Running Head: EMR INTEROPERABILITY 1

EMR Interoperability

Alexis Leskovac

Delaware Technical Community College

NUR 410: Nursing Informatics

Jacqueline Henaghan

April 18, 2021

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Computer charting has created an increased need for interoperable data systems.

Interoperability in healthcare is defined as the ability for information technology systems and

software applications to communicate, exchange data accurately and effectively, and to use the

information that has been exchanged (Iroju et al., 2013). Today’s electronic medical record

(EMR) systems lack interoperability, creating a discrepancy in transfer of information and data.

Regardless of where the provider or patient are physically located, there is an increased need for

universal visibility of the patient’s EMR. Without interoperability between EMR systems, time is

wasted recollecting information and critical information is missed (Azarm et al., 2017). At Beebe

Medical Center, the emergency department uses IBEX for their EMR while the rest of the

hospital uses Cerner. As a registered nurse in the intensive care unit, we receive a great deal of

our admissions from the emergency department. Due to lack of interoperability, patient

information is often lost in translation or pieced together throughout their admission. There are

several suggestions on how to resolve the barriers to interoperability. This paper will examine

barriers to patient care, ethical and legal issues, and opportunities for workflow improvements

related to EMR interoperability.

The introduction of Information and Communication Technology (ICT) has led to the

widespread adoption of electronic health systems (EHR) in the healthcare industry. EHRs have

enhanced collection, storage, retrieval, and access to health information. They have also

contributed to the efficiency of information delivery. Since patients have several healthcare

providers, and they may move from one location to another, health information is needed to be

available in all EHRs at all points of care. This is so that quick, efficient exchange of accurate

information can occur at any given moment. This necessary, seamless exchange of sensitive

information opens the door to several ethical issues. Data privacy, confidentiality, control of
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access to patient’s information, the commercialization of de-identified patient information, and

ownership of patient information are among the many ethical issues related to EHRs (Ganiat &

Olusola, 2015).

Ethics is a philosophical discipline concerned with the human behavior of right versus

wrong (Ganiat & Olusola, 2015). In informatics, the concept of conflicting values is well

established. Nurses must be competent in ethical principles, the professional code of ethics for

nurses, pertinent laws, and conflict resolution skills when it comes to ethical dilemmas (Sewell,

2019). Regarding interoperability of EHRs, ethics refers to practice, attitudes, values, principles,

and codes that strictly guide healthcare professionals and patients during the exchange and use of

health information. Other ethical issues related to the use of ICT include ownership of health

information, benefits and risks of utilizing ICT for patient care, and the effects of ICT on the

physician-patient relationship (Ganiat & Olusola, 2015).

Four key bioethical principles – autonomy, beneficence, non-maleficence, and justice –

can be discussed through the lens of EHR interoperability. Autonomy is defined as an

individual’s right to determine their own healthcare. This means that patients must have access to

their health information even though it is created and managed by healthcare professionals

(Ganiat & Olusola, 2015). Patients also have the right to know when their health information is

being exchanged, otherwise their trust and confidence may be hindered and they could withhold

pertinent information due to lack of trust. There are exceptions where patient information may be

released without consent, such as reporting communicable diseases. Despite these rights, patients

still should not be given complete autonomy of their health information. This is because they

could modify or delete information they wish not to share, and this could have life-threatening
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consequences. Therefore, it is still debated in healthcare over who actually owns the patient’s

information (Ganiat & Olusola, 2015).

Beneficence is the act of doing good. In healthcare, beneficence ensures that patient

information is utilized to the best interest of the patient (Ganiat & Olusola, 2015). Non-

maleficence means to do no harm, as long as it is within the capabilities of healthcare providers

and without undue harm to themselves. In EHR interoperability, non-maleficence ensures that

patient information is only exchanged among authorized individuals. Non-maleficence also

ensures that this information is only used to improve the health status of the patient (Ganiat &

Olusola, 2015). Justice, defined as fairness or equality, is seen in the interoperability of EHRs

when health information is used to provide equal and timely healthcare to everyone. The

principle of justice also ensures respect of privacy, confidentiality, and security of health

information during exchange and use (Ganiat & Olusola, 2015).

The American Nurses Association Code of Ethics Provisions 3, 5, 7, and 8 are applicable

for EHR information. Provision 3 highlights the nurse’s ethical duty to protect the patient’s right

to privacy and confidentiality. Provision 5 addresses the nurse’s ethical duty to maintain

competence and continuous learning. Provision 7 captures the nurse’s ethical duty to conduct

nursing research, contribute to scholarly inquiry, and the development of nursing and health

policies. Provision 8 addresses the nurse’s ethical duty to protect the public from

misinterpretation and misinformation (Sewell, 2019). Unlike codes of ethics, laws state exactly

what is expected and have penalties if not abided by. Challenges that face the ethical principles

of EHR interoperability include security, privacy and confidentiality, ownership of patient

information, and the commercialization of de-identified patient records (Ganiat & Olusola,

2015). Health information is prone to security challenges, such as unauthorized access. This
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could include, “malicious personnel, medical fraud, unauthorized modification of patient’s

information, data hacking, unauthorized destruction of patient’s data as well as eavesdropping of

patient information over a network” (Ganiat & Olusola, 2015). EHRs are vulnerable to privacy

and confidentiality challenges due to the sensitive information they acquire, store, and exchange,

such as social security numbers, insurance, and payment information (Ganiat & Olusola, 2015).

The question of who owns the patient’s health information still stands. De-identification is the

process of preventing a patient’s identity from being associated with their information. EHR

vendors, such as Cerner and All scripts, have sold copies of their patient databases to

pharmaceutical companies, medical device manufacturers, and health researchers (Ganiat &

Olusola, 2015). Patients can easily be re-identified by combining their name, address, date of

birth, medical record number, disease, drug regime, zip code, and gender. Therefore, the risk of

re-identification poses as a breach of confidentiality and privacy (Ganiat & Olusola, 2015). Data

security breaches are unlawful and can result in fines, imprisonment, or both (Sewell, 2019).

To mitigate the challenges introduced by EHR interoperability, some recommendations

have been given. If patient information is to be de-identified and used for commercial purposes,

it is suggested it be anonymized and any information be removed which can make the patient

easily identified (Ganiat & Olusola, 2015). To enhance physician-patient trust, patients should be

informed before their information is shared among authorized personnel, unless otherwise stated

by law (Ganiat & Olusola, 2015). To constantly monitor all activities during information

exchange and use in EHRs, adequate security measures such as, audit trail systems should be

instituted. This would offer insight to who is accessing information, what information was

accessed, and when the information was accessed (Ganiat & Olusola, 2015).
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At Beebe Medical Center (BMC), there are currently two electronic medical record

(EMR) systems being used within one single organization. The Emergency Department (ED)

utilizes IBEX as their EMR system, while the Intensive Care Unit (ICU), and all other floors

within the hospital, use Cerner. The EMR, or electronic health record (EHR), is a legal document

that contains patient information such as, demographics, progress notes, vital signs, medical

history, allergies, laboratory results, and radiology images. This electronic record is designed to

be modifiable, easily accessible by multiple authorized healthcare professionals, and utilized for

patient care decisions. Hence, the necessity for efficiency, interoperability, and accuracy.

Having two EMR systems at BMC is a problem because they cannot “talk” to one

another. This lack of interoperability creates opportunities for missing data and any

corresponding patient care decisions that could impact patient safety. At BMC, all ED charting

occurs in IBEX and is placed in an “ED note”. This ED note is only accessible by charge nurses

prior to the patient being admitted. Any medications, line placements, chest tubes, bedside

procedures, intake and output values, ED nurse assessments, physician assessments, orders, or

consults that occur in the ED do not translate into Cerner. The only information that transfers to

Cerner is laboratory results and radiology images. Instead, the remaining information is put into

the ED note which is then transcribed into a lengthy, 10–15-page or longer, document. This

document is then placed in a folder under the “notes” section within Cerner. To make viewing

more challenging, the document is typed in paragraph format and the pages must be clicked

through, one by one. The viewer is unable to scroll through the document for prompt information

retrieval.

This process is unorganized, inefficient, and time-consuming when needing to search for

specific information. For example, it is expected that the start date and time of all peripheral
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intravenous (PIV) devices be documented under the line placement category within Cerner. This

is to keep track of how long the PIV has been in place so we can reduce infection by changing

dressings every seven days. Since the ED often places the PIVs, this documentation is woven in

their lengthy ED note and often, floor nurses do not take the extra step to find the date and time

of insertion. Therefore, this information remains blank in the EMR and PIVs remain in place

longer than they should with past due dressing changes, posing higher risk for infection and poor

patient outcomes. This example is minor compared to other challenges introduced by the lack of

interoperability between two EMRs and the risk of missing data.

More detrimental examples of missing data could involve allergies and drug interactions.

Medication and allergy reconciliation is difficult enough in one EMR, so the challenge is

magnified by having two. Another risk is missing significant data from test results such as,

laboratory results, imaging, and procedures. The results often return to the EMR from which they

were ordered (Payne et al., 2012). As previously mentioned, the only results that translate from

IBEX to Cerner are laboratory results and radiology imaging. Often, time is wasted calling the

laboratory, provider, and ED trying to determine whether certain labs were already collected in

the ED, or if they still need to be performed. This could lead to duplicate testing at the expense

of the patient or the organization. Missing pregnancy or lactation information could lead to

inappropriate medication dosing, missing renal function changes could lead to inappropriate

administration of IV contrast dyes, and incomplete past medical/family history could lead to

inaccurate risk assessments (Payne et al, 2012).

The greater the number of places required to search for patient information, the greater

the risk for missed patient data. The ideal solution would be that BMC purchases Cerner for ED

documentation to promote EMR interoperability within the organization and to minimize

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opportunities for missed data. An alternative to this solution would be to allow floor nurses, in

addition to charge nurses, accessibility to the ED note prior to the patient’s admission. This

allows the receiving nurse to gain a more thorough report, thereby offering safer care, and more

sound clinical decisions. Additionally, the ED note that gets transcribed to Cerner should be

revised in terms of visibility and functionality. The patient’s information should be documented

in a more organized format, rather than written in paragraphs, to make finding information more

efficient. The document should also be made so authorized personnel can scroll through, rather

than click through page by page. If BMC cannot adopt Cerner as the ED EMR system, then

another suggestion is to install banners that indicate data is present in another EMR to prevent

patient information from being missed (Payne et al., 2012).

Organizations may be reluctant to change EMRs due to time consumption and expense

(Payne et al., 2012). Initial implementation of Cerner as the EMR system in the ED at BMC

would naturally slow down workflow. It would take a considerable amount of information

technology (IT) support to implement this change, and ED nurses and providers would have to

be trained to operate a new system. The cost alone of switching from a multitude of commercial

EMRs to a single vendor EMR is a barrier for most organizations. However, as previously

discussed, the risk for incomplete or inaccurate information exchange, decreased quality of care,

and potential patient safety risks is prevalent when more than one EMR is utilized within a single

organization (Payne et al., 2012). Therefore, mitigating these challenges by switching to a single

vendor will offer more long-term benefits that outweigh the short-term setbacks.

Switching to a single vendor EMR would financially assist organizations, such as BMC,

in the long-term by preventing costs associated with duplicate orders, hospital acquired

infections (HAIs), and patient harm due to missed data. This could include duplicate radiology
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images, laboratory tests, or medications. HAIs could be the result of missed data when the start

date and time for PIV insertion are not translated from the ED note to Cerner under line

placement documentation. Having one single vender allows for increased patient safety when

allergy and medication lists, pregnancy and lactation status, renal function, past medical history,

and family history are all documented in one location. The interoperability of this data storage,

exchange, and use will ultimately promote staff satisfaction. Once everyone is trained to use one

system, less time will be spent connecting the dots when a patient is admitted from the ED. Time

that was once spent to determine if certain labs were obtained or not, can now be spent treating

the patient’s lab values. Healthcare workers that were once required to be competent with two

EMR systems, can now master just one.

A workflow map can be used to demonstrate the current process of having more than one

EMR at BMC, IBEX and Cerner. This will show how the lack of interoperability contributes to

opportunities for missing data and additional work for the registered nurses (RNs). An additional

workflow map will demonstrate what this exchange of data looks like after change has been

implemented. For this paper, the change will be that BMC adopts the same EMR vendor in the

ED that the rest of the hospital uses, Cerner. This comparison in workflow maps offers a

visualization that supports the argument that a change in current process is necessary and will

promote positive outcomes.

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Workflow Map 1: BMC utilizing Cerner and IBEX

Workflow Map 2: BMC utilizing only Cerner

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While EHR interoperability enhances the exchange of health information and contributes

to prompt healthcare delivery, it does not come without a cost. EHRs face ethical challenges and

test ethical principles. Nurses must remain well-versed in their code of ethics, as well as laws and

regulations pertaining to informatics to protect the patient’s information. Based on research,

BMC should adopt the following recommendations in a policy to counteract the challenges

associated with EMR interoperability: anonymization of de-identified patient information,

informed consent, and adequate security measures. Having more than one EMR within a single

organization poses a risk to patient safety and impacts the ability of healthcare workers to

provide efficient and safe care. To reduce risks towards patient safety and improve quality of

care, it is recommended that BMC purchase Cerner for ED documentation to promote EMR

interoperability. BMC should also include in their policy that allergy and medication lists,

pregnancy and lactation status, renal function, past medical history, and family history are all

documented in one location. EMR interoperability is in its early stages of development. It will

likely take a considerable amount of time before all challenges are mitigated. For now, BMC can

counteract barriers to patient care associated with EMR interoperability by adopting one,

universal EMR system and following the policy recommendations in this report.
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References

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Ganiat, I. O., & Olusola, O. J. (2015). Ethical issues in interoperability of electronic healthcare

systems. Communications on Applied Electronics, 1(8), 12-18.

https://www.researchgate.net/profile/Iroju-

Olaronke/publication/277921194_Ethical_Issues_in_Interoperability_of_Electronic_Heal

thcare_Systems/links/563c9e9308ae405111aa2e24/Ethical-Issues-in-Interoperability-of-

Electronic-Healthcare-Systems.pdf

Iroju, O., Soriyan, A., Gambo, I., & Olaleke, J. (2013). Interoperability in healthcare: Benefits,

challenges and resolutions. International Journal of Innovation and Applied Studies, 3(1),

262-270. https://doi.org/10.3182/20140824-6-ZA-1003.00493

Payne, T., Fellner, J., Dugowson, C., Liebovitz, D., & Fletcher, G. (2012). Use of more than one

electronic medical record system within a single health care organization. Applied

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Sewell, J. (2019). Informatics and nursing: Opportunities and Challenges (6th ed.). Wolters

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