In the past when a provider walked into an Emergency Room to examine a patient, they were left to solely rely on the medical information they received from the patient and/or family. Would it not be helpful if we had access to charts containing all vital medical information when treating patients? That is what we could achieve with interoperability of patient medical records. “Interoperability is the ability of different information and communication technology systems and software applications to communicate, to exchange data accurately, effectively, and consistently, and to use the information that has been exchanged” (Iroju, 2013). There are two different types of interoperability that can be used in healthcare – syntactic interoperability and semantic interoperability. Syntactic interoperability sends data from one electronic system to another. However, it does not guarantee that the receiving system can process the data that is sent. Semantic interoperability allows the data that is received to be processed in a useable format. This continues to be unachievable in the healthcare setting (Iroju, 2013). We do still see the benefits of interoperability in healthcare, it allows the provider to have all the information that is needed to take care of the patient in one location. Along with the benefits of having an interoperable system, there are always challenges that come with it. You should make sure the software that you are using to exchange information is compatible. You need to use standard processes and terminologies to allow the data to easily exchange between systems. Your uses need to be open to change, and be willing to enter data into the EHR in a usable format. Finally, you need to phase out legacy systems that do not meet the national standards (Iroju, 2013). Once your organization has surpassed these barriers it will be ready to implement HIE (Health Information Exchange) software. HIE software will allow lab, radiology, clinical outpatient, pharmaceutical and inpatient data to be stored in one location. Some of these software vendors also allow you to electronically transfer this data into your organization’s EHR. Other features of an HIE will assist a provider in patient management. You can set up reminders for clinical decision support, run reports on the complete data from multiple organizations, vaccine information can be shared with multiple organizations and you can submit data to chronic care registries to assist with developing technologies. The benefits of interoperability in healthcare are endless. Having the patient’s information readily available can help decrease medical errors and either save a patient’s life or increase their quality of life (Lupşe, 2012). The overall goal of healthcare is to provide optimal care to improve or alleviate the health status of people in a variety of settings, from hospitals and ambulatory care centers to community clinics and telehealth medicine. To achieve the best care possible, patients must be able to receive accurate, timely, efficient and effective assessment, diagnosis, treatment and follow up. Healthcare informatics serves as a tool to enhance the systems that provide and track patient care. No one system works alone, however, and neither does one discipline of healthcare professionals. Patient-directed care requires a multidisciplinary, collaborative approach, and interoperability is vital to the effectiveness of this care. Interfacing engines are a key driving force in emerging healthcare technology. Several of the most interconnected aspects of healthcare that are focusing on interoperability include the departments of pharmacy, radiology, laboratory and clinical documentation. Consequently, healthcare information systems that promote interoperability among these divisions contribute to more comprehensive patient care, as well as achieving a reduction in medical costs, medical errors and duplicate tests. The next section of the emerging technology paper will discuss interfacing programs and designs within and among these fields that boost interoperability and may lead to progressive clinical outcomes. To begin, interoperability creates the opportunity for different healthcare information systems and applications to communicate within and outside of an organization, such as among healthcare networks and accountable care organizations (Biedermann & Dolezel, 2017). Every department that contributes to an interfacing engine to achieve interoperability helps the organization. Pharmacies are on the forefront of this emergence, through such programs as computerized provider order entries (CPOE), electronic drug prescriptions (e-scribing), electronic medical administration records (eMAR), and applications that increase medical adherence and decrease medication errors. According to John Hopkins Medical Center patient safety experts, medication errors may be the third leading cause of death in the United States, and in fact, many medication errors and their causal link to fatalities may be underreported (Cha, 2016). Thus, any interfacing engine that decreases the incidence of medication errors is of vital importance, not just at one institution but among all patient healthcare providers. An example of a user-computer interface clinical pharmacy information system that has the potential to decrease medication errors is PharmaNet, a community-based medication repository. In British Columbia, researchers explored the use of a “provincially managed electronic repository,” which comprises all the electronic medical records of community pharmacies into a central data system (Kitson, Price, Bowen, & Lau, 2013, p. 169). This composite system, in turn, provides healthcare professionals real-time information at the time of prescribing medications and dispensing drugs, as well as data related to a patient’s potential need for medication reconciliation. Moreover the investigators found usability could be increased by a chronological dispensing record with alerts and updates for users, and healthcare providers at any organization could verify a patient’s pharmaceutical history to decrease polypharmacy, medication duplications and overdoses. Similarly, researchers at the Medical College of Wisconsin, Milwaukee investigated the effect of CPOE to pharmacy interface on order-infusion pump discrepancies. They observed the rate of medication errors between drugs and intravenous fluids, specifically medication orders and the actual administration of the intravenous fluids via the bedside infusion pump settings (Russell, Triscari, Murkowski, & Scanlon, 2015). Researchers compared the incidence of medication discrepancies and errors before and after a CPOE system and pharmacy system interface. The CPOE-pharmacy interface engine caused provider-ordered entries to move immediately and directly to the hospital’s pharmacy system for verification and, if necessary, reconciliation, as compared to the previous tiered system in which the provider-ordered entries were printed on a paper chart and re-entered manually into the pharmacy system before verification. This bidirectional closed-loop system, researchers found, led to an overall decrease in medication discrepancies, including unauthorized medication discrepancies and discrepancies between providers’ orders and programmed settings. However, as the authors discussed, further study is needed to positively correlate the new CPOE-pharmacy interface with a reduction in adverse patient events. Furthermore, interfacing engines may help promote medication adherence and proper medication use, especially among patients with complex and chronic conditions. According to Dixon, Jabour, Phillips, and Marrero, medication adherence requires a multidisciplinary, collaborative approach that involves “advanced EHR, clinical decision support, and patientcontrolled technologies” (2013, p. 517). The researchers created a clinical dashboard within an EHR system that integrated data and information from a patient’s EMR, personal health record (PHR), and pharmacy claims. The interface of the clinical dashboard was first instituted in primary care clinics. Users who opened a patient’s chart could see the result of the integrated system, including whether patients had likely followed their medication regime or a proper refill schedule. This pharmaceutical validation then prompted users to initiate a conversation regarding the patient’s medication adherence with the purpose of contributing to more open communication among patients and healthcare providers about the patients’ medication usage and adherence, and consequently, stricter medication adherence and a decrease in medicationrelated harm. Applications that integrate laboratory results with the EHR decrease extraneous or duplicate testing, and therefore medical costs. For example, researchers in Spain investigated the implementation of an integrated system between a university hospital hemodialysis unit and five outsourced hemodialysis centers (Núñez-Benjumea, Moreno-Conde, Jódar-Sánchez, MartínezGarcía, & Parra-Calderón, 2014). Here, healthcare providers created a Standard-based Interoperability Framework in which the existing healthcare system was integrated with a regional laboratory information system, which then automatically shared patients’ EHR and laboratory test reports from each location, including both routine and emergent results. After reviewing the incidence of shared communication before and after the interoperable system implementation, researchers found that the Standard-based Interoperability Framework between the hospital and outreach centers led to a decrease in the number of emergent laboratory tests ordered per patient, and the consequent system change to a totally electronic system led to “better information management, reduced delays due to report exchange, and improved traceability and, therefore, reduction in duplicities in lab test requests” (Núñez-Benjumea, Moreno-Conde, Jódar-Sánchez, Martínez-García, & Parra-Calderón, 2014, p. 621). In radiology, the Digital Imaging and Communication in Medicine (DICOM) is the “universal format for interoperability in medical imaging” (Hirsch, Siegel, Balasubramanian, & Wan, 2015, p. 407), and has been used by many healthcare organizations since its conception in 1993. However, even accepted international standards can be improved for enhanced interoperability, as shown by healthcare researchers through their investigation of the potential diagnostic worth of radiology automatic contrast injectors. Researchers found that specific parameters within DICOM support underused modalities and metadata in relation to the automatic contrast injectors, which could result in lower department costs, a decrease in patient administration of a commonly-used radiological medication, better documentation of dosing, and increased patient safety and image quality (Hirsch, Siegel, Balasubramanian, & Wan, 2015). The implication that even non-emerging technologies may be improved for better interoperability is far reaching. However, so too is the implication that health information systems already being utilized by healthcare organizations may link their metadata and modalities to enhance patient care. As mentioned previously, healthcare professionals do not work in an isolated environment, and patient care requires a multidisciplinary, collaborative approach using interfaced systems. Documentation systems, for example, in which providers may look up a variety of pharmaceutical, lab and radiological tests and results decreases time spent searching across a variety of platforms, organizations or papers for specific reports, and the increase in staff productivity allows for clinical-patient contact. In addition, documentation systems that provide alerts may also improve patient care. To demonstrate, researchers studied the implementation of an automated alert system within a medical group practice of over three hundred thirty clinicians that provided users with many valuable functions, including “notification of discharges, reminders of the need for follow-up visits, drugs added during inpatient stays, and recommendations for laboratory monitoring of high risk drugs” (Fields et al., 2012, p. 87). The studied system integrated multiple fields into one interfacing engine from a variety of sources, including the hospital’s admission, discharge, transfer registration system, the medical practice’s scheduling system, patients’ EMR and health plans and electronic laboratory interfaces with the EMR. The time spent in creating such a large interfacing engine was significant, but the potential for enhanced continuity of care for a patient population who is at “high risk for hospital readmission, emergency department visits and adverse events,” according to Fields, Garber, Gagne, Tija, Preusse, Donovan, Kanaan, and Gurwitz (2012, p. 88), is a milestone in patient care and interoperability. Insert Sarah – Public Health section When we think of interoperability of a patient’s medical records we see an EHR interfacing with another software to develop a medical chart that encompasses all aspects of a patient’s medical care. Many times we do not think of providing a patient with their personal health record being a useful resource that should be included in the interoperability of the EHR. A patient’s personal health records “is an individual’s electronic record of health-related information that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual” (Kraan, 2015). The patient portal is a useful tool that allows the patient to use technology to navigate their healthcare. However, a patient portal is not a personal health record. Portal information is only considered a personal health record if the data is extracted from the portal (Kraan, 2015). The patient portal allows the patient to message their doctor, request a refill, update their demographic and insurance information, request an appointment, pay a bill and much more. All of this can be accomplished through an easily accessible platform at the convenience of the patient. The usage of patient portals has also increased due to the meaningful use incentive program. Providers are required to provide a patient with access to the portal; from there the patient needs to sign into the portal, certain documents and testing must be transmitted to the portal, and the provider must use secure messaging to contact their patients (Otte-Trojel, 2014). There were multiple studies that reviewed patient activation levels and the effects on health outcomes and patient satisfaction. “Patient activation is the patients’ willingness and ability to take independent actions to manage their health and care” (Hibbard, 2013). The study showed that patients with high activation levels were more likely to be compliant with preventative care measures and making healthy lifestyle choices (Hibbard, 2013). The patient portal gives the patient the ability to be active in their healthcare. This is just another example of how interoperability of healthcare can play a major role in health outcomes in our patient population. Cloud based technology is essential in the implementation of interoperability as it helps provide a secure platform for storage and access of patient medical and health records for both the patients and medical providers. Cloud computing is defined as “the storing and large-scale processing of data by multiple users by means of a shared information technology infra-structure in which resources can be requested and released on demand, and by using a remote access connection that is usually established via the Internet (or via a private network in exceptional cases)” (Molnár-Gábor, Lueck, Yakneen, & Korbel, 2017, p. 2). Cloud based technology complements interoperability by creating an affordable platform necessary to exchange healthcare information and data. “Increasing the level of information sharing—supported by the interoperability of systems—requires substantially improved methods for accurately identifying patients and matching their records throughout the health care system” (Perlin, Baker, Brailer, Fridma, Frisse, Halamka, & Tang, 2016, p.5). In regard to patient care the “cloud” affords medical professionals the opportunity to access a patient’s EHR and EMR. Ease of access to patient information is vital in providing proper and thorough patient care especially in cases where patients are seen by multiple specialists. Cloud technology makes it possible for multiple specialists to collaborate with each other to provide their patients with appropriate care all the while avoiding repetitive treatments and duplicate therapies. In addition to doctor-doctor collaboration, the “cloud” provides a platform in which doctors can virtually collaborate with their patients (i.e. patient portals). Patients can use these patient portals via the cloud to converse with their doctors as well as share vitals on a daily basis, such as daily blood glucose levels for diabetic patients, for example. This allows for a more in-depth health and medical record and overall improved quality of patient care. Furthermore, cloud based technology allows applications for advancements in medical research as it creates a platform to share information and findings on a global level. For example, in one research study regarding genetics and genomics, “cloud computing enables the comprehensive integration of genomic and clinical data, and the global sharing and collaborative processing of these data within a flexibly scalable infrastructure (Molnár-Gábor, Lueck, Yakneen, & Korbel, 2017, p. 1). Cloud technology allows for the comparison of collected data across multiple spectra (i.e. EHR and genomic, behavioral, sensory and public health data) which may contribute to medical advancements and improvements to the quality of care available to patients. Improvements to quality of care, for example, are: i. reduced wait times, length of hospitalization and cost of health care ii. providing the right intervention at the right time iii. streamlining of healthcare processes iv. improved outcomes through smarter decisions v. early detection of disease outbreaks vi. discovery of new social behaviors (Eze, Kuziemsky, Lakhani, & Peyton, 2016, p. 319). Cloud based technology has grown in popularity in the healthcare industry not only due to its applications in healthcare but also because of its affordability in comparison to other platforms available for data storage. “Some of the significant benefits of cloud computing include device and location independence, 24x7 support, lower total cost of ownership (TCO), reliability, scalability, sustainability, agile deployment, lower capital expenditure and a single infrastructure to fulfill all computing, networking and storage needs for various applications” (Eze, Kuziemsky, Lakhani, & Peyton, 2016, p. 317). Prior to the availability of cloud based storage healthcare providers were forced to use their own servers and keep up with the constant demands for more storage which can become expensive over time. Furthermore, they were forced to heavily rely on their own IT departments, another added expense, should they find themselves in a system failure. Cloud based technology is provided externally (i.e. Amazon, Google) and these providers alleviate the stresses of maintaining privately-owned servers as well as offering software support when needed, all the while at a lower operating cost. Various platforms for cloud storage are available to healthcare providers (i.e. Software as a Service [SaaS], Platform as a Service [PaaS] and Infrastructure as a Service [IaaS]) and are chosen based on specific needs and demands (Eze, Kuziemsky, Lakhani, & Peyton, 2016, p. 317). As cloud technology is becoming more heavily utilized, we find that its applications are growing exponentially, especially at a governmental level. It is crucial for legislature to adapt alongside the healthcare industry and interoperability in terms of laws such as HIPAA in the United States. 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