DNP 825 Module 4 Interoperability and Health Information Exchange Example

The Scan Was Already Done: Health Information Exchange, Repeat Imaging and Getting Outside Records Into the Emergency Workflow

Student Name

Doctor of Nursing Practice Program, Aspen University

DNP 825: Health Information Management and Informatics

Instructor Name

Month Day, Year

The Scan Was Already Done: Health Information Exchange, Repeat Imaging and Getting Outside Records Into the Emergency Workflow

Patients move among hospitals, clinics and emergency departments, but their records often do not. When an emergency clinician cannot see a CT scan done three days earlier at another hospital, the scan may be repeated, exposing the patient to more radiation, delay and cost. Health information exchange, the electronic sharing of clinical information across organizations, is meant to prevent this. This paper examines interoperability in a composite community emergency department that belongs to a regional health information exchange, reviews evidence on the benefits of exchange, analyzes why available information is still not used, and proposes changes to bring outside records into the clinical workflow.

The Problem

The emergency department handles roughly 52,000 visits annually, and a review of three months of imaging found that 11% of patients who had a CT scan had undergone a CT of the same body region at another hospital in the region within the previous 30 days. The department has had access to the regional exchange for three years, through a separate portal that requires a second login. Audit logs showed that clinicians queried the exchange for fewer than 6% of visits. Nurses reported that they rarely had time to search it at triage, and physicians said that by the time they looked, orders were already placed.

The pattern mattered most for patients who move among several hospitals in the region, such as those with sickle cell disease, chronic pain or complex heart failure, who were also the patients most likely to receive repeated imaging and radiation over time.

Evidence on Benefits

Research supports the expected benefits. A study of emergency department visits in two states found that repeat imaging was common, occurring in 14.7% of CT cases, 20.7% of ultrasound cases and 19.5% of chest x-ray cases, and that exchange was associated with reductions in repeat imaging of 8.7, 9.1 and 13.0 percentage points respectively, reductions of 44% to 67% relative to the average (Lammers et al., 2014). An updated systematic review pooled 24 studies; the seven strong enough to support causal conclusions each found at least one advantage of exchange, among them avoided duplicate tests and imaging, savings and safer care, and none found harm; community exchanges were more likely than vendor-mediated exchanges to show benefit (Menachemi et al., 2018).

Why Available Information Goes Unused

Connectivity alone does not produce benefit. Several barriers keep clinicians from using exchange data. Separate portals and logins interrupt workflow in a setting where minutes matter. Search results may return long lists of documents without clear indication of what is new or relevant. Images may be available only as reports rather than viewable studies. And information may be withheld or delayed by organizations or vendors for competitive or technical reasons. A survey of leaders of health information exchange organizations found that information blocking, practices that interfere with the exchange of electronic health information, was widely reported among both electronic health record vendors and health care organizations, and it examined policy strategies to address it (Adler-Milstein & Pfeifer, 2017). Federal rules have since prohibited information blocking, but organizational and technical barriers remain.

Proposed Changes

The proposed changes focus on workflow. First, the exchange query runs automatically when a patient is registered, using the patient's demographic information, so that results are waiting rather than requiring a search. Second, the emergency department's electronic record displays a banner at triage when outside imaging or visits from the past 30 days are found, with a single click to view them inside the record rather than in a separate portal. Third, triage nurses are trained to note the banner and ask patients about recent care elsewhere, documenting findings in the triage note so that physicians see them before ordering. Fourth, radiology agrees to import outside images for comparison when a repeat study is being considered, which may make the repeat unnecessary. Fifth, the department works with the exchange to prioritize imaging and emergency visit data, since those are most relevant to emergency decisions.

The Nurse's Role at Triage

Triage nurses are the first clinicians to see most emergency patients and are well placed to make outside information useful. In the redesigned workflow, the triage nurse sees the banner, opens the summary of recent outside visits and imaging with one click, and adds a short line to the triage note, for example that a CT of the abdomen was done at another hospital four days ago for similar pain and that the report is available. The nurse also asks the patient to confirm the history, since exchange data can be incomplete or attached to the wrong person, and documents any discrepancy.

This small addition changes the information available at the moment orders are placed. Rather than depending on a physician to search a separate portal after deciding what to order, the relevant history is already in front of everyone involved. Nurse educators will include the workflow in triage competency training, and a monthly audit will check how often the triage note records outside imaging when the banner appears.

Measures and Privacy

Measures include the proportion of visits with an automatic query, the proportion in which outside records were viewed, and the rate of repeat CT within 30 days of an outside CT of the same body region. Radiation exposure and imaging cost avoided will be estimated. Privacy safeguards include limiting automatic queries to patients registered for treatment, logging every access and auditing access monthly, and honoring patients' choices where state law allows them to opt out of exchange.

Conclusion

The composite emergency department had access to a regional health information exchange but used it rarely, and one in nine patients undergoing CT had recently been scanned elsewhere. Evidence shows that exchange can reduce repeat imaging substantially when information reaches clinicians. The barriers are mainly in workflow, and the remedies are automatic queries, integrated display, triage nursing practice and radiology collaboration. Interoperability becomes valuable when outside information appears at the moment decisions are made.

References

Adler-Milstein, J., & Pfeifer, E. (2017). Information blocking: Is it occurring and what policy strategies can address it? The Milbank Quarterly, 95(1), 117-135. https://doi.org/10.1111/1468-0009.12247

Lammers, E. J., Adler-Milstein, J., & Kocher, K. E. (2014). Does health information exchange reduce redundant imaging? Evidence from emergency departments. Medical Care, 52(3), 227-234. https://doi.org/10.1097/MLR.0000000000000067

Menachemi, N., Rahurkar, S., Harle, C. A., & Vest, J. R. (2018). The benefits of health information exchange: An updated systematic review. Journal of the American Medical Informatics Association, 25(9), 1259-1265. https://doi.org/10.1093/jamia/ocy035