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The Potential of Health Information Exchange to Assist Emergency Nurses
CLINICAL
THE POTENTIAL OF HEALTH INFORMATION EXCHANGE TO ASSIST EMERGENCY NURSES Authors: Shirley A. Thorn, PhD, MN, MAdmin, RN, and Michael A. Carter, DNSc, DNP, Memphis, TN
Health information exchange holds the promise of sharing critical information about patients across organizations. We have found that emergency nurses have little or no involvement in using health information exchange and, often, they are not granted access by individual hospital policies. Yet,
emergency nurses need to know this information and must have full access to health information exchange. We provide recommendations to ensure that emergency nurses are able to reach their full potential in using health information exchange to care for patients.
rs J is a 72-year-old woman who presents to the emergency department complaining of a nontraumatic sudden-onset headache that she describes as a sharp pain in her head that began a couple of days ago. She has taken acetaminophen tablets and “something” from a prescription bottle with little relief. In the course of obtaining a history, the emergency nurse learns that Mrs J has a history of headaches. Mrs J was seen in another hospital's emergency department yesterday with the same chief complaint. She states that she had “some blood tests” and a computed tomography (CT) scan before she received “a shot” and was discharged home with another prescription, but she does not remember the name of the prescription. Mrs J's medication history is vague, and she does not have a list of her current medications. The emergency nurse needs to retrieve Mrs J's health files to review her history, especially her prior test results and medications from her emergency visit the previous day. The nurse is aware that the emergency department has a health information exchange (HIE) system, but unfortunately, hospital policies do not grant access privileges to emergency nurses. The nurse alerts the emergency physician that Mrs J's information and test results from the previous day may be in the HIE system. The emergency physician was hired 4 months ago and has not received access privileges for
the HIE system. The other 2 physicians in the department have access privileges, but they are busy with critically ill patients. It is late in the evening, and the emergency nurse knows that there will be a considerable delay in receiving Mrs J's faxed test results from the other hospital. The nurse wonders whether the tests should just be repeated. The preceding example shows the experience of 1 emergency nurse in a hospital emergency department with HIE. Emergency nurses in this organization are not granted access privileges to the HIE system, resulting in information not being available at the point of care.
M
Shirley A. Thorn is Assistant Professor, Loewenberg School of Nursing, University of Memphis, Memphis, TN. Michael A. Carter is University Distinguished Professor, College of Nursing, University of Tennessee Health Science Center, Memphis, TN. For correspondence, write: Shirley A. Thorn, PhD, MN, MAdmin, RN, 7581 Cross Village Dr, Germantown, TN 38138, USA; E-mail: sathorn@ memphis.edu. J Emerg Nurs 2013;39:e91-e96. Available online 29 January 2013. 0099-1767/$36.00 Copyright © 2013 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2012.12.007
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Introduction
Emergency nurses must frequently make use of information technology to perform their work. However, there are sometimes confusing policies, procedures, and risks involved with the use of technology. 1 One component of this technology is the new HIE systems. HIE is the electronic exchange of health information between participating organizations and providers, 2,3 including public health systems. 4 Nurses can play a key role in HIE, but they need to understand the implications of electronic health records and HIE to be effective players in using technology in the care of patients. The American Recovery and Reinvestment Act of 2009 contains a section referred to as the HITECH (Health Information Technology for Economic and Clinical Health) Act that allocated $19 billion for information technology, specifically, the expansion and adoption of electronic health records and HIE. 5 Incentive payments through the Medicare and Medicaid systems support the implementation of health care information technology, meaningful use of electronic health records, and HIE. 5,6 A certified electronic health record has the capability and security features to attain the criteria for meaningful use. 7 “Meaningful use” is a technical term that means the electronic record must have the components of (1) collecting demographic data, diagnostic test results, and
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TABLE
HIE access: Personnel granted access privileges in emergency departments Charge nurses ‡
NPs/ PAs
Emergency physicians §
Chest pain nurses ‖
Scribes ¶
Site*
Emergency nurses †
EHR system #
A B C D
No Yes No No
No Yes Yes No
—** Yes Yes Yes
Some Some Some All
— Yes Yes —
— Yes — Yes ††
No Yes Yes No
EHR, Electronic health record; NPs, nurse practitioners; PAs, physician assistants. * Four selected study sites with HIE access privileges governed by hospital policies. † Emergency nurses at site B could apply for access; sites A, C, and D denied nurses access. ‡ Sites B and C granted charge nurses access. § Emergency physicians at all sites could apply for access privileges, but not all the physicians at sites A, B, and C had access; all the physicians at site D had access. ‖ Registered nurses were employed specifically in chest pain clinics. Sites A and D did not have designated chest pain clinics separate from the emergency department. ¶ Sites B and D hired scribes who were granted HIE access privileges. # All 4 study sites had electronic health record systems, but 2 sites had not implemented electronic documentation in the emergency department at the time of the study. ** Site A did not hire nurse practitioners or physician assistants in the emergency department. †† Site D hired scribes in preparation for the implementation of electronic documentation with the expectation that physician productivity would decline with the electronic health record system.
electronic prescriptions; (2) providing decision support and clinical quality measurement reports; and (3) having HIE capabilities. 4,8,9 As can be seen, these components are the very ones that emergency nurses use in their role. Nurses have the potential to influence achieving meaningful use criteria and HIE success if they are allowed to be full participants in using technology to deliver patient care. HIE use is being promoted as technology that has the potential of delivering benefits for patients, such as improving continuity of care. 1 One of the goals of meaningful use is to improve quality of care. 7 The Institute of Medicine and Joint Commission have established National Patient Safety Goals to increase health care technology that shares information and improves patient safety. 10 HIE has the potential to reduce costs and improve safety by providing information at the point of care. 11–15 So far, this potential has not been fully realized. 2,11,16–18 HIE can also have design flaws that cause errors or disrupt workflow. 17,19 Nurses could help minimize these flaws and should be full partners in the design and implementation of HIE systems 20 because hospitals and ambulatory care facilities are where HIE is used. 13,21 Nurses are the largest contributor of notes to the electronic health record, 22 which is the source of data for HIE. Therefore nurses need to have HIE access and be active partners in all facets of HIE systems if meaningful use is to succeed. 20 Background
Little has been reported concerning how emergency nurses use HIE. We recently conducted an institutional review board–approved study about how emergency physicians use
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HIE in their daily practice (S.A.Thorn, unpublished data, January 2013). In that study we learned a great deal about how nurses use HIE. We studied 4 large urban emergency departments, including a Level I Trauma Center, located within a major metropolitan area. A centralized HIE database was implemented in the region in 2006 that linked over 450 providers in 15 clinics and 9 major hospitals including all the studied hospitals. We found that emergency nurses had a variety of roles in HIE use in these hospitals. Role of Emergency Nurse
The most common reason that emergency nurses did not use HIE was a lack of access privileges. Individual hospital policies controlled access with user logins and passwords. The emergency physicians reported that they considered the HIE system to be secure and important for care, but they could not understand why emergency nurses lacked access. Three of the four study sites did not allow emergency nurses HIE access, although 2 of the sites granted access privileges to charge nurses (Table). Two hospitals hired scribes who electronically documented information for emergency physicians. The scribes had HIE access, but the emergency nurses did not have access at 1 of the sites. One of the complaints of the emergency physicians was the uncertainty over whom had HIE access privileges and whom did not have access. The problems with HIE access were not restricted to just emergency nurses. There were emergency physicians who did not have HIE access because of the time and difficulty obtaining privileges. As a workaround, the emergency physicians without access relied on other physicians to log
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into the HIE system for them, or if charge nurses were granted access, the charge nurse retrieved patient data in the HIE system. In other instances where residents did not have HIE privileges, emergency physicians had to log into the HIE system and retrieve patient information for the residents. All the workarounds were time-consuming, inefficient, and frustrating for the end-users of the HIE system. Emergency nurses at 1 hospital site could obtain HIE privileges if they wanted access; however, 1 of the physicians reported that “most of them don't have the time or inclination.” This person went on to say, “I don't know if it's any particular benefit to them.” One of the issues may be the lack of communication focused on emergency nurses using HIE and the value of having patient information available at the point of care. The process of receiving access privileges was a source of frustration. One emergency physician said that he “had heard almost nothing” about HIE and he never heard anyone talk about how helpful HIE was. There was little education on the HIE system during the implementation phase, and emergency physicians were not familiar with the full functional features, such as trending values. Overall, there was minimal HIE education and an absence of champions for the users of HIE. Emergency nurses most likely did not receive any information regarding the HIE system because they had not been granted access privileges. Nurses at the 2 sites with designated chest pain clinics did have HIE access. The role of the chest pain nurses was described as reviewing the patient's HIE data and identifying whether there was pertinent information. If the chest pain nurse identified pertinent information, such as a recent electrocardiogram tracing, the report was brought to the attention of the emergency physician caring for the patient. In some cases HIE information was printed and presented to the emergency physician. The charge nurse's role was more clerical, such as printing information from the HIE system for the emergency physician, than decision making. The physicians explained that the charge nurse printed HIE information that he or she “feels would be pertinent to the most recent discharge summary” or nurses printed reports requested by the emergency physician. Because the charge nurse was not the nurse caring for the patient, it was unclear whether all the appropriate information was included. In other cases the charge nurse printed information before the emergency physician examined the patient, but this process was not consistent, and there was no system to ensure that someone had checked to determine whether there was HIE information for the patient. There was also uncertainty about how the printed HIE information was managed in the emergency department. Printed HIE information was
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thought to be either shredded or sent to the unit if the patient was admitted. The practice of printing HIE reports was a workaround and was inefficient. Discussion and Implications
The most frequent complaint was the issue of the HIE system not being user-friendly. There were too many clicks to find information, or information was missing. However, nurse practitioners used HIE quite frequently in the emergency departments that had nurse practitioners. The higher HIE usage rate was attributed to nurse practitioners being assigned to the fast-track areas where patients frequently visit multiple facilities for minor complaints, and HIE is more valuable in this situation. On other occasions, the emergency physician would ask the charge nurse or nurse practitioner to log in and find HIE information while the physician saw patients. Overall, emergency physicians attributed low usage rates to a system that was not intuitive and obtaining access privileges was cumbersome and time-consuming. Medication histories were frequently a problem. Patients arrived at the emergency department without a current list of medications, or they were unable to provide information. Emergency nurses had the difficult and timeconsuming task of phoning pharmacies in an attempt to clarify the patient's current medications. In addition, the emergency nurses also had the responsibility of entering updated medication histories into the electronic health record for data entry into the HIE system. The lack of updated medication histories was an HIE flaw that resulted in further inefficiencies and delays in processing patients through the emergency department. Emergency departments used protocols to move patients through the department more quickly by having nurses order tests and having the results available when the emergency physician examined the patient. Although some emergency physicians viewed the protocols as timesaving, they also viewed the protocols as wasteful. Without HIE access, emergency nurses are not able to check the patient's history or whether the patient recently had the same tests at another facility before ordering the protocol. As a result, the ordered tests may not be necessary, which further reduces efficiency. Recommendations for Emergency Nurses
In the example, there are a number of questions related to Mrs J's care because the nurse did not have HIE access. What laboratory tests were performed at the other hospital,
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and what were the results? What were the findings from the CT scan? Why did Mrs J receive a new prescription during her visit? What was the medication injection? Did a consultant see Mrs J? Is there an updated medication history recorded in the HIE system? A lack of information from Mrs J's visit to another emergency department the previous day hampered the emergency nurse's efforts to have a complete clinical picture of Mrs J's chief complaint. Treatment is delayed while the team discusses whether the tests should be repeated or whether someone in the emergency department with HIE privileges is available to access the system. The US health care system is undergoing change with the introduction of exchanging health care information between organizations across geographic regions. Having the right information at the right time and place ensures that a full clinical picture is available at the point of care in order for professionals to make the best possible health care decisions. Incomplete or missing information causes at least one-tenth of the errors and adverse events that occur during patient visits. 23 In addition, ED efficiency is impaired because almost one-third of the visits have missing information that results in increased time spent in the emergency department (an average of 1.2 hours). 24 Clinicians and staff are forced to spend time looking for missing information, and this time could be better spent delivering care to patients. 25 The Institute of Medicine reports that providing patient information through increased technology will facilitate coordinated communication and ultimately increase safety. 26 Access to critical patient information is necessary for nurses because emergency nurses are often the first professional contact for patients entering emergency departments. We present the following recommendations to help achieve the potential benefits of HIE, help solve the problems that impede workflow that are deterring HIE use, and increase the role of emergency nurses to their full potential in using HIE in patient care. RECOMMENDATION 1
The first recommendation is to grant emergency nurses unrestricted HIE access privileges. Nurses need all the available patient information at the point of care to maximize the delivery of nursing care. There are multiple patient events that could benefit from emergency nurses using HIE. For example, emergency nurses frequently care for comatose patients or patients who are poor historians, and the nurses are at a disadvantage when denied access to all the available health information. The same occurs when ordering protocols and repeating tests because the emergency nurse does not have access to the patient's most recent results and treatments available in the HIE
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system. Without HIE access, emergency nurses may not be aware of the patient's medication history, and managing medication reconciliation becomes even more time-consuming with the added risk of duplicating a patient's existing prescriptions. Limiting access to critical patient information by excluding emergency nurses from using HIE is detrimental to the decision-making process and impedes efforts to decrease errors. There is an increased risk of missing important pieces of patient information when members of the team are unsure whom has HIE access or whom has accessed the HIE for patient information. Emergency physicians reported that the more information available at the point of care, the better the decision making; therefore, emergency nurses should have the same benefit of the patient's full health record. Improving patient outcomes requires the participation of all members of the health care team. RECOMMENDATION 2
The second recommendation is to amend security policies governing hospital emergency departments so that HIE access privileges are granted to all emergency nurses. Although security of all electronic information is always a risk concern, placing undue restrictions on nurses caring for patients is not in the best interests of quality patient care or safe delivery of care. The nurses are currently using electronic documentation systems that require security policies that should include access to HIE systems. To encourage HIE use, the process to acquire HIE privileges should be easy for the nurse. The granting of HIE privileges to all members of the health care team needs to be seamless and integrated into the workflow if HIE usage rates are going to increase to ensure sustainability of HIE systems. Workarounds such as other physicians or charge nurses accessing HIE information because HIE access is restricted increase the potential for errors and cause confusion and frustration. The result is an HIE system that is not being fully used; moreover, available patient information is not being used for the patient's benefit. RECOMMENDATION 3
The third recommendation is to provide education and communication about the HIE system to emergency nurses. As end users of electronic documentation systems, the nurse is frequently the resource and go-to person on the unit to provide information, troubleshoot problems, or help enter information into the electronic documentation systems. Emergency physicians recognized that nurse practitioners seem to use the HIE system more than physicians do, although the nurse practitioners had not received any additional hands-on training. In addition, physicians who
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did not have HIE access or were too busy seeing patients relied on nurse practitioners or charge nurses with HIE privileges to retrieve or print information. Nurses as active HIE users can help address the problems of using HIE by sharing their knowledge of the system, much the same as they currently do with electronic health records. Providing emergency nurses with ongoing education sessions, as well as having nurses as HIE champions, is a step to increasing HIE use and decreasing inefficient workarounds. RECOMMENDATION 4
The fourth recommendation is to include emergency nurses as active partners with full participation in the design, implementation, and evaluation of HIE systems. Nurses are key players in obtaining information when a patient enters the emergency department. Correcting the flaws in the HIE system is necessary if HIE is going to be incorporated into the workflow of emergency departments. The emergency physicians indicated that they struggled with not knowing the full functional abilities of the HIE system. HIE use in emergency departments is reported to be as low as 15%, 21 which indicates that design flaws are problematic and causing inappropriate workarounds. The current practice of relying on the charge nurse to pull or print HIE information is inefficient, compromises workflow, and increases the risk of errors when the charge nurse is not at the bedside caring for the patients. Furthermore, using the charge nurse in a clerical role is an inefficient use of expertise and resources. The emergency physicians reported that chest pain nurses were the primary resource in providing a clearer picture of the patient's history by reviewing HIE data and extracting needed information for the physicians. Therefore involving emergency nurses in the design and implementation phases can help correct flaws that impede use and can help the emergency physicians obtain HIE information without the aid of nurses. This would also reduce the wasteful and time-consuming practice of printing and shredding patient information.
Conclusion
Emergency nurses have the expertise to help achieve successful integration of HIE into the workflow of emergency departments, provide more information at the point of care to reduce errors, and help obtain the best possible outcomes for patients. However, organizations must acknowledge nurses as full partners in the health care team and grant nurses unrestricted HIE access privileges. The success of HIE depends on emergency nurses being recognized as problem solvers and patient advocates who
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need to be involved in the design, implementation, and evaluation of HIE systems. REFERENCES 1. Kopala B, Mitchell ME. Use of digital health records raises ethics concerns. JONAS Healthc Law Ethics Regul. 2011;13(3):84-9. 2. Vest JR, Jasperson J. What should we measure? Conceptualizing usage in health information exchange J Am Med Inform Assoc. 2010;17(3):302-7. 3. Dixon BE, Zafar A, Overhage JM. A framework for evaluating the costs, effort, and value of nationwide health information exchange. J Am Med Inform Assoc. 2010;17(3):295-301. 4. Adler-Milstein J, Bates DW, Jha AK. A survey of health information exchange organizations in the United States: implications for meaningful use. Ann Intern Med. 2011;154(10):666-71. 5. Blumenthal D. Stimulating the adoption of health information technology. N Engl J Med. 2009;360(15):1477-9. 6. Greene J. Obama's $19 billion boon to health care IT: mammoth investment fasttracks electronic health records. Ann Emerg Med. 2009;53(5):24A-7A. 7. Health IT.gov. Office of the national coordinator EHR incentives & certification: meaningful use definition & objectives. Available at: http:// www.healthit.gov/providers-professionals/meaningful-use-definitionobjectives. Accessed May 15, 2012. 8. Conrad D, Schneider JS. Enhancing the visibility of NP practice in electronic health records. J Nurs Pract. 2011;7(10):832-8. 9. Klein CA. Electronic health records 101. Nurse Pract. 2011;36(1):15-8. 10. Catalano K, Fickenscher K. Complying with the 2008 national patient safety goals. AORN J. 2008;87(3):547-56. 11. Maenpaa T, Asikainen P, Gissler M. The utilization rate of the regional health information exchange: how it impacts on health care delivery outcomes. J Public Health Manag Pract. 2012;18(3):215-23. 12. Johnson KB, Gadd C. Playing smallball: Approaches to evaluating pilot health information exchange systems. J Biomed Inform. 2007;40(6 suppl):S21-6. 13. Shapiro JS, Kannry J, Lipton M. Approaches to patient health information exchange and their impact on emergency medicine. Ann Emerg Med. 2006;48(4):426-32. 14. Kaelber DC, Bates DW. Health information exchange and patient safety. J Biomed Inform. 2007;40(6 suppl):S40-5. 15. Wright A, Soran C, Jenter CA, Volk LA, Bates DW, Simon SR. Physician attitudes toward health information exchange: results of a statewide survey. J Am Med Inform Assoc. 2010;17(1):66-70. 16. Hincapie AL, Warholak TL, Murcko AC, Slack M, Malone DC. Physicians’ opinions of a health information exchange. J Am Med Inform Assoc. 2011;18(1):60-5. 17. Harrison MI, Koppel R, Bar-Lev S. Unintended consequences of information technologies in health care—an interactive sociotechnical analysis. J Am Med Inform Assoc. 2007;14(5):542-9. 18. Marchibroda JM. Health information exchange policy and evaluation. J Biomed Inform. 2007;40(6 suppl):S11-6. 19. Koppel R, Kreda DA. Healthcare IT usability and suitability for clinical needs: challenges of design, workflow, and contractual relations. Stud Health Technol Inform. 2010;157:7-14.
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20. Sensmeier J. Alliance for nursing informatics statement to the Robert Wood Johnson foundation initiative on the future of nursing: acute care, focusing on the area of technology, Oct 19, 2009. Comput Inform Nurs. 2010;28(1):63-7. 21. Johnson KB, Unertl KM, Chen Q. Health information exchange usage in emergency departments and clinics: the who, what and why. J Am Med Inform Assoc. 2011;18(5):690-7. 22. Hripcsak G, Vawdrey DK, Fred MR, Bostwick SB. Use of electronic clinical documentation: time spent and team interactions. J Am Med Inform Assoc. 2011;18(2):112-7.
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23. Elder NC, Vonder Meulen MB, Cassedy A. The identification of medical errors by family physicians during outpatient visits. Ann Fam Med. 2004;2(2):125-9. 24. Stiell A, Forster AJ, Stiell IG, Van Walraven C. Prevalence of information gaps in the emergency department and the effect on patient outcomes. CMAJ. 2003;169(10):1023-8. 25. Smith PC, Araya-Guerra R, Bublitz C. Missing clinical information during primary care visits. JAMA. 2005;293(5):565-71. 26. Institute of Medicine. The future of emergency care in the United States health system. Ann Emerg Med. 2006;48(2):115-20.
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September 2013
THE POTENTIAL OF HEALTH INFORMATION EXCHANGE TO ASSIST EMERGENCY NURSES Authors: Shirley A. Thorn, PhD, MN, MAdmin, RN, and Michael A. Carter, DNSc, DNP, Memphis, TN
Health information exchange holds the promise of sharing critical information about patients across organizations. We have found that emergency nurses have little or no involvement in using health information exchange and, often, they are not granted access by individual hospital policies. Yet,
emergency nurses need to know this information and must have full access to health information exchange. We provide recommendations to ensure that emergency nurses are able to reach their full potential in using health information exchange to care for patients.
rs J is a 72-year-old woman who presents to the emergency department complaining of a nontraumatic sudden-onset headache that she describes as a sharp pain in her head that began a couple of days ago. She has taken acetaminophen tablets and “something” from a prescription bottle with little relief. In the course of obtaining a history, the emergency nurse learns that Mrs J has a history of headaches. Mrs J was seen in another hospital's emergency department yesterday with the same chief complaint. She states that she had “some blood tests” and a computed tomography (CT) scan before she received “a shot” and was discharged home with another prescription, but she does not remember the name of the prescription. Mrs J's medication history is vague, and she does not have a list of her current medications. The emergency nurse needs to retrieve Mrs J's health files to review her history, especially her prior test results and medications from her emergency visit the previous day. The nurse is aware that the emergency department has a health information exchange (HIE) system, but unfortunately, hospital policies do not grant access privileges to emergency nurses. The nurse alerts the emergency physician that Mrs J's information and test results from the previous day may be in the HIE system. The emergency physician was hired 4 months ago and has not received access privileges for
the HIE system. The other 2 physicians in the department have access privileges, but they are busy with critically ill patients. It is late in the evening, and the emergency nurse knows that there will be a considerable delay in receiving Mrs J's faxed test results from the other hospital. The nurse wonders whether the tests should just be repeated. The preceding example shows the experience of 1 emergency nurse in a hospital emergency department with HIE. Emergency nurses in this organization are not granted access privileges to the HIE system, resulting in information not being available at the point of care.
M
Shirley A. Thorn is Assistant Professor, Loewenberg School of Nursing, University of Memphis, Memphis, TN. Michael A. Carter is University Distinguished Professor, College of Nursing, University of Tennessee Health Science Center, Memphis, TN. For correspondence, write: Shirley A. Thorn, PhD, MN, MAdmin, RN, 7581 Cross Village Dr, Germantown, TN 38138, USA; E-mail: sathorn@ memphis.edu. J Emerg Nurs 2013;39:e91-e96. Available online 29 January 2013. 0099-1767/$36.00 Copyright © 2013 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2012.12.007
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Introduction
Emergency nurses must frequently make use of information technology to perform their work. However, there are sometimes confusing policies, procedures, and risks involved with the use of technology. 1 One component of this technology is the new HIE systems. HIE is the electronic exchange of health information between participating organizations and providers, 2,3 including public health systems. 4 Nurses can play a key role in HIE, but they need to understand the implications of electronic health records and HIE to be effective players in using technology in the care of patients. The American Recovery and Reinvestment Act of 2009 contains a section referred to as the HITECH (Health Information Technology for Economic and Clinical Health) Act that allocated $19 billion for information technology, specifically, the expansion and adoption of electronic health records and HIE. 5 Incentive payments through the Medicare and Medicaid systems support the implementation of health care information technology, meaningful use of electronic health records, and HIE. 5,6 A certified electronic health record has the capability and security features to attain the criteria for meaningful use. 7 “Meaningful use” is a technical term that means the electronic record must have the components of (1) collecting demographic data, diagnostic test results, and
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TABLE
HIE access: Personnel granted access privileges in emergency departments Charge nurses ‡
NPs/ PAs
Emergency physicians §
Chest pain nurses ‖
Scribes ¶
Site*
Emergency nurses †
EHR system #
A B C D
No Yes No No
No Yes Yes No
—** Yes Yes Yes
Some Some Some All
— Yes Yes —
— Yes — Yes ††
No Yes Yes No
EHR, Electronic health record; NPs, nurse practitioners; PAs, physician assistants. * Four selected study sites with HIE access privileges governed by hospital policies. † Emergency nurses at site B could apply for access; sites A, C, and D denied nurses access. ‡ Sites B and C granted charge nurses access. § Emergency physicians at all sites could apply for access privileges, but not all the physicians at sites A, B, and C had access; all the physicians at site D had access. ‖ Registered nurses were employed specifically in chest pain clinics. Sites A and D did not have designated chest pain clinics separate from the emergency department. ¶ Sites B and D hired scribes who were granted HIE access privileges. # All 4 study sites had electronic health record systems, but 2 sites had not implemented electronic documentation in the emergency department at the time of the study. ** Site A did not hire nurse practitioners or physician assistants in the emergency department. †† Site D hired scribes in preparation for the implementation of electronic documentation with the expectation that physician productivity would decline with the electronic health record system.
electronic prescriptions; (2) providing decision support and clinical quality measurement reports; and (3) having HIE capabilities. 4,8,9 As can be seen, these components are the very ones that emergency nurses use in their role. Nurses have the potential to influence achieving meaningful use criteria and HIE success if they are allowed to be full participants in using technology to deliver patient care. HIE use is being promoted as technology that has the potential of delivering benefits for patients, such as improving continuity of care. 1 One of the goals of meaningful use is to improve quality of care. 7 The Institute of Medicine and Joint Commission have established National Patient Safety Goals to increase health care technology that shares information and improves patient safety. 10 HIE has the potential to reduce costs and improve safety by providing information at the point of care. 11–15 So far, this potential has not been fully realized. 2,11,16–18 HIE can also have design flaws that cause errors or disrupt workflow. 17,19 Nurses could help minimize these flaws and should be full partners in the design and implementation of HIE systems 20 because hospitals and ambulatory care facilities are where HIE is used. 13,21 Nurses are the largest contributor of notes to the electronic health record, 22 which is the source of data for HIE. Therefore nurses need to have HIE access and be active partners in all facets of HIE systems if meaningful use is to succeed. 20 Background
Little has been reported concerning how emergency nurses use HIE. We recently conducted an institutional review board–approved study about how emergency physicians use
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HIE in their daily practice (S.A.Thorn, unpublished data, January 2013). In that study we learned a great deal about how nurses use HIE. We studied 4 large urban emergency departments, including a Level I Trauma Center, located within a major metropolitan area. A centralized HIE database was implemented in the region in 2006 that linked over 450 providers in 15 clinics and 9 major hospitals including all the studied hospitals. We found that emergency nurses had a variety of roles in HIE use in these hospitals. Role of Emergency Nurse
The most common reason that emergency nurses did not use HIE was a lack of access privileges. Individual hospital policies controlled access with user logins and passwords. The emergency physicians reported that they considered the HIE system to be secure and important for care, but they could not understand why emergency nurses lacked access. Three of the four study sites did not allow emergency nurses HIE access, although 2 of the sites granted access privileges to charge nurses (Table). Two hospitals hired scribes who electronically documented information for emergency physicians. The scribes had HIE access, but the emergency nurses did not have access at 1 of the sites. One of the complaints of the emergency physicians was the uncertainty over whom had HIE access privileges and whom did not have access. The problems with HIE access were not restricted to just emergency nurses. There were emergency physicians who did not have HIE access because of the time and difficulty obtaining privileges. As a workaround, the emergency physicians without access relied on other physicians to log
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into the HIE system for them, or if charge nurses were granted access, the charge nurse retrieved patient data in the HIE system. In other instances where residents did not have HIE privileges, emergency physicians had to log into the HIE system and retrieve patient information for the residents. All the workarounds were time-consuming, inefficient, and frustrating for the end-users of the HIE system. Emergency nurses at 1 hospital site could obtain HIE privileges if they wanted access; however, 1 of the physicians reported that “most of them don't have the time or inclination.” This person went on to say, “I don't know if it's any particular benefit to them.” One of the issues may be the lack of communication focused on emergency nurses using HIE and the value of having patient information available at the point of care. The process of receiving access privileges was a source of frustration. One emergency physician said that he “had heard almost nothing” about HIE and he never heard anyone talk about how helpful HIE was. There was little education on the HIE system during the implementation phase, and emergency physicians were not familiar with the full functional features, such as trending values. Overall, there was minimal HIE education and an absence of champions for the users of HIE. Emergency nurses most likely did not receive any information regarding the HIE system because they had not been granted access privileges. Nurses at the 2 sites with designated chest pain clinics did have HIE access. The role of the chest pain nurses was described as reviewing the patient's HIE data and identifying whether there was pertinent information. If the chest pain nurse identified pertinent information, such as a recent electrocardiogram tracing, the report was brought to the attention of the emergency physician caring for the patient. In some cases HIE information was printed and presented to the emergency physician. The charge nurse's role was more clerical, such as printing information from the HIE system for the emergency physician, than decision making. The physicians explained that the charge nurse printed HIE information that he or she “feels would be pertinent to the most recent discharge summary” or nurses printed reports requested by the emergency physician. Because the charge nurse was not the nurse caring for the patient, it was unclear whether all the appropriate information was included. In other cases the charge nurse printed information before the emergency physician examined the patient, but this process was not consistent, and there was no system to ensure that someone had checked to determine whether there was HIE information for the patient. There was also uncertainty about how the printed HIE information was managed in the emergency department. Printed HIE information was
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thought to be either shredded or sent to the unit if the patient was admitted. The practice of printing HIE reports was a workaround and was inefficient. Discussion and Implications
The most frequent complaint was the issue of the HIE system not being user-friendly. There were too many clicks to find information, or information was missing. However, nurse practitioners used HIE quite frequently in the emergency departments that had nurse practitioners. The higher HIE usage rate was attributed to nurse practitioners being assigned to the fast-track areas where patients frequently visit multiple facilities for minor complaints, and HIE is more valuable in this situation. On other occasions, the emergency physician would ask the charge nurse or nurse practitioner to log in and find HIE information while the physician saw patients. Overall, emergency physicians attributed low usage rates to a system that was not intuitive and obtaining access privileges was cumbersome and time-consuming. Medication histories were frequently a problem. Patients arrived at the emergency department without a current list of medications, or they were unable to provide information. Emergency nurses had the difficult and timeconsuming task of phoning pharmacies in an attempt to clarify the patient's current medications. In addition, the emergency nurses also had the responsibility of entering updated medication histories into the electronic health record for data entry into the HIE system. The lack of updated medication histories was an HIE flaw that resulted in further inefficiencies and delays in processing patients through the emergency department. Emergency departments used protocols to move patients through the department more quickly by having nurses order tests and having the results available when the emergency physician examined the patient. Although some emergency physicians viewed the protocols as timesaving, they also viewed the protocols as wasteful. Without HIE access, emergency nurses are not able to check the patient's history or whether the patient recently had the same tests at another facility before ordering the protocol. As a result, the ordered tests may not be necessary, which further reduces efficiency. Recommendations for Emergency Nurses
In the example, there are a number of questions related to Mrs J's care because the nurse did not have HIE access. What laboratory tests were performed at the other hospital,
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and what were the results? What were the findings from the CT scan? Why did Mrs J receive a new prescription during her visit? What was the medication injection? Did a consultant see Mrs J? Is there an updated medication history recorded in the HIE system? A lack of information from Mrs J's visit to another emergency department the previous day hampered the emergency nurse's efforts to have a complete clinical picture of Mrs J's chief complaint. Treatment is delayed while the team discusses whether the tests should be repeated or whether someone in the emergency department with HIE privileges is available to access the system. The US health care system is undergoing change with the introduction of exchanging health care information between organizations across geographic regions. Having the right information at the right time and place ensures that a full clinical picture is available at the point of care in order for professionals to make the best possible health care decisions. Incomplete or missing information causes at least one-tenth of the errors and adverse events that occur during patient visits. 23 In addition, ED efficiency is impaired because almost one-third of the visits have missing information that results in increased time spent in the emergency department (an average of 1.2 hours). 24 Clinicians and staff are forced to spend time looking for missing information, and this time could be better spent delivering care to patients. 25 The Institute of Medicine reports that providing patient information through increased technology will facilitate coordinated communication and ultimately increase safety. 26 Access to critical patient information is necessary for nurses because emergency nurses are often the first professional contact for patients entering emergency departments. We present the following recommendations to help achieve the potential benefits of HIE, help solve the problems that impede workflow that are deterring HIE use, and increase the role of emergency nurses to their full potential in using HIE in patient care. RECOMMENDATION 1
The first recommendation is to grant emergency nurses unrestricted HIE access privileges. Nurses need all the available patient information at the point of care to maximize the delivery of nursing care. There are multiple patient events that could benefit from emergency nurses using HIE. For example, emergency nurses frequently care for comatose patients or patients who are poor historians, and the nurses are at a disadvantage when denied access to all the available health information. The same occurs when ordering protocols and repeating tests because the emergency nurse does not have access to the patient's most recent results and treatments available in the HIE
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system. Without HIE access, emergency nurses may not be aware of the patient's medication history, and managing medication reconciliation becomes even more time-consuming with the added risk of duplicating a patient's existing prescriptions. Limiting access to critical patient information by excluding emergency nurses from using HIE is detrimental to the decision-making process and impedes efforts to decrease errors. There is an increased risk of missing important pieces of patient information when members of the team are unsure whom has HIE access or whom has accessed the HIE for patient information. Emergency physicians reported that the more information available at the point of care, the better the decision making; therefore, emergency nurses should have the same benefit of the patient's full health record. Improving patient outcomes requires the participation of all members of the health care team. RECOMMENDATION 2
The second recommendation is to amend security policies governing hospital emergency departments so that HIE access privileges are granted to all emergency nurses. Although security of all electronic information is always a risk concern, placing undue restrictions on nurses caring for patients is not in the best interests of quality patient care or safe delivery of care. The nurses are currently using electronic documentation systems that require security policies that should include access to HIE systems. To encourage HIE use, the process to acquire HIE privileges should be easy for the nurse. The granting of HIE privileges to all members of the health care team needs to be seamless and integrated into the workflow if HIE usage rates are going to increase to ensure sustainability of HIE systems. Workarounds such as other physicians or charge nurses accessing HIE information because HIE access is restricted increase the potential for errors and cause confusion and frustration. The result is an HIE system that is not being fully used; moreover, available patient information is not being used for the patient's benefit. RECOMMENDATION 3
The third recommendation is to provide education and communication about the HIE system to emergency nurses. As end users of electronic documentation systems, the nurse is frequently the resource and go-to person on the unit to provide information, troubleshoot problems, or help enter information into the electronic documentation systems. Emergency physicians recognized that nurse practitioners seem to use the HIE system more than physicians do, although the nurse practitioners had not received any additional hands-on training. In addition, physicians who
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did not have HIE access or were too busy seeing patients relied on nurse practitioners or charge nurses with HIE privileges to retrieve or print information. Nurses as active HIE users can help address the problems of using HIE by sharing their knowledge of the system, much the same as they currently do with electronic health records. Providing emergency nurses with ongoing education sessions, as well as having nurses as HIE champions, is a step to increasing HIE use and decreasing inefficient workarounds. RECOMMENDATION 4
The fourth recommendation is to include emergency nurses as active partners with full participation in the design, implementation, and evaluation of HIE systems. Nurses are key players in obtaining information when a patient enters the emergency department. Correcting the flaws in the HIE system is necessary if HIE is going to be incorporated into the workflow of emergency departments. The emergency physicians indicated that they struggled with not knowing the full functional abilities of the HIE system. HIE use in emergency departments is reported to be as low as 15%, 21 which indicates that design flaws are problematic and causing inappropriate workarounds. The current practice of relying on the charge nurse to pull or print HIE information is inefficient, compromises workflow, and increases the risk of errors when the charge nurse is not at the bedside caring for the patients. Furthermore, using the charge nurse in a clerical role is an inefficient use of expertise and resources. The emergency physicians reported that chest pain nurses were the primary resource in providing a clearer picture of the patient's history by reviewing HIE data and extracting needed information for the physicians. Therefore involving emergency nurses in the design and implementation phases can help correct flaws that impede use and can help the emergency physicians obtain HIE information without the aid of nurses. This would also reduce the wasteful and time-consuming practice of printing and shredding patient information.
Conclusion
Emergency nurses have the expertise to help achieve successful integration of HIE into the workflow of emergency departments, provide more information at the point of care to reduce errors, and help obtain the best possible outcomes for patients. However, organizations must acknowledge nurses as full partners in the health care team and grant nurses unrestricted HIE access privileges. The success of HIE depends on emergency nurses being recognized as problem solvers and patient advocates who
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need to be involved in the design, implementation, and evaluation of HIE systems. REFERENCES 1. Kopala B, Mitchell ME. Use of digital health records raises ethics concerns. JONAS Healthc Law Ethics Regul. 2011;13(3):84-9. 2. Vest JR, Jasperson J. What should we measure? Conceptualizing usage in health information exchange J Am Med Inform Assoc. 2010;17(3):302-7. 3. Dixon BE, Zafar A, Overhage JM. A framework for evaluating the costs, effort, and value of nationwide health information exchange. J Am Med Inform Assoc. 2010;17(3):295-301. 4. Adler-Milstein J, Bates DW, Jha AK. A survey of health information exchange organizations in the United States: implications for meaningful use. Ann Intern Med. 2011;154(10):666-71. 5. Blumenthal D. Stimulating the adoption of health information technology. N Engl J Med. 2009;360(15):1477-9. 6. Greene J. Obama's $19 billion boon to health care IT: mammoth investment fasttracks electronic health records. Ann Emerg Med. 2009;53(5):24A-7A. 7. Health IT.gov. Office of the national coordinator EHR incentives & certification: meaningful use definition & objectives. Available at: http:// www.healthit.gov/providers-professionals/meaningful-use-definitionobjectives. Accessed May 15, 2012. 8. Conrad D, Schneider JS. Enhancing the visibility of NP practice in electronic health records. J Nurs Pract. 2011;7(10):832-8. 9. Klein CA. Electronic health records 101. Nurse Pract. 2011;36(1):15-8. 10. Catalano K, Fickenscher K. Complying with the 2008 national patient safety goals. AORN J. 2008;87(3):547-56. 11. Maenpaa T, Asikainen P, Gissler M. The utilization rate of the regional health information exchange: how it impacts on health care delivery outcomes. J Public Health Manag Pract. 2012;18(3):215-23. 12. Johnson KB, Gadd C. Playing smallball: Approaches to evaluating pilot health information exchange systems. J Biomed Inform. 2007;40(6 suppl):S21-6. 13. Shapiro JS, Kannry J, Lipton M. Approaches to patient health information exchange and their impact on emergency medicine. Ann Emerg Med. 2006;48(4):426-32. 14. Kaelber DC, Bates DW. Health information exchange and patient safety. J Biomed Inform. 2007;40(6 suppl):S40-5. 15. Wright A, Soran C, Jenter CA, Volk LA, Bates DW, Simon SR. Physician attitudes toward health information exchange: results of a statewide survey. J Am Med Inform Assoc. 2010;17(1):66-70. 16. Hincapie AL, Warholak TL, Murcko AC, Slack M, Malone DC. Physicians’ opinions of a health information exchange. J Am Med Inform Assoc. 2011;18(1):60-5. 17. Harrison MI, Koppel R, Bar-Lev S. Unintended consequences of information technologies in health care—an interactive sociotechnical analysis. J Am Med Inform Assoc. 2007;14(5):542-9. 18. Marchibroda JM. Health information exchange policy and evaluation. J Biomed Inform. 2007;40(6 suppl):S11-6. 19. Koppel R, Kreda DA. Healthcare IT usability and suitability for clinical needs: challenges of design, workflow, and contractual relations. Stud Health Technol Inform. 2010;157:7-14.
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23. Elder NC, Vonder Meulen MB, Cassedy A. The identification of medical errors by family physicians during outpatient visits. Ann Fam Med. 2004;2(2):125-9. 24. Stiell A, Forster AJ, Stiell IG, Van Walraven C. Prevalence of information gaps in the emergency department and the effect on patient outcomes. CMAJ. 2003;169(10):1023-8. 25. Smith PC, Araya-Guerra R, Bublitz C. Missing clinical information during primary care visits. JAMA. 2005;293(5):565-71. 26. Institute of Medicine. The future of emergency care in the United States health system. Ann Emerg Med. 2006;48(2):115-20.
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