Group D: Team Project Paper

HIE Exchange in an Emergency Room Environment

Wade Astin, Tracy V. Nunnery, Biljana Spasic, John Stoudenmire

MED INF 405 DL Sec 55

Summer 2012

Northwestern University

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Contents

What is an HIE? ............................................................................................................................................................. 3

Benefits of a HIE ....................................................................................................................................................... 3

Types of HIE ............................................................................................................................................................. 4

Examples of existing HIE ......................................................................................................................................... 4

Stakeholders .................................................................................................................................................................. 5

Functional Requirements ............................................................................................................................................... 7

Clinical Functionality .................................................................................................................................................... 8

Use of Standards ............................................................................................................................................................ 8

Technical Design ........................................................................................................................................................... 9

Data Flow Example ................................................................................................................................................. 10

Barriers to Implementing HIE ..................................................................................................................................... 11

Conclusion ................................................................................................................................................................... 12

References ................................................................................................................................................................... 13

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What is an HIE?

While it is widely accepted that use of the electronic medical record can improve the quality and safety of healthcare

delivery, the EMR is itself part of a much larger vision of a unified network of health information exchange across

multiple providers. However, adoption of the electronic medical record (EMR) – a fundamental building block of

this vision - has been slow. In 2009, Bluementhal, described that “…only 17% of U.S. physicians and 8 to 10% of

U.S. hospitals have at least a basic electronic health record system. Far fewer have — and routinely use — the types

of comprehensive systems that would allow them to fully realize the potential of the technology” (Blumenthal

2009). While the Bush Administration initially tried to jump start more widespread development of the EMR by

creating in 2004 the Office of the National Coordinator (ONC) for Health Information Technology, the Obama

Administration gave a more decisive push in 2009 with the Health Information Technology for Economic and

Clinical Health Act (HITECH), part of the American Recovery and Reinvestment Act. This legislation codifies the

ONC, and charges it with developing not only widespread use of EMR but also a system of governance for a

nationwide health information network.

A Health Information Exchange (HIE) is defined as the “electronic movement of health-related information among

organizations according to nationally recognized standards” The Healthcare Information and Management Systems

Society (HIMMS) definition develops this idea further by adding that health information is to be exchanged, “… in

an authorized and secure manner.” (HIMSS, 2012) The participants of a HIE can include many entities such as

hospitals, doctor groups, labs, pharmacies, and payers. As use of the electronic medical record expands, more

specialized caregivers can also join HIEs, including rehabilitation and long-term care facilities. The most common

type of data shared include lab results, clinical summaries, medication lists, and medical image reports. Below is a

graphic from GE’s eHealth that helps illustrate the concept of a HIE.

Figure 1. HIE Concept map

(GE eHealth)

Benefits of a HIE

The ONC provides several benefits for the establishment of a HIE. (healthit.gov, 2012)

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Provides a vehicle for improving quality and safety of patient care

Provides a basic level of interoperability among EHRs maintained by individual physicians and

organizations

Stimulates consumer education and patients' involvement in their own health care

Helps public health officials meet their commitment to the community

Creates a potential loop for feedback between health-related research and actual practice

Facilitates efficient deployment of emerging technology and health care services

Provides the backbone of technical infrastructure for leverage by national and State-level initiatives

The North Carolina Health Information Exchange (NCHIE) is an example of an active HIE. The NCHIE provides a

list of the benefits they have experienced:

Emergency Departments with connectivity to an HIE have improved productivity by more than 20%

Across all insurance types, EHR sites were associated with significantly higher achievement of care and

outcome standards and greater improvement in diabetes care.

By reducing their dependence on paper records, a practice seeing 3,000 patients annually could save

$24,000.

At the highest level of health IT adoption, only 0.001% of prescriptions would require a phone call between

a pharmacist and physician (NCHIE, 2012)

Types of HIE

HIMSS provides descriptions of the three common HIE types: the Centralized, the Decentralized (Federated), and

the Hybrid. (HIMSS, 2012)

Centralized: A typical centralized architecture is implemented as a logical, single database that aggregates

identified data from multiple sources in one location. All data exists in a single warehouse. Participants

send their data to a central repository.

Decentralized (Federated): A federated architecture model provides organizational control of the health

information and provides the framework for data-sharing capability to organizations widely distributed

across regions. This model allows the data source organizations to manage and store the patient health

information and indices. When requested, data is queried from the data source organization and not stored

centrally.

Hybrid: A hybrid architecture model uses a system where some health information and data is physically

stored and managed in a central location and other data is stored and managed by data source organizations

with a common framework for data-sharing capability. When requested, data is queried from either the

central repository or the source organizations depending on use cases.

According to HIMSS the Hybrid model is described as the “best of both worlds” from setup, socio-economic,

political and management perspectives. HIMSS also describes the Hybrid model as the most flexible. HIMMS

shows that the Hybrid model has only medium risks, but also a high amount of benefits. (HIMSS, 2012)

Examples of existing HIE

There are several examples of HIEs already in use, both public and private. For example, the Indiana Health

Information exchange network claims to be the largest Health Information Exchange in the nation. The IHIE

explains that they are “providing a secure and robust statewide health information technology network that

connects over 90 hospitals, long-term care facilities, rehabilitation centers, community health clinics and other

healthcare providers in Indiana. This network serves more than ten million patients and over 20,000 physicians

throughout the country. ” (Indiana Health Information Exchange, 2012) While the Indiana Health Information

Exchange is the largest, the Delaware Health Information Exchange Network (DHIN), launched in 2007, describes

themselves as the first operational statewide information exchange, and currently celebrated their fifth anniversary

since HIE “go live”. (DHIN, 2012) As stated above, North Carolina also has a mature HIE.

An example of a private vendor supplying a HIE is “eHealth” a Health Information Exchange product offered by GE

healthcare. It is interesting to note the GE’s Health Information Exchange (HIE) solution states that it’s framework

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supports all three models of HIE. GE advertises that, “Data can be stored in several ways, as dictated by business

and security requirements including federated, centralized or hybrid systems.” (GE Healthcare, 2012)

Stakeholders

The successful implementation of an HIE depends heavily on a number of different stakeholders. Stakeholder

support and buy-in can be critical in determining whether a project succeeds or fails. “Data accessibility, reliability,

and accuracy are critical factors in obtaining the trust of stakeholders, including consumers, and in sustaining long-

term data exchange on a large scale” (Acker, 2007). Ideally, projects should have stakeholders who are informed of

the goals, represent the needs of the organization, committed to the project and also authorized to make decisions

(Rozanski, 2005). In an emergency room setting, these primary stakeholders include patients, providers and the

hospital in which it operates. Secondary stakeholders also exist including payers of health care services, employers,

providers of health care plans and the community which the HIE serves. Overall, a successful HIE requires “a

coordinated set of behavior changes on the part of providers, insurers, and payers” (Wagner, 2006).

In a business sense, some stakeholders rely on an HIE to “look like, act like, and operate like a business when in fact

the stakeholders come from many different industry sectors and are sometimes competitors” (Middleton, 2010). For

physicians, patients, researcher and the community at large, the measure of success may be quite different. For these

constituents, an efficient and functioning HIE system translates into increased access and speed for services, a

higher quality of care, an increase in patient safety, lower costs for health care as well as improved collaboration,

measurement of evidence-based medicine initiatives and expedited coordination of care among providers of health

care services.

Involving stakeholders in the early phases of a project can have a number of benefits. Stakeholders can actively

support the project and encourage confidence in others and influence resources. Stakeholders can also be critical in

gauging the reaction of others and helping shape approaches, anticipating criticism or adjusting the project as

needed. Because of their importance in the success of a project, their input should be a determining factor in the

architecture of the system. “The first step in Stakeholder Analysis is to identify who your stakeholders are. The next

step is to work out their power, influence and interest, so you know who you should focus on. The final step is to

develop a good understanding of the most important stakeholders” (Mind Tools, 2012). After the stakeholders are

identified, it is also important to understand their motivations, communications patterns, influences as well as the

nature of their investment in the project. The needs of the stakeholders can then be clarified and prioritized and

included as a part of the overall project design. “A very good way of answering these questions is to talk to your

stakeholders directly – people are often quite open about their views, and asking people's opinions is often the first

step in building a successful relationship with them” (Mind Tools 2012).

Improvements to a system of care which include HIE can have a positive impact on the overall health of the

community and can also improve the accessibility of coordination of services for the under-served. In an ER

environment, the most obvious stakeholder of an optimally-functioning HIE is the patient. The advantages to

patients can include reduced wait times to receive services, improved engagement with the physicians and nursing

staff, greater access to their personal health information, reduced medical error rates and duplicative lab testing or

medication administrations. All of these factors can provide an overall improvement of the quality of care they

receive. “Research conducted by the eHealth Initiative suggests that the more consumers learn about the creation of

secure HIEs, the more they support these initiatives. The HIE message that tends to resonate the most with

consumers is that of having access to information in an emergency medical situation, followed by access to medical

records when out of state and access to medical records when visiting a doctor” (Wiegand, 2007).

Physicians, nursing and staff can also clearly benefit from the advantages provided by HIE. The data physicians use

to guide their decisions and formulate care plans can be based upon more reliable, accurate and up-to-date patient

information. The availability of accurate past medical histories is especially important in an ER, since information is

needed quickly and patients may be incapacitated or unable to communicate. “From the physician stakeholder

perspective, the goal of reduced costs and improved revenues will be achieved through savings in time, overhead,

human resources and materials, as well as through the ability to see more patients” (Fleming, 2010). Physicians are

also able to more easily and accurately document patient encounters, electronically order clinical labs or prescribe

medications or collaborate and follow-up with other members of the care team.

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From a financial perspective, an HIE can increase revenues by increasing the number of patient encounters per

provider, per day. Malpractice insurance rates can also be lessened as a result of the higher quality of care and

potential reduction in error rates. “For hospital stakeholders, goals might be defined as a reduction in time spent on

patient intake and shorter wait times in Emergency Departments. The HIE could result in a reduction in medication

errors due to more complete information at the point of care, and streamlined communications of orders and results

that can lead to earlier discharges, when medically appropriate, which save the hospital money in payment models

that are based on per episode vs. length of stay” (Fleming, 2010).

Another positive impact of an HIE is the reduced storage footprint as compared to paper-based record keeping. In

the ER where space may be constrained and records rooms inconveniently located, an HIE can provide ready-access

to information and paper storage areas can be otherwise repurposed - - This results in reduced waiting times for ER

patients, an increased throughput of patients and potentially increased revenue from improved claims management

and capture of services rendered to patients.

Figure 2. HIE stakeholders

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(Middleton, 2010)

Research, quality of care and public health initiatives can also be important stakeholders in health information

exchanges. “Local health information exchanges (HIEs) hold the promise of collecting patient clinical data across

sites of care to provide more complete and timely information for treatment, as well as supporting quality

improvement and reporting, public health activities, and clinical research” (Grossman, 2008). Especially when

integrated as a part of an emergency room, HIE is positioned to support population heath and quality assurance

initiatives. Using discretely coded patient data, patients who exhibit common characteristics or sharing a common

condition can be easily identified and managed. This can be leveraged to assist with quality of care initiatives by

providing a means to assess the quality of care for patients with a within a disease or symptom-specific cohort. Data

which is coded and shared within an HIE can be critical in identifying potential candidates for clinical research and

also be used to detect sentinel events and syndromic surveillance efforts. Information from an ER or group of ERs

can create a repository of data which can be monitored for specific symptoms or conditions. When shared within the

context of an HIE, the presence or occurrence of a significant of environmental, bioterror or epidemiological event

can be detected over a large region.

There are also secondary stakeholders who can be beneficiaries of an HIE-enabled system. For payers of service

such as insurance companies, an HIE can improve the capability to determine the use of quality measures as well as

utilization rates and provide efficiencies in the review of claims and resolution of disputes. Employers can also

realize similar benefits and cost reductions improving preventative medicine and management or chronic disease,

improving employee attendance and reducing worker’s compensation claims. Employer stakeholders will realize a

positive “through a reduction in the amount of time spent managing claims appeals, reductions in Emergency

Department visits by employees with chronic conditions—which also results in costs related to lost productivity—

and improved management of workers compensation claims” (Fleming, 2010).

Functional Requirements

An emergency department has unique HIE and EHR needs, with functional requirements being met by an

Emergency Department Information Systems (EDIS). The environment is high-speed and dynamic. The ED needs to

have rapid and accurate access to records already in the hospital’s system as well as communication and sharing of

patient information from and to other medical organizations including the primary physician. Rothenhaus, T.,

Kamens, D., Keaton, B. F., Nathanson, L., Nielson, J., Mcclay, J. C., Taylor, T. B. & Villarin, A. (2009) offer

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suggestions on emergency department-specific functional requirements. These are broken into clinical functionality,

administrative functions and other considerations.

Clinical Functionality

Patient Entry: Rothenhaus, T., Kamens, D., Keaton, B. F., Nathanson, L., Nielson, J., Mcclay, J. C., Taylor, T. B. &

Villarin, A. (2009) define this as the process of uniquely identifying a patient in the EDIS. The process can begin at

triage, entering the patient into the EDIS and assigning a unique identifier.

Patient tracking: Tracking consists of patient-centered and department-centered tracking. Patient- centered tracking

includes a clinical course which follows the patient through the ED process and patient-location tracking which

tracks all phases of the hospital process from pre-arrival through discharge.

Department dashboards: These are administrative tools which monitor key performance indicators. Examples

include the number of patients: waiting to be seen, in waiting room and awaiting inpatient bed assignment.

Clinical Documentation: The system must be able to provide quick, efficient, accurate and complete patient

information. Having the ability to utilize already gathered patient information can reduce time and redundancy. The

system must also be able to link documentation to medical billing.

Computer Provider Order Entry (CPOE): A requirement of HIE as well as an EDIS is that a physician should be

able to order laboratory, radiology, medications, nursing tasks and medical equipment. In order to complete orders

and prioritize tasks, physicians benefit from a task management system and order acknowledgement replies.

Result Reporting: Rothenhaus, T., Kamens, D., Keaton, B. F., Nathanson, L., Nielson, J., Mcclay, J. C., Taylor, T.

B. & Villarin, A. (2009) state that key features are easy access and review within the context of each EDs particular

workflow. The system should be easily customizable for the specific needs of the ED.

Discharge Management: An HIE and EDIS should be able to exchange data to both medical organizations for

follow-up as well as patients. Examples of functions can include prescriptions, discharge education and instructions

and follow-up information.

Administrative Functions: Billing and financial management are key functions required for an EDIS. A function of

an HIE and EDIS should be auditing and logging data for reporting. Another function could be the reporting of

mandated public health diseases.

Other Considerations: HIE and particularly an EDIS should have directory services as a component to the system.

Types of directories can include users or individuals, organizations and locations, data services by organizations or

service providers and semantics or terminology as well as translation services, (HLN Consulting, LLC). Also,

emergency departments require an HIE which can communicate data between disparate computer systems. These

should be in compliance with HL7 standards as well.

Use of Standards

Standards provide a framework or format for which information systems, EHRs and medical providers can work

together. A standard is a recognized, approved and adopted way of doing things in the industry. Standards are

critical in creating interoperability among varying systems. Most official IT standards are set by ANSI (American

National Standards Institute), IEEE (Institute of Electrical and Electronic Engineers) and VESA (Video Electronics

Standards Association), (Webopedia). In HIE, other standards apply as well. Although no emergency department-

specific standards were noted, ED utilizes many standards implemented throughout HIE.

Meaningful Use: The Health Information Technology for Economic and Clinical Health (HITECH) Act

was created to improve healthcare quality, safety and efficiency through the use of HIE/EMR and private

and secure electronic information exchange, (Office of the National Coordinator for Health Information

Technology). Medical professionals who are in compliance with the meaningful use objectives can be

eligible for Medicaid and Medicare incentives.

LOINC: LOINC (Logical Observation Identifiers Names and Codes) is a database and standard for

measuring laboratory results. Vreeman, D. (2010) states LOINC was developed to provide a definitive

standard for identifying clinical observation in electronic reports. This standard has been designated for use

in the U. S. Federal Government systems for the exchange of clinical health information, (U.S. National

Library of Medicine).

SNOMED-CT: SNOMED-CT (Systemized Nomenclature of Medicine-Clinical Terms), according to the

International Health Terminology Standards Development Organization, is the most comprehensive,

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multilingual healthcare terminology in the world . This standard is able to cross-map to other international

standards and is used in more than fifty countries. SNOMED can assist in recording, storing and retrieving

data within the EMR as well.

RxNorm: According to the National Library of Medicine, RxNorm provides normalized names for clinical

drugs and links its names to many of the drug vocabularies commonly used in pharmacies. NLM adds that

RxNorm now includes the National Drug File-Reference Terminology (NDF-RT) from the Veterans Health

Administration, (National Library of Medicine).

DICOM: “DICOM is a global Information-Technology standard that is used in virtually all hospitals

worldwide,” states DICOM (Digital Imaging and Communications in Medicine). Among other functions,

DICOM is designed to create interoperability of systems used to produce, store, retrieve and view medical

images. This standard ensures interoperability among many medical departments and units. Examples

include radiology, cardiology and neurology.

HL-7: HL-7 provides a comprehensive framework and related standards for the exchange, integration,

sharing, and retrieval of electronic health information (Health Level 7 International). HL-7 standards define

how information is packaged and communicated from one party to another, setting the language, structure

and data types required for seamless integration between systems.

CCD: A continuity of care document is an electronic summary of all of a patient’s clinical information.

This standard provides physicians with the ability to share a patient’s medical history and current condition

in a comprehensive representation. CCD is typically used in among other capacities, emergency

departments. CCD is one of two formats required by the government to achieve meaningful use.

Technical Design

Data exchange within and between healthcare organizations faces numerous challenges. Technical challenges start

with the complexity of the US Healthcare delivery system, lack of standardization and inadequate infrastructure. The

number of systems requiring interoperability is large, the systems are based on different technical and data

architectures, and their interoperability capabilities are on different maturity and readiness levels. Implementation of

a HIE as a central hub for data exchange eliminates the need for point to point interfaces between systems and

organizations. Instead, interoperability is established between each system and HIE. The diagram below shows the

roles of major stakeholders in health data exchange.

Figure 3. Healthcare Ecosystem

(Knickerhm, 2011)

In order to improve efficiency and quality of care, and reduce cost, Emergency Departments require data exchange

with almost all health data exchange stakeholders internal or external to their organizations. This requires

interoperability with a large number of disparate systems. For those reasons Emergency Departments are often early

HIE adopters and strong proponents of system’s interoperability with well established HIE. (Shapiro, 2006).

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The quality of patient care in ED benefits from easy and fast access to complete patient record and the most current

health information. The required information includes problem lists, diagnoses, allergies, medications and diagnostic

results, as well as a summary of patient health history, chronic conditions, etc. To take full advantage of HIE, ED

system’s interoperability requires data exchange that supports Continuity of Care Document (CCD) standard and

unrestricted access. Where there is no CCD interface available, interoperability via other standard HL7 messages is

a substitute. In cases of limited interoperability, HIE should provide a contact information for the healthcare

provider in support of two way data exchange via secure email.

Major concerns with making data available to many providers via HIE are related to security, such as controlled

access to all data and in particular restricted data, sharing with authorized providers only, ensuring patient privacy,

and maintaining confidentiality of personal health information. Security and access control are addressed by

implementing strict policies and procedures, and maintaining master provider directory with the appropriate

credentials. Unique identification of patients across all data sources that utilize HIE is managed via the master

patient index.

Figure 4. HIE architecture/tech design

Data Flow Example

HIMSS provides interoperability use cases to illustrate data exchange scenarios. The case referenced in the diagram

below illustrates clinical and data flow in a Emergency Department encounter, and exchange of restricted data with

other healthcare organizations and their systems, PCP and patient via HIE. In this use case HIE processes utilize

provider profiles to authorize appropriate access, enable required high level of interoperability and maintain integrity

of restricted data. The use case support Meaningful Use requirements of improving quality, efficiency and

coordination of care, enabling increased patients’ involvement, and protecting privacy. (HIMSS, 2012)

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Figure 5. HIMSS Interoperability Showcase, EMS and ED Encounter

(HIMSS, 2012)

Barriers to Implementing HIE

Cost can be a limiting factor for adoption of healthcare information technology, and especially in the case of an HIE.

Since participation in system of electronic data exchange is highly dependent on the existence of an electronic

medical record system, this cost must also be considered as a part of any financial evaluation. “The cost of

implementing an EHR [is] estimated at $5,500 to $36,000 per physician” (Burton, 2004). Hardware, software and

maintenance needs are responsible for a portion of these costs but there are other costs relating to loss of

productivity during implementation, training and reduced number of patients which can be accommodated. In

addition to these expenses, there are also costs associated with the integration with external systems as well as fees

to access the HIE network. Federal programs have provided financial support to fund systems to share health

information. These funds are time-limited, with no assurances of future funding. “Failure to come up with a

sustaining financial model has doomed regional data-sharing organizations in the past; participants often don't see

the value in funding the exchanges out of their own pockets once the initial support dries up” (McGee, 2010).

In a system which is designed to share sensitive patient data, concerns regarding security and privacy must be fully

considered. “Because the United States has a large, private data collection industry governed by a conflicting

patchwork of federal and state laws and agencies, federal regulations will need to be modified to encourage secure

data exchange in the Nationwide Health Information Network” (Fontaine, 2010). Ensuring the security of sensitive

patient information is collective responsibly and includes protections for sharing, storage, transmission, archive and

dissemination. Although “there is scant legal precedent to offer guidance about the liability of a physician who acts

on clinical information made available in such situations” (Fontaine, 2010), legal and liability issues are important

considerations since physicians could act upon incorrect data or fail to act on correct data which is provided by an

HIE.

Interoperability is significant barrier to HIE implementation and may also be one of the most persistent since

“getting data in front of doctors and other clinicians is one of the biggest challenges HIEs face” (McGee, 2010).

Many proprietary commercial and home-grown EHR systems lack the necessary functionality to be able to exchange

data with other systems in a meaningful way. If a physician’s EMR is unable to directly interface with an external

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system, there are other options such as portals which can provide the necessary information. “The problem with

portals is that they force doctors to take an extra step to view data--to remember to check the portal for new

information every time they're about to treat a patient. Doctors often end up using the HIE less as a result, and some

provider groups decide the exchange isn't worth the investment if their clinicians aren't using it” (McGee, 2010). A

primary reason for the lack of interoperability is the variability of coding systems used by organizations and EHR

vendors. A fully-interoperable HIE structure requires systems to be able to communicate with each other using a

known and agreed-upon lexicon for medications, laboratory values, conditions and other health care parameters.

Although standards for medical codes have been encouraged at the national level, interoperability continues to be a

significant technical barrier to HIE participation.

An International Journal of Medical Informatics article from 2007 reports that “almost two thirds of primary care

physicians surveyed in 2006 cited the lack of a strategic plan as a barrier to health IT implementation” (Anderson,

2007). These issues are coupled with physician who may be reluctant to use technology or who see electronic

systems as the cause for an increased workload. Physicians may also be concerned that new systems will interfere

with their established workflow and that training and learning new systems is both time-consuming and difficult.

Some organizations may also lack the necessary in-house technical staff or expertise to effectively support an HIE.

As reported in an article in from The Commonwealth Fund, “if careful consideration goes into developing policies

that address these challenges, the exchanges will be able to accomplish what they are intended to do: expand access

to affordable health insurance coverage, improve the quality of coverage, and reduce costs. These are outcomes that

will benefit the health system overall” (Jost, 2010).

Some organizations or agencies may have concerns with sharing information and potentially collaborating with

competing organizations. Participation in an HIE “requires competing and adversarial parties to collaborate and

share their most valued asset: patients and their data” (Grossman, 2006). The “fragmented and competitive US

health care system [provides] few offsetting incentives for sharing clinical data” (Anderson, 2007). This loss of

competitive advantage, either real or perceived, is certainly a factor which may impede willingness to participate in

a data-sharing system.

Conclusion

An emergency department has unique needs and has much to gain from access to a HIE. While access to the HIE

may occur outside the EMR workflow, an HIE offers a relatively easy insight into a patient’s scenario, Information

regarding historical problems, past procedures, allergies, active medications, etc. saves both time and resources upon

each ED visit. In fact, the NCHIE reports that “Emergency Departments with connectivity to a HIE have improved

productivity by more than 20%.” The claim is also supported by research by Frisse et al (2012), where Emergency

Room encounters in Tennessee were studied over a 13 month period. They reported that HIE access for the ED

resulted in a decrease in hospital admissions and cost savings primarily through reductions in duplicative CT and

Lab tests (Frisse, 2012). Through the use of standard terminologies, such as LOINC, SNOMED-CT, RX Norm, even

the complex barriers to semantic interoperability can be reduced; however, there is still much work to do in these

realms. Barriers such as software and hardware costs, ensuring security and privacy, staffing shortages, and the

Clinician perception of a disruption to clinical workflow also remain a challenge.

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References

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