largest termite and pest control firm, offered its
customers a “lifetime” guarantee that could be renewed each
year by paying a definite amount specified in its contracts with
the customers. The contracts gave no indication that the fees
could be raised for any reasons other than certain narrowly

specified ones. Beginning in 1980, Orkin unilaterally breached
these contracts by imposing higher-than-agreed-upon annual
renewal fees. Roughly 200,000 contracts were breached in this
way. Orkin realized $7 million in additional revenues from
customers who renewed at the higher fees. The additional fees
did not purchase a higher level of service than that originally
provided for in the contracts. Although some of Orkin’s
competitors may have been willing to assume Orkin’s pre-1975
contracts at the fees stated therein, they would not have offered
a fixed, locked-in “lifetime” renewal fee such as the one Orkin
originally provided.
· Under the three-part test for unfairness stated in the course
textbook (see page 1363), did Orkin’s behavior violate FTC Act
§ 5’s prohibition against unfair acts or practices?
· Discuss each element of the three-part test and how it applies
to the Orkin case.
Your initial response should be a minimum of 200 words.
Week 6 - Discussion 1
Required Resources
Text
· Chapter 20: Product Liability
· Chapter 48: The Federal Trade Commission Act and Consumer
Protection Laws
· Chapter 49: Antitrust: The Sherman Act
· Chapter 50: The Clayton Act, the Robinson-Patman Act, and
Antitrust Exemptions and Immunities
Text

· Chapter 47: Administrative Law
Website
United States Consumer Product Safety Commission (Links to
an external site.). (www.cpsc.gov/)
· This website provides information about the United State
Consumer Product Safety Commission and may assist you in
your Final Paper this week.
Accessibility Statement (Links to an external site.)Privacy
Policy
Instructions
Prior to beginning work on this discussion,
· Review Chapter 49 of the course textbook.
Coed Theatres (Coed), a Cleveland area movie theater booking
agent, began seeking customers in southern Ohio. Shortly
thereafter, Superior Theatre Services (Superior), a Cincinnati
booking agent, began to solicit business in the Cleveland area.
Later, however, Coed and Superior allegedly entered into an
agreement not to solicit each other’s customers. The Justice
Department prosecuted them for agreeing to restrain trade in
violation of § 1 of the Sherman Act. Under a government grant
of immunity, Superior’s vice president testified that Coed’s vice
president had approached him at a trade convention and
threatened to start taking Superior’s accounts if Superior did
not stop calling on Coed’s accounts. He also testified that at a
luncheon meeting he attended with officials from both firms,
the presidents of both firms said that it would be in the interests
of both firms to stop calling on each other’s accounts. Several
Coed customers testified that Superior had refused to accept

their business because of the agreement with Coed. The trial
court found both firms guilty of a per se violation of the
Sherman Act, rejecting their argument that the rule of reason
should have been applied and refusing to allow them to
introduce evidence that the agreement did not have a significant
anticompetitive effect.
· What is the rule of reason and how does it differ from the per
se rules?
· Should the rule of reason have been applied in this case?
Explain why or why not.
Your initial response should be a minimum of 200 words.

Week 6 - Discussion ForumRequired ResourcesTextSharpe, N. .docx

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