Sharing health data through health information systems is a requirement for clinicians to provide the best possible care. It's impossible to communicate information efficiently without the use of two important concepts: interoperability of health information systems and health information data standards. In this article, we'll define and discuss these key factors using a typical case scenario for nursing care in a hospital setting. We'll also provide detailed definitions and information pertinent to achieving an optimal care process through participation in development of interoperability guides using health information technology (HIT) standards.
Bridging information gaps to ensure continuity of care is a large component of a nurse's role. Whether a patient is being treated in an acute care setting or is discharged to home, it's essential to have the necessary information at the right place and time to enable clinicians to make the right decisions and deliver high-quality care. To provide access to patient data in a consistent and timely way, information systems must be interoperable. Consider the following scenario:
A 70-year-old male is admitted to a hospital unit after presenting to the ED with productive cough, acute rib pain, shallow breathing, decreased lung sounds bilaterally, pulse oximetry saturation of 88%, temperature of 102.2° F (39° C), heart rate of 108 beats/minute, and BP reading of 156/88 mm Hg. The chest X-ray performed in the ED showed bilateral lower lobe and right middle lobe infiltrates. The medical diagnosis is pneumonia.1
Reading this scenario, perhaps you're thinking of the process needed to admit and care for this patient. Some of the questions you may be asking are:
- Did I receive all the clinical information currently available?
- What lab studies, X-rays, or other test results are pending? When will the results arrive?
- What can I do to mitigate the impact of waiting for pending results on the patient's care?
- What are the expected outcomes or goals for this patient?
- Has this patient been at this facility previously? If so, when was his last visit?
- Are the relevant clinical records available?
- Is there previous clinical data information that may be used to prepare the current care plan for this patient?
- What are the best practices for pneumonia? How can these guidelines be used for this patient?
The nursing workflow is enhanced in electronic health record (EHR) environments designed to share data with care delivery partners. The dataflow and the clinical information flow work together. Here are some examples of how interoperable systems can help nurses:
- An electronic summary report is received before the patient's arrival on the unit, including pending lab results and any clinician orders.
- The pharmacy system sends notification when the patient's unit dose medication will be arriving.
- The ED system automatically notifies the other service bureaus of the patient's pending admission. The respiratory therapist then arrives on the unit to set up the oxygen as ordered.
- Clinical Decision Support provides a list of the expected outcomes/goals for the pneumonia patient according to best practices.
- The patient's EHR provides records of the previous acute care episode, including the pertinent health history.
Nursing dataflow includes documentation of all nursing activities, clinical data encoding, and sending and retrieving the identical information in human and machine readable formats. Nursing workflow and dataflow work are processed together simultaneously in EHRs.2 Attention to interoperability in EHR design is necessary. Integration into the workflow and the use of data standards support this activity, resulting in benefits to the patient and care providers. Consider the combined workflow and dataflow diagram in Figure 1. This workflow demonstrates how data standards provide the optimal platform for interoperability in health information systems.
What's interoperability and how's it achieved?
There are a number of definitions for interoperability. However, there are two definitions that may help to clarify the term and the process:
- The International Engineering Consortium defines interoperability as the ability of two or more systems or elements to exchange information and use the information that has been exchanged.3 Interoperability is the ability of health information systems to work together within and across organizational boundaries to advance the effective delivery of healthcare for individuals and communities.4
- Interoperability in practice means the ability to access data across time and care settings without regard for where the data are originally stored. Today many organizations use electronic interfaces to enable data to be shared. These interfaces require vendors to customize software for each situation; for example, to get lab data from the lab information system to the hospital information system or to get radiology images from the picture archiving and communications system to the EHR system.
Unfortunately, electronic interfaces are expensive and difficult to maintain. For example, if a new version of the software is released, the interface must also be updated. There are many single vendor EHR systems available today that integrate departmental components or modules so data are consistently available at the point of care. However, many healthcare organizations have taken a different approach that requires customized integration of separate systems to achieve one cohesive EHR; complex, multiple interfaces aren't viable in meeting the continuity of care needs of our future healthcare environment. To solve this problem, we must look to health information data standards and their implementation.
What are some of the necessary interoperability considerations to ensure that nurses can provide safe, quality care for the pneumonia patient?
- The electronic clinical data sent must be identical to the data received.
- The data can be electronically compared or trended with previous data.
- The data can also be sent to the patient's personal health record and/or sent to the healthcare provider ambulatory health record.
- The data and clinical documentation can be shared throughout an acute care or ambulatory care system, including any specific departments within the system that are necessary for the safe, quality care of the patient.
- When the patient transfers to a long-term-care or home-care setting, all clinical documentation should be available electronically before transfer so the healthcare entity has the most current and up-to-date information to provide the best safe, quality care.
- Data can be compiled for comparison with other similar de-identified data for purposes of developing best practice in healthcare related to pneumonia.
- The data sent need to be completely secure, as all clinical data are subject to Health Insurance Portability and Accountability Act rules for confidentiality.
Implementation of data standards seems daunting, but once these standards are in place, they create a much more efficient and less costly method. Adoption of standards also supports legal use of the health record and enhanced justification for healthcare decision making.
How do HIT standards contribute to interoperability?
Standards are defined as a document or set of documents established by consensus and approved by a recognized body that provides, for common and repeated use, rules, guidelines, or characteristics for activities or their results aimed at the achievement of the optimum degree of order in a given context.5 Technically, HIT standards define electronic messaging, which includes the message content and how the message will be transported between the sender and the receiver of the message. The message may be a name, a signature, a completed document (lab or special procedures report), a radiology image, a BP reading, or many other items related to a specific patient's care. The computer message must include an identifying element within the message, so the clinical data are attributed to the correct patient. Sometimes the identifier is a number that relates to a standard used, so that even though the message (the patient's BP) changes, the place to send the message remains unchanged.
HIT standards may include data sets (a list of recommended data elements with uniform definitions relevant for a particular use), value sets (valid vocabulary values for a defined purpose), data models, clinical architecture, security frameworks, and terminology or other designated standards derived from authoritative sources. HIT standards may also be specific to a particular field of healthcare, such as pharmacy, medical devices, or laboratory information management. Often, a reference terminology such as Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) works with HIT standards to help organize the content of an EHR and reduce the variability of the message by providing a common controlled vocabulary for the expression of clinical concepts.
In the scenario for the pneumonia patient, any assessment data collected at the bedside would be sent in a specific type of message designed to hold clinical data that are related to other vital sign data. The use of SNOMED CT as a terminology standard ensures that a uniform meaning is communicated and the BP reading is categorized as a vital signs message, not a lab message.
Standards working together to provide one solution
HIT standards used in isolation may identify one problem with one or more solutions for a specific purpose. However, when standards work together, solutions are able to be implemented with less difficulty and used throughout the care process. To implement an interoperable system, multiple standards must work together. HIT standards need to be implemented in a consistent way in order for two different systems to be able to communicate and share data. Integrating the Healthcare Enterprise (IHE) provides implementation guides, also called IHE profiles. An IHE profile may be written using HIT standards to solve problems at the point of care or for related infrastructure issues.
In the previous scenario, the interoperability requirements include:
- current clinical information accessible at the point of care
- clinical information sent to any department where the information may be needed (such as the respiratory department)
- clinical data received from the ED
- current (up to the minute) clinical information available for nursing handoff or discharge report
- current medical and nursing orders accessible at the point of care
- current and trended lab reports, special procedures, or X-rays accessible at the point of care
- current problem lists, progress reports, and health assessments accessible at the point of care
- discharge summaries with instructional sheets available for the patient and customized to his diagnoses.
IHE has developed a number of profiles for specific clinical areas that provide a way to address interoperability problems related to needed clinical data. Each IHE profile defines a particular interoperability challenge and works to solve the issue or a set of closely related issues using HIT standards. EHR vendors implement these profiles into their products and work with IHE to test them in a neutral setting to confirm that their EHR products can send, receive, and store clinical data across time and care settings. Nurses can participate in IHE committees to define the interoperability challenges in their workflow and offer input to the IHE profile development process.
Opportunities for involvement
To deliver timely, efficient, and high-quality healthcare, clinicians need up-to-date information about each patient receiving care in acute and chronic healthcare settings. Currently, clinical data don't move freely between care settings and time. Addressing interoperability challenges using HIT standards and implementing guides such as IHE profiles can provide a path toward the seamless exchange of clinical data to advance continuity of care by clinicians for the benefit of individuals and communities.