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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. We are seeing an increase in legislature adapting to cloud based technology.
“The eHealth [cloud] platform [proposed in Bangladesh] would connect physicians, patients,
hospitals, government departments, insurance companies, and pharmaceutical companies to the
same platform” (Eze, Kuziemsky, Lakhani, & Peyton, 2016, p. 317-318). Applications such as
this provide a cohesive link between all facets of healthcare which will ultimately improve
healthcare across the board.
References
Biedermann, S., & Dolezel, D. (2017). Introduction to Healthcare Informatics (2nd ed.). Chicago, IL:
American Health Information Management Association.
Cha, A. E. (2016, May 3). Researchers: Medical errors now third leading cause of death in United
States. The Washington Post. Retrieved from https://www.washingtonpost.com/news/to-yourhealth/wp/2016/05/03/researchers-medical-errors-now-third-leading-cause-of-death-in-unitedstates/?utm_term=.772893542b2e
Dixon, B. E., Jabour, A. M., Phillips, E. O. K., & Marrero, D. G. (2014). An informatics approach to
medication adherence assessment and improvement using clinical, billing, and patient-entered
data. Journal of the American Medical Informatics Association, 517-521.
Eze, B., Kuziemsky, C., Lakhani, R., & Peyton, L. (2016). Leveraging Cloud Computing for Systematic
Performance Management of Quality of Care. Procedia Computer Science, 98, 316-323.
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pharmacy interface on order-infusion pump discrepancies. Journal of drug delivery, 2015.
Schoenhagen, P., & Liu, H. (2016). Computed tomography, electronic health record, and private medical
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