Running Head: EHR INTEROPERABILITY

EHR Interoperability

Teryn Green

Delaware Technical Community College

NUR 410: Nursing Informatics

Karen Wagamon

October 3, 2021
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Electronic health records (EHR) allow clinicians to access patient information at the click

of a button. Anything from past medical histories to current treatment and interventions being

conducted can be accessed by all members of the care team. EHRs have established a concise

location for all types of patient data including scans, procedures, and med administration times

(Hoover, 2017). The implementation of EHRs in practice has resulted in a 60% reduction in

medication administration errors and a 52% drop in adverse reactions (Hoover, 2017). The

elimination of duplicate testing, handoff misinformation, and loss of pertinent medical

documents have been alleviated by the application of EHRs. The growth of computer charting

within the medical field has created an increased need for interoperable data systems. An

interoperable system can accurately communicate data through an exchange within the system or

from one system to another (Iroju et al., 2013).

Ethical Issues with EHRs

With every great thing, there are bound to be some drawbacks and EHRs are no

exception to that rule. One major issue with the previous method of documenting through paper

charts was a possible exposure of patient information. Paper forms can easily be misplaced, lost,

or picked up by the wrong person which in the end, results in a violation of the patient’s rights.

Some patients are unable to advocate for themselves or act as active members in their care due to

their illness acuity or cognitive deficits. This inability for patients to advocate for themselves

instills a stronger sense of privacy that nurses must maintain as one of their clinicians.

The Health Insurance Portability and Accountability Act (HIPAA) is a very widely

known act within the medical field. HIPAA ensures the protection of patient privacy concerning

their medical information (CDC, 2019). Despite EHR's elimination of some of the possible
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offenses to this act, they have created avenues for misutilizations in other ways. Violations of

HIPAA are taken very seriously, and all members of the care team must ensure the

confidentiality of their patients is maintained at all times (CDC, 2019). Provision 2 of the nursing

code of ethics states that as the nurse, the primary commitment is to the patient, provision 4

addresses the need for nurses to hold themselves accountable as the authority of a patient’s care

(American Nurses Association, 2015). With the nursing code of ethics in mind and an

understanding of a patient’s rights and the laws and acts to uphold them, nurses must address

these issues regarding EHRs and privacy whenever it deems necessary.

Although EHR interoperability can enhance the healthcare delivery process, there will

still be downfalls to these revolutionary systems. EHRs allow clinicians to easily access patient

information, but that ease of retrieval could be detrimental when the wrong person is granted

access to the chart (Hoover, 2017). EHRs risk the exposure of sensitive patient information when

clinicians do not take the proper steps to protect the individuals under their care. For instance,

leaving a computer logged on with an EHR of a patient pulled up, sharing personal passwords

with others, and members of the facility not directly involved in care accessing a patient’s

information, are all ways in which clinicians risk violating HIPAA. In the nursing code of ethics,

provision 3 states that the nurse must protect the rights of the patient (American Nurses

Association, 2015). Ensuring medical staff does not abuse the simplicity at which they can

access a patient’s information is something every nurse must hold themselves and their peers

accountable for (CDC, 2019). Protecting passwords, closing out of EHRs when leaving a

workstation, and reporting any staff that is attempting to access information to a patient that is

not under their care are all steps that must be taken to ensure confidentiality.
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Current EHR Systems at Beebe Healthcare

An EHR houses all patient information for nurses, providers, and all other medical staff

to utilize. These systems are important when reviewing patient demographics, provider notes,

vital signs, lab results, scans, procedure findings, medication administrations, and much more

(Hoover, 2017). Within Beebe Hospital, there are currently two EHR systems being utilized to

document information or interventions for patients. The first and more widely used EHR is

Cerner which is used by every floor of the hospital except the emergency department (ED). In

the ED, the EHR in use is IBEX, no other floors have access to this system or the information

within it.

When a patient presents to the ED they are registered and triaged and eventually brought

into one of the ED rooms. At that point, the patient is seen by the ED nurse and providers,

assessments are conducted, and orders are placed and then completed. If needed the patient will

receive various scans, lab tests, or medications for the treatment of their chief complaint. All of

the information collected, assessments completed, orders placed, and medications passed are

charted within IBEX. Lab results and radiology tests are the only pieces of data charted within

Cerner at this time. Once it has been decided that the patient is to be admitted to one of the

hospital's floors the data collected and documented in IBEX is transcribed in an ED note which

is accessible in Cerner. Once the patient is brought to the floor all charting from this point

forward is completed in Cerner. The major issue with having two systems in use within one

facility to conduct documentation is the lack of communication between the databases.

The ED note that populates can be up to 30 pages long and is very unorganized making it

hard to understand which medications were given in the ED or what the baseline assessments
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were before admission to the floor. These ED notes are not available to nurses on the floor before

the patient's admission therefore when a nurse is preparing to receive a handoff report from an

ED nurse, they are unable to simultaneously look up the patient's information and ask questions

to clarify something they may see within the ED nurse's charting. This chaotic process results in

a great deal of confusion for floor nurses and can result in many issues about missed or duplicate

medication administrations or overlooked lab results or scans. Having one system hospital-wide

or two systems that can effectively cross over information from one database to the other would

not only result in better patient care but also increased faculty satisfaction, and reduced costs.

Interoperability can Help

The best outcome for patients and medical staff at Beebe Healthcare would be moving all

of the floors to one EHR system. More places holding information about a patient result in a

greater risk for missed data. Patients will have an improved level of care as their nurses will be

able to provide a smoother continuity of treatment as they transition from the ED to their floor of

admission. Information regarding allergies, family or patient medical histories, suicide

screenings, and medication administrations would all be readily available for nurses on the floor

reducing possible duplicate med passes or improper dosing (Payne et al., 2012). Within the EHR

any ordered tests, scans, or medication administrations only result as completed within the

system they were ordered (Payne et al., 2012). Although lab results can populate in Cerner when

ordered through IBEX, it does not mark the task as completed which can cause duplicate blood

draws, costing the hospital money and the patient unnecessary distress. The less time a nurse

must spend searching within a 20-30 page note to understand if a lab was already collected or if a

medication was already administered increases that nurse’s ability to perform the tasks they need

to for the patient.

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The optimal outcome for Beebe healthcare would be for the administration to purchase

Cerner for the ED to utilize as well. With one EHR in use, after the initial process of registration

and triage, the patient would be brought back into an ED room where the nurse would complete

all charting within Cerner. All orders and interventions would be input to the Cerner database,

allowing for the floor nurses to pick up where the ED staff left off in terms of med passes, blood

draws, and assessments. This unified system may be an adjustment for the nursing staff at first

but overall will establish an improvement in workflow. Beebe administration may be reluctant to

make the transition to one system due to time consumption and expenses related to training the

current staff on the new system and the purchasing of the system altogether (Payne et al., 2012).

Another option to mitigate the risk of missed information could be to install a banner system

within Cerner to notify nurses that there is additional information that has not been charted

within Cerner present in the ED note (Payne et al., 2012). The implementation of these banners

will not change the inconvenience for floor nurses that must pillage through pages of ED notes,

but it will at least provide them a reminder that it exists. Lastly, if one selected system is

unrealistic at this time, one way around this option would be to allow nurses on other floors

access to IBEX. This option would face much criticism from the other units as they are as

equally unfamiliar with IBEX as the ED is with Cerner, leaving the implementation of Cerner

hospital-wide as the more sensible option. When observing data on cost-effectiveness, benefits of

one system, and overall patient and staff satisfaction, switching to one vendor would result in the

most long-term benefits.

Workflow Maps of Beebe Healthcare

Below are two workflow maps that analyze the current and proposed EHR usage within

Beebe Healthcare. The first map demonstrates the current process of having more than one EMR
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at Beebe, IBEX, and Cerner. Within the first map, a lack of interoperability is displayed,

revealing opportunities for missing data and additional work for the floor nurses. The second

workflow map demonstrates what this exchange of data looks at over the admission process after

a change has been implemented to one EHR system, Cerner. The use of workflow maps to

compare the effectiveness of each process provides a visualization that supports the claim that a

change in the current process will promote positive outcomes.

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Workflow Map 1: Current Beebe Hospital EHR Process with Cerner and IBEX
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Workflow Map 2: Proposed Beebe Hospital EHR Process using only Cerner
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Conclusion

While technology continues to grow nurses must grow with it to ensure they are

maintaining the standard of practice that they vowed to by receiving their license. Remaining

diligent in including accurate documentation in the correct EHR and maintaining patient

confidentiality while using the selected systems is vital at every level of care. The evidence-

based practice supports not only the continued use of EHRs to improve patient care but also has

proven the necessity of an EHR that can effectively communicate throughout every area of the

hospital. Beebe Healthcare would greatly benefit from adopting an EHR system that allows for a

more cohesive collection of data and execution of interventions. The current systems in place

that consist of two incompatible EHRs pose a risk to patient care and hospital growth. It is

heavily recommended that the administration at Beebe analyze the current processes and select

one EHR to implement hospital-wide, promoting EHR interoperability. The concept of

interoperability within the hospital setting continues to grow and evolve. Only time will tell how

future systems will be altered to establish more cohesive communication. As for now, Beebe

Healthcare can counteract the incompatibilities in the current EHR systems by limiting their

facility to one as mentioned in the policy recommendations in this report.

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References

American Nurses Association. (2015). Code of ethics with interpretative statements. Silver

Spring, MD: Author. Retrieved from

http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNur

ses/Code-of-Ethics-For-Nurses.htm

Health Insurance Portability and Accountability Act of 1996 (HIPAA) | CDC. (2019, February

21). https://www.cdc.gov/phlp/publications/topic/hipaa.html

Hoover, R. (2017). Benefits of using an electronic health record. Nursing2020 Critical Care,

12(1), 9–10. https://doi.org/10.1097/01.CCN.0000508631.93151.8d

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

Clinical Informatics, 3(4), 462–474. https://doi.org/10.4338/ACI-2012-10-RA-0040