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Informatics Project:

Interoperability of Electronic Health Records

Makenzie D. Helsel

Delaware Technical Community College

NUR 410-5W1: Nursing Informatics

Dr. Jackie Henaghan

November 29, 2020

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Informatics Project: Interoperability of Electronic Health Records

Introduction

Informatics is a widely discussed topic within healthcare. Healthcare informatics has

been described as “a combination of computer science, information science, and nursing science

designed to assist in the management and processing of nursing data, information and knowledge

to support the practice of nursing and the delivery of nursing care” (Sewell, 2019, p. 6-7).

The idea of interoperability is imperative in the future of healthcare informatics.

Interoperability can be defined as “the ability to capture, communicate, and exchange data

accurately, effectively, securely, and consistently with different information technology systems,

software applications, and networks in various settings” (Orlova et al., 2016, p. 55).

Interoperability is apparent in the use of electronic health records (EHRs) for patient information.

In other words, interoperability allows multiple patient information systems, such as in-patient

charting systems, to “talk” to one another and share patient information.

The ability for healthcare organizations to share patient information is an on-going

problem within healthcare. Not to mention the use of multiple EHR vendors within one

organization, but consider the trail of information needed when a patient progresses from the

emergency department, to in-patient care, discharge to a rehabilitation center, and then possibly

home with home-health. All of these organizations utilize different EHR systems which makes

the transfer of patient information very difficult. By adapting to the idea of interoperability

between healthcare systems, optimal patient care can be achieved.

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Review of Literature

When considering the topic of EHR interoperability, it is important to be aware that

numerous EHR vendors exist. According to an article by Reisman (2017), “hundreds of

government-certified EHR products are in use across the country, each with different clinical

terminologies, technical specifications, and functional capabilities” (Reisman, 2017, p. 572).

Even with technology advancements seen in healthcare, the impact of informatics on process

improvement is still widely needed. “Despite massive effort and investment in health

information systems and technology, and many years of widespread availability, the full

promised benefits of EHRs are far from fruition” (Reisman, 2017, p. 572). Due to the fact that

the multiple systems utilized for patient information do not communicate all data, patients are at

risk for errors, particularly medication errors. “Quite simply, EHR systems just don’t support

effective interoperability at an adequate level” (Orlova et al., 2016, p.56).

The idea of true interoperability is a very important area for quality improvement. “For

two EHR systems to be truly interoperable, they must be able to exchange and then use the data”

(Reisman, 2017, p. 573). The idea of making total interoperability possible is a difficult concept.

The article states that “not even those EHR systems built on the same platform are necessarily

interoperable because they are often highly customized to an organization’s unique workflow

and preferences” (Reisman, 2017, p. 573). Additionally, one must consider that in order to

establish interoperability, organizations must agree to a standardization of EHRs. “Currently,

healthcare organizations use various standards in their information systems, but standards are not

adopted uniformly across organizations” (Orlova et al., 2016, p. 54).

An article titled “Healthcare’s latest interoperability push” (Leventhal & Haglan, 2017)

continues the discussion of interoperability of EHR vendors. The article states that “big name
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EHR vendors have shown an increased willingness to collaborate as their hospital and health

system clients ramp up the pressure for patient data to be made available whenever and wherever

they need it” (Leventhal & Haglan, 2017, p. 35). This information is beneficial in validating the

promotion of interoperability between EHR vendors. Noting the numerous numbers of EHR

vendors, one can imagine that the topic of total interoperability is something that will not be

achieved overnight. It would require the support and participation of many organizations.
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Ethical/Legal Considerations

A research article titled “Health IT, hacking, and cybersecurity: National trends in data

breaches of protected health information” (Ronquillo et al., 2018) discusses how the increased

use of technology and informatics in healthcare poses major threats on the protection and privacy

of patient information. While continuously moving more and more towards technology forward

healthcare processes, such as EHRs, ethical and legal dilemmas may arise. Nurses must be

vigilant in the protection of patients’ rights.

“The rapid adoption of health information technology (IT) coupled with growing reports

of ransomware, and hacking has made cybersecurity a priority in health care” (Ronquillo et al.,

2018, p. 15). The research study included statistics regarding healthcare data breaches that

occurred in the United States between 2013 and 2017. According to Ronquillo et al., over the

five-year span, 128 EHR breaches were discovered, which affected 4,867,337 patients.

Additionally, there were 363 hacking incidents which involved 130,720,378 patient records. Not

only does healthcare information breaches affect patient’s privacy, but it may also place our

technology forward healthcare systems “off-line”. This could disrupt necessary processes,

putting patient’s health and safety at risk. Lastly, these attacks may cost healthcare systems

millions of dollars in ransom.

When you consider the technological advancements utilized in healthcare today, it is easy

to look at how technology improves patient outcomes and increases workflow efficiency for

healthcare providers. It is clear that the benefits of electronic health records outweigh any

negative possibilities. However, it does not diminish the risk. “Due to the digital nature of

electronic healthcare systems, they are easily accessible and can be shared” (Rezaeibagha et al.,

2015., p. 23). As mentioned previously, interoperability is a quality improvement topic within

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healthcare informatics today. “Interoperability is a feature that enables information systems to

exchange information, thereby enhancing the availability of information” (Rezaeibagha, 2015, p.

26). The goal of EHR interoperability is to move away from paper charting and towards

interconnected systems of electronic charting that enhance patient care and safety. Not only

would EHRs be present within one facility, but interoperability also suggests that these systems

must be interconnected to share all patient information. “EHRs are shared among different

systems and this openness raises considerable concern about patient privacy owing to the

possibility of unauthorized access or misuse owing to improper security implementation”

(Rezaeibagha, 2015, p. 23). With that being said, risks for leaks in patient information increases.

An important role for nurses when considering EHRs is protecting patient information.

The topic of HIPPA is commonly discussed in healthcare, which requires all healthcare members

to protect patient health information. According to the QSEN Institute (2020), healthcare

informatics includes confidentiality of protected health information in electronic health records.

“Nurses are uniquely positioned to help protect against and report cybercrimes because they are

one of the largest employed populations in the healthcare industry and they are on the front line

of patient care and healthcare technology use” (Kamerer & McDermott, 2020, p. 48).

When considering the nurses role with patient information, the nursing code of ethics can

offer insightful information. The nursing code of ethics provision three states, “the nurse

promotes, advocates for, and protects the rights, health, and safety of the patient (American

Nurses Association, 2015, p. 9). Similarly, to the protection of patient rights, is the topic of

privacy. “Privacy is the right to control access to, and disclosure or nondisclosure of,

information pertaining to oneself and to control the circumstances, timing, and extent to which

information may be disclosed” (American Nurses Association, 2015, p. 9). EHR safety not only
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includes the ideas of cyber security, but also simply breaches of patient information by nurses.

Simply accessing a patient’s chart without a proper reason can be considered a breach of HIPPA.

For example, if a family member or friend is a patient in the hospital, you as the nurse do not

have clearance to access that patient’s chart unless you are a direct member of the patients care

team. This is noted in the nursing code of ethics and is a direct breach of patient privacy.

Moving forward in healthcare as technology continues to advance, it remains the nurse’s

role to protect patients. “Interoperability demands information security, including restriction of

unauthorized access, use, disclosure, and modification of data, in order to ensure confidentiality,

integrity, and availability” (Rezaeibagha, 2015, p. 26). Cybersecurity education must be

provided to not only nurses, but all healthcare team members. By providing said education, the

promotion of safety and patient rights when utilizing healthcare technology is taught. All

healthcare facilities should maintain strong IT departments as well, therefore further ensuring

protection of patient rights. Healthcare organizations must maintain proper malware, data

encryption software, etc. Educating nurses about phishing emails is an important part of cyber

security. Hackers may utilize very realistic emails which a nurse or team member may

unknowingly and unintentionally interact with. IT often promotes education surrounding this

topic by sending out false phishing emails from the organization to act as learning opportunities

for employees. By promoting education surrounding this topic, patient privacy is ensured.

Lastly, nurses must be familiar and comfortable with the nursing code of ethics. Information

surrounding the protection of patient rights and privacy are imperative to our role as a nurse.
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Current Workflow Map

At a local hospital, Beebe Healthcare, two different electronic health records (EHRs) are

utilized. While numerous EHR vendors exist, Beebe Healthcare utilizes two unique charting

systems between the Emergency Department (ED) and the in-patient units. Currently, IBEX is

used in the ED and Cerner is used for in-patient charting. Having two different EHR systems is

not an ideal situation and leads to room for possible patient care errors.

The current workflow of EHR documentation begins when the patient arrives at the ED.

While the patient remains in the ED, most documentation will occur in IBEX. This includes any

nursing assessments/documentation, ED physician assessment, orders, medications, and

procedures performed. The only information that is readily available in Cerner are lab results

and diagnostic imagining as these findings are directly published into Cerner. Once the patient

has been admitted to the hospital, the admitting physician will take over in regards to patient care

orders, which will then be entered into Cerner. The admitting physician will publish a history

and physician (H&P) note into Cerner. However, the timing of this varies depending on the

physician’s availability.

When the patient is being transferred from the ED to an in-patient unit, the ED nurse will

call report to the primary nurse. The nurse receiving report must briefly rely solely on the report

given by the ED nurses for most of the imperative information regarding the patient, as at the

time of report the ED record is not available in Cerner, and most often neither is the H&P. The

floor nurses do not have access to IBEX unless they are the charge nurse. As IBEX and Cerner

do not communicate, when the patient is admitted to the hospital, the IBEX ED report will be

“transcribed” into an “ED Note” in Cerner. This results in a report, often more than ten pages

long, of all the events that occurred in the ED.

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The problem with having more than one EHR used within one hospital, or EHRs that do

not share all information, is that miscommunication and errors may occur. The current process is

particularly difficult for the nurse who is admitting the patient. The nurse must take the time to

search through the numerous pages of the ED note to find necessary information which is

pertinent for patient care. Medications given in the ED are not documented in Cerner, which

leads to the possibility of medications errors occuring. Too often the admitting physician will

order medications in Cerner which may have been already been given in the ED. However, they

are not documented in Cerner which may appear as a medication that still needs to be given. The

admitting nurse must search through the ED note to find what medications were given, including

important information such as dose and time. Additionally, information surrounding procedures

are not charted in Cerner. The nurse must also search the ED note to find out when and where

placement of IV’s, foleys, chest tubes, and other devices occurred in order to accurately

document them in Cerner. Overall, the current process of documentation between two EHR

systems can be improved.

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Current Workflow Diagram

Current process of how patient information between the Emergency Department (utilizing IBEX)

and in-patient charting (CERNER) is transferred when using two EHR systems:

Does the
Start: Patient arrives to the Patient is assessed by patient
Emergency the primary RN & ED require
Department (ED) physician medical
treatment?

YES

NO

Any medications given ED physician enters

Assessments are
or procedures orders/medications into
documented in IBEX Stop
performed in ED are IBEX for primary RN to
documented in IBEX follow

NO
Is the patient to be Stop
admitted into the
hospital?

YES

Lab results &

diagnostic imaging Admitting physician
are found in CERNER will assess patient &
enter orders into
CERNER

All further
Stop charting will occur The ED record will be transcribed into
in CERNER an “ED Note” into Cerner where in-
patient team members will be able to
assess the care provided in the ED (in-
patient RNs will be unable to view IBEX
charting)
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Workflow Process Improvement Plan

The improved workflow process plan includes the ability for both the emergency

department and in-patient units to have patient information, orders, and all charting available in

one by utilizing a singular electronic health system. With utilizing only one EHR vendor, all

imperative patient information could be easily located. This would decrease the risk of medical

errors occurring, increase nurse productivity, and improve patient outcomes.

With the new workflow process, patients admitted into the ED would have ideal care

flow throughout their stay in the hospital. Previously, while in the ED, all orders received, tasks

performed, and medications given were only readily available in IBEX, the ED charting system.

The only way to view this information once the patient had been admitted into the hospital was

by searching through numerous pages of a transcribed ED note in Cerner. The new concept of

one singular EHR utilized allows for all medications given, performed procedures, and other

imperative information that describes the patient’s emergency visit to be documented and

available in Cerner.

The most important benefit of changing the current process of ED to in-patient charting is

improved patient outcomes with the prevention of medical errors. As mentioned previously, one

of the biggest problems with the two current systems is the fact that medication administration

that occurs in the ED does not transfer to Cerner. There are numerous times where medications

are present in the medication administration section of Cerner that may have been given in the

ED. It becomes the responsibility of the admitting nurse to ensure the ED record is thoroughly

read to make sure any duplicate medications are not administered. By utilizing one EHR vendor,

medication discrepancies would not occur.

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Another important benefit to implementing change would be improved nurse

productivity. Especially when admitting a critical patient, you as the nurse are bombarded with

an influx of new orders and tasks to perform. As previously stated, the ED record is transcribed

into a note in Cerner, which is often many pages long. This requires time for the nurse to read

through the ED note to find imperative information needed to care for the patient. Although

report is received from the ED nurse, the primary nurse must ensure the patients safety by

referencing the actual ED note to ensure the information reported off is correct. By eliminating

the need for the ED note by utilizing one singular EHR vendor, all information will be present

and readily available for the primary nurse to view. This will in turn increase nurse productivity

by eliminating unnecessary time viewing the ED note.

The process improvement plan may also financially benefit the healthcare system as well.

EHR vendors require payment for utilization of their systems. Therefore, when a hospital

utilizes more than one system, they must pay for both. Additionally, by utilizing a singular EHR

vendor, we have introduced the idea of preventing medical errors, thus decreasing cost spent.

Medical errors also cost healthcare facilities when patients require additional medical treatments

and prolonged hospital stays. By decreasing the risk for medical errors, hospitals can help to

decrease the possibility of further financial constraints.

Another option to one singular EHR vendor would be utilizing informatics and

technology to promote total interoperability. The topic of interoperability is a popular idea in

healthcare at this time, surrounding the push for EHRs. As mentioned previously,

interoperability is the concept that all EHRs, whether that be in-patient or out-patient centers,

should have the ability for all information and data to be accurately transferred between various

systems. The current process of a transcribed ED note is not efficient, nor is it the safest way to
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reflect patient information. However, if the two systems were able to communicate, patient

information could be present in both. Additionally, it has been mentioned that total

interoperability is something that will take time and participation from EHR vendors. To

implement change at this current time where total interoperability has not been achieved, a

temporary but efficient goal would be to ideally have a singular EHR vendor for the entire

organization.

Utilizing a workflow map can assist in designing quality improvement plans within a

healthcare organization. By comparing the previous workflow map to the workflow after

implementing the change in the current process, one can visualize the ease that utilizing one

electronic health record can have. Other healthcare facilities may be able to utilize the workflow

map as a guide to process design at their facilities as well.

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Workflow with Implemented Change Diagram

Improved process implemented on how patient information between the Emergency Department

and in-patient charting is transferred by now utilizing one EHR vendor (Cerner):

Start: Patient arrives to the Patient is assessed by

Emergency the primary RN & ED
Department (ED) physician Does the
patient
require
medical
treatment?
YES

Is the
ED physician’s orders patient to be
will be found in admitted
NO
NO
CERNER into the Stop
hospital?

Stop
Admitting physician
will assess patient &
enter orders into
YES CERNER

All assessments, mediations

given, lab & diagnostic
results, and procedures
performed can be found
documented in CERNER

Stop
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Nursing Policy

(Example Policy)

Delaware Healthcare Systems:

Interoperability of Electronic Health Records

Purpose: To promote total interoperability of electronic health records in Delaware for efficient

transfer and accessibility of patient information, while promoting safety and optimal patient care.

Scope: All healthcare team members involved in patient care: physicians, nurses, therapies,

laboratory, pharmacy

Policy/Procedure:

1. Healthcare organizations in Delaware will aim for interoperability within all healthcare

organizations

2. Any organization utilizing more than one electronic health record that has not established

interoperability must utilize one singular vendor

3. Healthcare organizations must maintain a strong IT department

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Conclusion

Nursing informatics is utilized in all aspects of healthcare. Interoperability is a popular

topic within healthcare informatics, as the goal of electronic health record interoperability is to

promote safety, optimize patient care, and encourage efficiency. Total interoperability is still an

ongoing process; it has not yet been achieved. However, steps can be made during this time to

still promote patient safety. As mentioned previously, by utilizing one singular EHR vendor

within healthcare organizations (until interoperability can be achieved), the risks of medical

errors due to miscommunication can be mitigated. The hope is that through the use of every

growing technology within healthcare, interoperability can be the future of healthcare.

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References

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements.

https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-

for-nurses/coe-view-only/

Kamerer, J. L. & McDermott, D. (2020). Cybersecurity: Nurses on the front line of prevention

and education. Journal of Nursing Regulation, 10(4), 48-53.

https://doi.org/10.1016/S2155-8256(20)30014-4

Leventhal, R. & Hegland, M. (2017). Healthcare’s latest interoperability push. Healthcare

Informatics, 34(1), 35-37.

Orlova, A., Rhodes, H., & Warner, D. (2016). Standardizing Data and HIM Practices for

Interoperability. Journal of AHIMA, 87(11), 54-58.

QSEN Institute. (2020). QSEN competencies. Retrieved from https://qsen.org/competencies/pre-

licensure-ksas/

Reisman M. (2017). EHRs: The challenge of making electronic data usable and interoperable. P

& T: A peer-reviewed journal for formulary management, 42(9), 572–575.

Rezaeibagha, F., Win, K. T., & Susilo, W. (2015). A systematic literature review on security and

privacy of electronic health record systems: technical perspectives. Health Information

Management Journal, 44(3), 23-38. https://doi-

org.libproxy.dtcc.edu/10.1177/183335831504400304
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Ronquillo, J. G., Winterholler, J. E., Cwikla, K., Szymanski, R., & Levy, C. (2018). Health IT,

hacking, and cybersecurity: National trends in data breaches of protected health

information. JAMIA Open, 1(1), 15-19. https://doi.ord/10.1093/jamiaopen/ooy019

Sewell, J. (2019). Informatics and nursing: Opportunities and challenges, (6th ed.). Philadelphia:

Wolters Kluwer