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"Even at our best, we are only out for ourselves."

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Unmasking the Motives of the Good Samaritan

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Unmasking the Motives of the Good Samaritan

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When we see someone in distress, we experience our own personal feelings of distress, such as shock, alarm, worry, or fear. This unpleasant emotional arousal compels us to want to increase our own well-being by reducing these feelings. One way to achieve this goal is to reduce the other person's current distress. An example of this would be the seemingly selfless act of giving money to a beggar to relieve one's own discomfort at seeing the beggar in need. Helping, then, is only the quickest means to reducing our own distress. What appears to be altruistically motivated behavior is really only self interest in disguise. Human beings, in essence, act from self-interest and self-interest alone.

Andre, C., & Velasquez, M. (2015). Unmasking the Motives of the Good Samaritan. Scu.edu. https://www.scu.edu/ethics/ethics-resources/ethical-decision-making/unmasking-the-motives-of-the-good-samaritan/.

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The Three Frameworks to Guide Ethical Decision Making

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The Three Frameworks to Guide Ethical Decision Making

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There are three broad frameworks to guide ethical decision making: The Consequentialist Framework; The Duty Framework; and the Virtue Framework.

In the Consequentialist framework, we focus on the future effects of the possible courses of action, considering the people who will be directly or indirectly affected. We ask about what outcomes are desirable in a given situation, and consider ethical conduct to be whatever will achieve the best consequences. The person using the Consequences framework desires to produce the most good.

In the Duty framework, we focus on the duties and obligations that we have in a given situation, and consider what ethical obligations we have and what things we should never do. Ethical conduct is defined by doing one’s duties and doing the right thing, and the goal is performing the correct action.

In the Virtue framework, we try to identify the character traits (either positive or negative) that might motivate us in a given situation. We are concerned with what kind of person we should be and what our actions indicate about our character. We define ethical behavior as whatever a virtuous person would do in the situation, and we seek to develop similar virtues.

Brown University. (2013). A framework for making ethical decisions. https://www.brown.edu/academics/science-and-technology-studies/framework-making-ethical-decisions

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A patient who is injured during medical treatment may be able to bring a successful claim against a health care provider if the patient can prove that the injury resulted from the provider’s failure to follow the accepted standard of care. The duty of care generally requires that the provider use reasonably expected knowledge and judgment in the treatment of the patient, and typically would also require the adept use of the facilities at hand and options for treatment. Experts are hired by the litigating parties to assist the court in determining the applicable standard of care.

The University of Washington School of Medicine. (2014). A case-based approach to ethical decision-making. https://depts.washington.edu/bhdept/ethics-medicine/bioethics-topics/detail/56

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From a clinical ethics perspective, informed consent is a communication process, and should not simply be treated as a required form for the patient’s signature. Similarly, the legal concept of informed consent refers to a state of mind, i.e., understanding the information provided to make an informed decision.  Health care facilities and providers use consent forms to document the communication process. From a provider’s perspective, a signed consent form can be valuable evidence the communication occurred and legal protection in defending against a patient’s claim of a lack of informed consent.

The University of Washington School of Medicine. (2014). A case-based approach to ethical decision-making. https://depts.washington.edu/bhdept/ethics-medicine/bioethics-topics/detail/56

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Ethics provides a set of standards for behavior that helps us decide how we should act in certain situations. Ethics is all about making choices and providing reasoning as to why we should make these choices.

Utilitarianism: Utilitarianism is one of the most common approaches to making ethical decisions, especially decisions with consequences that affects large groups of people, in part because it instructs us to weigh the different amounts of good and bad that will be produced by our action. This conforms to our feeling that some good and some bad will necessarily be the result of our action and that the best action will be that which produces the greatest amount of good and does the least amount of harm for all who are involved.

The Common Good Approach: This perspective revolves around the idea that our actions should contribute to ethical communal life. The argument for this approach is that the best society should be guided by the “general will” of the people which would then produce what is best for the people as a whole. This approach to ethics underscores the networked aspects of society and emphasizes respect and compassion for others, especially those who are more vulnerable.

The Egoistic Approach: One variation of the utilitarian approach is known as ethical egoism, or the ethics of self- interest. In this approach, an individual often uses utilitarian calculation to produce the greatest amount of good for him or herself. The argument for this approach is that self-interest is a prerequisite to self-respect as well as respect for others. The pursuit of self-interest is seen as leading to the benefit of society, although the benefit of society is seen only as the fortunate byproduct of following individual self-interest, not its goal.

Brown University. (2013). A framework for making ethical decisions. https://www.brown.edu/academics/science-and-technology-studies/framework-making-ethical-decisions

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7 Ways to Use Infographics in Healthcare

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7 Ways to Use Infographics in Healthcare

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7 Ways to Use Infographics in Healthcare + Templates

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Infographics should be information-rich, contextualize the information for the target audience, and produce an accurate meaning. When infographics are well designed, they can be very useful tools to support comprehension and improve patients' engagement with their own health data.

References
Arcia, A., Suero-Tejeda, N., Bales, M. E., Merrill, J. A., Yoon, S., Woollen, J., & Bakken, S. (2016). Sometimes more is more: iterative participatory design of infographics for engagement of community members with varying levels of health literacy. Journal of the American Medical Informatics Association : JAMIA, 23(1), 174–183. https://doi.org/10.1093/jamia/ocv079

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Infographics is simply an abbreviated term for an information graphic. Information is presented in a logical manner through the use of data visualizations, text, and pictures.
The most successful infographics contain an average of 396 words and a combination of data visualizations (bar graphs, line graphs and pie charts) and illustrations.

References
Scott, H., Fawkner, S., Oliver, C., & Murray, A. (2016). Why healthcare professionals should know a little about infographics. British journal of sports medicine, 50(18), 1104–1105. https://doi.org/10.1136/bjsports-2016-096133

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Use of Health Information for Informed Decisions

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Use of Health Information for Informed Decisions

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1) Enablers- Governance, policies and technology are in place to enable safe, effective and efficient collection, analysis and use of health information. Data is available, accurate, reliable, timely, comparable and accessible. Appropriate and standardized data is captured at the point of care.
2) Data is analyzed and used- Data is turned into actionable information and knowledge to support decision-making and continuous improvement.
3) Capacity and culture- Culture, capability and capacity aid people, processes and tools in the responsible collection, analysis and use of health information.
(Saba & McCormick, 2021, p. 667)

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The three states of data are data at rest, data in motion, and data in use. Data at rest refer to data on storage devices such as a removable USB thumb drive. Data in use refer to data that the information system is currently updating, accessing, reading, or processing. Data in motion are data moving between applications, between locations within a computer system, over the network, or over the Internet (Saba & McCormick, 2021, p. 104).

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Telling Stories with Data in 3 Steps (Quick Study)

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Microsoft Excel is one of the best and most user-friendly tools that can be used to visualize data.

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Smart pumps use drug libraries, which allow infusion pumps to perform functions that assist with programming and calculating dose and rate delivery as adapted by a healthcare institution and to patient care areas. Hard and soft limits or guardrails are programmed within Smart Pumps for medications. Some Smart Pumps contain software that allows for the automatic transmission to the EHR. A Smart Pump that has bidirectional communication is often referred to as an Interactive Smart Pump and allows for pre-populating of the infusion orders from the EHR to the infusion pump, thus saving time in programming the pump and reducing keying errors.

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Patient engagement combines the patient's knowledge, skills, ability, and willingness to manage their own care. Some methods of this include patient portals and OpenNotes.

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The three A's of security are authentication, authorization, and accountability. Authentication checks that you are who you say you are; an example of this would be passwords or a biometric feature is signatures. Authorization is when you can see and do what you are permitted by policy to see and do, in other words, what valid users are allowed to access. Accountability means that you are held responsible for what you see and do. This is really an issue of ethics more than anything. There may be alerts in place as well as auditing to help uphold accountability.

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One of the biggest data breaches of 2020 involves a healthcare business associate. An accounting firm known as BST & CO. CPAs in New York was hit by the Maze ransomware hacking group, which potentially compromised the data of 170,000 Community Care Physicians. The ransomware attack occurred in December and reported to HHS in February. Maze ransomware hackers infected a BST network that contained data from the firm’s local clients, including CCP, to which BST provides accounting and tax services. An investigation revealed the attack lasted for three days and some information tied to patients was compromised during the security incident, such as names, billing codes, insurance descriptions, and medical record numbers. There is a definite risk that the data was potentially accessed, acquired, or otherwise disclosed from the network. BST was listed on the Maze hackers’ dark web blog prior to the breach disclosure. CCP patients have since filed a lawsuit against BST over the ransomware attack, claiming the accounting firm was intentionally reckless and negligent when protecting sensitive data from unauthorized access and failing to employ reasonable and adequate measures to protect its systems.
Health Care Breaches

https://healthitsecurity.com/news/the-10-biggest-healthcare-data-breaches-of-2020-so-far

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A well-known patient safety leader, The Leapfrog Group, represents a coalition of healthcare purchasers and has been a driving force in the improvement of healthcare quality and safety. They are strong advocates for the use of CPOE systems. They have developed a CPOE "standard" including a requirement that organizations operating CPOE systems should demonstrate (via testing scenarios) to ensure that their inpatient CPOE system can alert physicians to at least half of common serious prescribing errors (Saba & McCormick, 2021, p. 561).

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When all the holes in the Swiss Cheese model line up just right, an error has occurred.

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The Institute for Safe Medication Practices (ISMP)

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The Institute for Safe Medication Practices (ISMP)

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The ISMP is devoted entirely to medication error prevention and safe medication use. They have published multiple guidelines and tips for the designers of EHRs as they configure medication orders and order sets. One such resource is the "Guidelines for standard order sets", a five-page checklist that allows organizations to configure and to evaluate the safety of their CPOE systems. ISMP also has a robust voluntary error-reporting program called the Medication Errors Reporting Program (MERP). The MERP is a system where healthcare providers can report any errors related to medication use.

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Office of the National Coordinator (ONC) for Health Information Technology- Safety Plan

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Office of the National Coordinator (ONC) for Health Information Technology- Safety Plan

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The ONC plan revolves around three key areas: learning, improving, and leading. The ONC aims to increase the quantity and quality of data and knowledge about health IT safety (Saba & McCormick, 2021, p. 557)

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In November 2011, the IOM published "Health IT and Patient Safety Recommendations: Building safer systems for better care". This 235pg document provided a comprehensive description of the state of EHRs and their ability to improve safety with a goal of making health IT-assisted care safer, putting our nation in the best position to realize the potential benefits of health IT (Saba & McCormick, 2021, p. 555).

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"To err is human" has been a driving force for improvement in patient safety across the nation. Literature supports the use of electronic health records (EHRs) to reduce medical errors. In one study that used quantitative and qualitative methods, however, 22 types of medication error risks associated with the use of computerized provider order entry (CPOE) were found. In another study, an unexpected increase in mortality in a pediatric ICU was observed that coincided with the implementation of their CPOE system. In another qualitative study that was designed to identify the types of unintended consequences seen with the implementation of EHR systems with CPOE, one category of the study was labeled "Generation of New Kinds of Errors" and indicated that new kinds of errors appear when CPOE is implemented. Examples include juxtaposition errors when users select an item next to the intended choice, a wrong patient being selected, desensitization to alerts (alert overload or fatigue), confusing order option presentations, and system design issues with poor data organization and display. Users get frustrated trying to find the right spot to enter a particular data element and end up entering orders on generic screens or in free-text comment sections, bypassing any rules and alerts configured; all potentially leading to medication errors (Saba & McCormick, 2021, p. 554).

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How Do Patient Portals and Personal Health Records Differ? April 25 2022

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Week 10: Quality & Unintended Consequences

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Week 10: Quality & Unintended Consequences

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“Traditional medicine began when you checked in for your appointment and it ended when you checked out. More and more, we're seeing clinicians want to engage with their patients in a more holistic, complete person way. This was driven in part by value-based care, but also because that’s just good patient retention, that's good patient experience. Patients are wanting to engage more. The patient portal is that mechanism to do that and it’s perfect for many practices.”

- Paul Brient, Chief Product Officer at Athenahealth on patient portals (April 2022)

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Sea Hero Quest is a mobile game that contributes to dementia research by gaining new insight into how we navigate the world.  The way in which players navigate the game, for instance, will help researchers to understand the mental process of 3D navigation, which is one of the first skills lost in dementia.

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Second Life is a virtual online world developed by the Linden Lab in 2003 in which players can develop their own avatars and role play. Many universities successfully implemented nursing simulation labs, for example, in which players could log on and have their own simulation lab.

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Gamification is defined as the use of game thinking and mechanics in a non-game context in order to engage users and solve problems.

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Amwell company can be accessed through your own personal computer at home. It allows the user to input their symptoms and even their insurance information (if applicable) and then connects them with a doctor for a video conference so that they can make an appropriate diagnosis.

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Chronic diseases, such as CHF, can be managed through services such as Medtronic. Patients can check their blood pressure, heart rate, and oxygen saturation at home and input it into a log online. Medtronic will also provide a scale to put in the homes of CHF patients to log their daily weights and any significant weight gain will notify the patient's healthcare provider that they are not doing well.

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The user experience is described as having a deep understanding of what users of a system want, need, and value as well as knowing their limitations and abilities to work within a given system. Factors that influence the user experience (useful, usable, valuable, desirable, findable, accessible, and credible). Usability is defined as how effective and efficient the user interacts within a system and how satisfied they are with their experiences when interacting with it (Saba & McCormick, 2021, p. 616).

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Telemedicine includes primary care and specialist referral services (ie interactive videos, patient data, diagnostics), remote patient monitoring (ie blood glucose or EKG monitoring), consumer medical and health information (ie online discussion groups), and medical education (ie online credits available for healthcare providers).

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Telehealth encompasses a broad application of healthcare services provided over health information exchanged from one site to another via advanced communication technologies. Telehealth services are delivered via a variety of applications and services using two-way video, email, unified communication systems, handheld devices, wireless tools, and other forms of telecommunications technology over networked programs, point-to-point connections, monitoring center links, and Web-based e-health patient service sites (Saba & McCormick, 2021, p. 615).

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Patient Protection and Affordable Care Act (ACA)

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Patient Protection and Affordable Care Act (ACA)

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One stipulation is that healthcare providers must encourage patients to engage in their own care and communicate with them electronically.
Hospitals are implementing and refining patient portals, where patients can check their own appointments, see their laboratory results, pay their medical bills, and send secure messages to their healthcare providers. Additionally, some hospitals are also interacting directly with private physician offices to ensure follow-up care as well as using telehealth services whenever indicated. Organizations such as home nursing agencies are also participating by sending text messages to check in on pregnant women and new mothers.

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The eHealth Exchange is the principal network used today to connect federal agencies and non-federal organizations, allowing them to work together to improve patient care and public health.

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Statewide HIE Coming to California This Summer

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Statewide HIE Coming to California This Summer

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A framework for the data exchange program is set to be finished this July by the California Health and Human Services Agency.

Just last year, Connecting for Better Health, a group of California’s most influential healthcare organizations and stakeholders, launched a coalition to support a California statewide HIE. The coalition stated that the need for a stronger health data exchange has become even more necessary since healthcare organizations in California have battled the COVID-19 pandemic as well as wildfire public health crises.

In January 2021, California Governor Newsom provided a budget proposal to allow the state to connect its fractured HIE networks onto one statewide network. Connecticut was the most recent state, along with 45 others, to implement a statewide HIE.

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California is preparing to launch its long-awaited statewide health information exchange (HIE) to improve patient data sharing between payers and healthcare providers throughout the state.

This recent development marks the first time California has begun putting together a data exchange program. The state has a history of fragmented and limited data exchanges, creating inequities in how data is accessed.

The statewide HIE will allow providers to gain access to patient health information, giving them insight into preexisting health conditions, said state representatives. These enhancements will boost care coordination for 40 million people living within California's 58 counties.

"We know that to succeed, providers will need to be able to share their patients' health information with each other and with critical safety-net programs," John Ohanian, chief data officer for the CHHS and director of the Center for Data Insights and Innovation, said to Capital Weekly.

"These data will need to be usable, accessible, timely, and secure for the organizations providing care as well as individual Californians who will need to be able to use them to improve their lives and well-being."

A framework for the data exchange program is supposed to be completed by the California Health and Human Services Agency this July.

The HIE also aims to improve patient outcomes for low-income, minority, and multicultural patients experiencing social determinants of health.

"Ask any healthcare professional or provider and they'll tell you: to take care of the patients and communities they serve, they need comprehensive health data to deliver the best care," Beth Goodman, the executive director of palliative care services at Charter Health Care Group based in Southern California stated.

"They'll also tell you that in California, it can be very difficult to do that across different healthcare providers and systems, Goodman continued. "As I've seen firsthand, HIE networks allow nurses, doctors, and other healthcare professionals to provide better-informed care-especially in an emergency-because we have real-time access to a patient's vital health information."

The development of a statewide HIE has been a long time coming for providers in California. In 2021, Connecting for Better Health, a group of California's most influential healthcare organizations and stakeholders, launched a coalition to support a California statewide HIE.

The coalition said that the need for a robust health data exchange proved to be essential as California healthcare organizations battled COVID-19 and wildfire public health crises.

In January 2021, California Governor Gavin Newsom provided a budget proposal to allow the state to connect its fractured HIE networks onto one statewide network.

The demand for HIE across states is certain. Recently, Connecticut joined the list of 45 other states and implemented a statewide HIE.

Source: EHR Intelligence

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California Set to Launch Statewide Health Information Exchange

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California is preparing to launch its long-awaited statewide health information exchange (HIE) to improve patient data sharing between payers and healthcare providers throughout the state. This recent development marks the first time California has begun putting together a data exchange program. The state has a history of fragmented and limited data exchanges, creating inequities in how data is accessed.

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California's Largest HIE: Manifest MedEx

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California's Largest HIE: Manifest MedEx

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Manifest MedEx, California's largest health information exchange (HIE)

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Published by Connecting for Better Health, February 2021

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Here's what a Health Information Exchange Network can do for California

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Week 7: Health Information Exchange (HIE)

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Week 7: Health Information Exchange (HIE)

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Health information exchanges (HIEs) are geographically defined entities that develop and manage a set of mandatory practices and terms as well as arrange for the governance and means of the electronic exchange of information (Saba & McCormick, 2021, p. 129).
The Strategic Health Information Exchange Collaborative (SHIEC) was founded in 2015 to enable HIEs to share best practices, promote sustainable business models, offer opportunities for joint ventures, and increase awareness of HIE perspectives among public and private entities. It is a national collaborative representing over 70 HIEs and covering over 200 million people in the United States (Saba & McCormick, 2021, p. 129).

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Chapter 43: Global eHealth and Informatics 

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Patient safety can be defined as freedom for a patient from unnecessary harm or potential harm associated with healthcare.

HIT provides important tools for improving patients’ safety by reducing medication errors, reducing adverse drug reactions, and improving compliance to practice guidelines. These tools include the EHR, CDS, computerized physician order entry, clinical alarm systems, and incident reporting systems.

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Unless there is health equity in access to technology sources of health information and knowledge, eHealth could serve to disenfranchise a large proportion of the world’s population and a significant number of health care providers in impoverished areas of the world.

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Although there are numerous advantages to the rapid increase in communication technologies, the advanced technology may be surpassing the pace for which security precautions can keep up.
Supported by the HIPAA Privacy and Security Rules passed in 1996, healthcare organizations have become more vigilant in establishing rules and policies governing participation in social media (Saba & McCormick, 2021, p. 373).

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Public health surveillance has a history of collecting epidemiological data such as incidence reports on infectious diseases. The field of Syndromic Surveillance emerged to apply a variety of computational technologies to the task of correctly identifying patterns of concern to public health agencies.

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Application of artificial intelligence in healthcare

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Augmenting human performance is a straightforward application of artificial intelligence (AI) in healthcare. CDS systems were intended to assure that clinicians had information available about potential treatment and diagnostic options and even to make specific suggestions.

The goal of precision medicine is to use an individual’s genetic makeup to determine the correct choice and dose of treatment.

Personalized medicine involves applying patient similarity algorithms to population health databases to predict trends in patients with similar characteristics. Personalized healthcare can also encompass the entire continuum of care from wellness to symptoms, to diagnosis and treatment, to the impact of behavioral and environmental influences on the totality of a patients’ experience.

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Clinical Decision Support (CDS) is a HIT component that is defined by HIMSS (Healthcare Information and Management Systems Society) as “a process for enhancing health-related decisions and actions with pertinent, organized clinical knowledge and patient information to improve health and healthcare delivery. CD encompasses a variety of tools to enhance decision-making in the clinical workflow, including computerized alerts and reminders to healthcare providers and patients; clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support; and contextually relevant reference information.

EHRs have improved patient safety by improving communications, making knowledge accessible, providing decision support, requiring key pieces of information for correct treatment, assisting with calculations, performing real-time checks, and assisting with monitoring. EHRs directly or indirectly improve patient safety by minimizing medication errors, improving documentation of data, enhancing the completeness of data, and improving the sustainability of data. However, EHRs also jeopardize patient safety with data entry errors, technical problems, minimal clinical alerts, and poor use of system communication channels.

There are three levels of testing involved with system implementation. The first level is often called a functional test in which the departmental teams test and verify the databases ensuring correct data have been entered into the system. The second level of testing, integrated systems testing, begins when all departments indicate successful completion of their functional testing. The final round of testing occurs during end-user training. It is essential to train the end users on how to use the system in their daily workflow- an EHR will function only as well as its users understand its operation and the operations streamline their workflow.

References:
Saba, V. K., & McCormick, K. A. (2021). Essentials of Nursing Informatics (7th ed.). New York: McGraw-Hill Education / Medical

Chapter 12: System Design Life Cycle: A Framework, pp. 211
Chapter 43: Global eHealth and Informatics pp. 700

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The Steps of the Evidence-Based Practice (EBP) Process

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The Steps of the Evidence-Based Practice (EBP) Process

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The Merging of Science and Art: EBP within a context of caring results in the highest quality of patient care (Figure 26.1)

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Technology doesn't define the practice, rather the practitioner's use of technology to meet the goals of nursing care defines the practice.

There is constant interaction within and across the DIKW (data, information, knowledge, and wisdom) hierarchy's concepts as well as the environment.

Key Terms:
Data: raw, uninterrupted facts without meaning (ex. numbers)
Information: reordered/labeled and now has meaning; data provide information on a person's basic condition
Knowledge: information is interpreted; data is fit into a pattern of prior knowledge
Wisdom: use of knowledge to make appropriate decisions and act on those decisions; synthesizes and appropriately uses a variety of knowledge

Data must be labeled or coded and organized so user can identify patterns and relationship between the data, thereby producing information.

User understands and interprets patterns and relationships in data, resulting in knowledge.

User applies knowledge as basis for making clinical judgments and decisions and choosing nursing actions for implementation.

Data at rest: data on storage devices (ex. USB thumb drive, past medical records); rarely changes
Data in use: information system is currently updating, accessing, reading, or processing (ex. health insurance number, diagnostic test results)
Data information: moves between applications and locations

References
Saba, V. K., & McCormick, K. A. (2021). Essentials of Nursing Informatics (7th ed.). New York: McGraw-Hill Education / Medical

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The key steps of integrating a new EHR into an organization:
1. Project planning- before a system purchase is made a multidisciplinary team should evaluate the needs of the organization and develop a plan
2. Analysis and requirements definition- this will examine the components that will be needed within the EHR to meet the functional and organizational needs of the organization
3. Design- what will be the EHR base of operation, and user interface
4. Implementation- practical application of the EHR in the organization
5. Integration and testing- trial of the EHR to ensure it will meet the needs of the organization
6. Acceptance- the approval of purchase and integration
7. Installation and deployment- this is the addition of the EHR into the organization and the loading of the EHR with patient data and organizational controls and algorithms
8. Maintenance- maintaining the hardware and software of the EHR

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Week 4: Transforming Data, Information, Knowledge, and Wisdom

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Week 4: Transforming Data, Information, Knowledge, and Wisdom

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NANDA International Frequently Asked Questions: Why Use NANDA-I Nursing Diagnoses?

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The American Nurses Association (ANA) recognizes nursing terminologies as supporting nursing practice.
Standard terminologies can be used to support data retrieval and exchange, design user interfaces using terminologies, and monitor the quality of patient care.

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The Omaha System consists of components that capture evaluation, assessment, and service delivery/activity data.

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The term interoperability describes the extent to which systems and devices can exchange data and interpret that shared data. For two systems to be interoperable, they must be able to exchange data and subsequently present that data such that it can be understood by a user.

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What is Interoperability?

It is the ability of different information systems, devices and applications (systems) to access, exchange, integrate and cooperatively use data in a coordinated manner, within and across organizational, regional and national boundaries, to provide timely and seamless portability of information and optimize the health of individuals and populations globally.

Health data exchange architectures, application interfaces and standards enable data to be accessed and shared appropriately and securely across the complete spectrum of care, within all applicable settings and with relevant stakeholders, including the individual.

Four Levels of Interoperability

Foundational (Level 1): Establishes the inter-connectivity requirements needed for one system or application to securely communicate data to and receive data from another

Structural (Level 2): Defines the format, syntax and organization of data exchange including at the data field level for interpretation

Semantic (Level 3): Provides for common underlying models and codification of the data including the use of data elements with standardized definitions from publicly available value sets and coding vocabularies, providing shared understanding and meaning to the user

Organizational (Level 4): Includes governance, policy, social, legal and organizational considerations to facilitate the secure, seamless and timely communication and use of data both within and between organizations, entities and individuals. These components enable shared consent, trust and integrated end-user processes and workflows

What is Health Information Exchange and Data Sharing?

Health information exchange, or HIE, provides the capability to electronically move clinical information among disparate healthcare information systems and maintain the meaning of the information being exchanged. The goal of health information exchange is to facilitate access to and retrieval of clinical data to provide safe, timely, efficient, effective and equitable patient-centered care. HIE can also be used by public health authorities to assist in the analysis of the health of populations.

The term HIE is generally used as either a verb or a noun.

Verb: The electronic sharing of health-related data between two or more organizations facilitated by applied standards for use by a variety of stakeholders to inform health and care.

Noun: Organizations within the United States that provide health information exchange technology and services at a state, regional or national level and often work directly with communities to promote secure sharing of health data.

In the European Union, the act of information exchange is often referred to as data sharing. The European Commission's Support Centre for Data Sharing uses the term to refer to the collection of practices, technologies, cultural elements and legal frameworks that are relevant to transactions in any kind of information digitally, between different kinds of organizations. This term is more broadly applied to all types of data sharing, but can also be specifically used for health-related data.

Interoperability Standards

Standards provide a common language and a common set of expectations that enable interoperability between systems and/or devices. In order to seamlessly digest information about an individual and improve the overall coordination and delivery of healthcare, standards permit clinicians, labs, hospitals, pharmacies and patients to share data regardless of application or market supplier.

Standards Development

A standards organization, standards body, standards development organization (SDO) or standards setting organization is focused on developing, coordinating, promulgating, revising, amending, reissuing, interpreting, or otherwise producing standards that are intended to address the needs of some relatively wide base of affected adopters.

In order to be recognized as an SDO, an organization may be accredited by the American National Standards Institute (ANSI) or the International Organization for Standardization (ISO). Standards are also developed by other groups such as trade unions or associations. The development and adoption of open, consensus-based standards can be a complex process involving many different stakeholders and subject matter experts.

There are over 40 different SDOs in the health IT arena. Some entities create standards, such as Health Level Seven (HL7), Systematized Nomenclature of Medicine (SNOMED) International, and the Clinical Data Interchange Standards Consortium (CDISC). Others, like Integrating the Healthcare Enterprise (IHE), do not develop new standards, but rather bundle complementary base standards into IHE profiles that are used to define a specific function or use case, and then are balloted. This creates a scenario that helps drive adoption of the base standards by providing implementation guidance that describes how multiple standards can be used together to support interoperable health information exchange.

The different SDOs and profiling organizations have varying compositions and processes, but generally follow shared principles based on developing standards through a multi-stakeholder, consensus-based process to respond to specific industry or market needs.

Types of Standards

In order to understand the types of health data standards available for use, informatics professionals organize these standards into the following specific categories: vocabulary/terminology, content, transport, privacy and security, and identifiers.

Vocabulary/Terminology Standards

Vocabulary/terminology standards address the ability to represent concepts in an unambiguous manner between a sender and receiver of information, a fundamental requirement for effective communication. Health information systems that communicate with each other rely on structured vocabularies, terminologies, code sets and classification systems to represent health concepts. Some common vocabulary standards currently used in the marketplace include:

Current Procedural Terminology (CPT®): A code set, maintained by the American Medical Association (AMA), used to bill outpatient and office procedures.

Healthcare Common Procedure Coding System: A set of healthcare procedure codes based on CPT that is used for Medicare reimbursement.

ICD-10 and ICD-11: The International Statistical Classification of Diseases and Related Health Problems (ICD) is a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. The 11th revision will replace the ICD-10 in January 2022.

Logical Observation Identifiers Names and Codes (LOINC®): A universal code system for identifying health measurements, observations and documents. These codes represent the "question" for a test or measurement. LOINC codes can be grouped into laboratory and clinical tests, measurements and observations.

National Drug Code (NDC): Maintained by the U.S. Food and Drug Administration, NDC provides a list of all drugs manufactured, prepared, propagated, compounded or processed for commercial distribution.

RadLex: A unified language of radiology terms for standardized indexing and retrieval of radiology information resources, managed by the Radiological Society of North America. It unifies and supplements other lexicons and standards, such as SNOMED-Clinical Terms and DICOM.

RxNorm: A terminology used to normalize names for clinical drugs and links its names to many of the drug vocabularies commonly used in pharmacy management and drug interaction software. By providing links between these vocabularies, RxNorm can mediate messages between systems not using the same software and vocabulary.

Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT): A comprehensive clinical health terminology product. It enables the consistent, processable representation of clinical content in electronic health records (EHRs). These codes often represent the "answer" for a test or measurement to the LOINC "question" code.

The Centers for Disease Control and Prevention (CDC) provide a number of code sets for vaccines (Vaccines Administered (CVX)) and manufacturers (Manufacturers of Vaccines (MVX)). These codes can be used in immunization messages.

The Unified Code for Units of Measure: A code system intended to include all units of measures used in international science, engineering and business to facilitate unambiguous electronic communication of quantities together with their units.

Content Standards

Content standards relate to the data content within exchanges of information. They define the structure and organization of the electronic message or document's content. This standard category also includes the definition of common sets of data for specific message types.

Consolidated CDA (C-CDA): A library of CDA templates, incorporating and harmonizing previous efforts from HL7, IHE, and Health Information Technology Standards Panel (HITSP). It represents harmonization of the HL7 Health Story guides, HITSP C32, related components of IHE Patient Care Coordination and Continuity of Care Documents, or CCD.

HL7's Version 2.x (V2): A widely implemented messaging standard that allows the exchange of clinical data between systems. It is designed to support a central patient care system as well as a more distributed environment where data resides in departmental systems.

HL7 Version 3 Clinical Document Architecture (CDA®): An XML-based document markup standard that specifies the structure and semantics of "clinical documents" for the purpose of exchange between healthcare providers and patients. It defines a clinical document as having the following six characteristics: persistence, stewardship, potential for authentication, context, wholeness and human readability.

Transport Standards

Transport standards address the format of messages exchanged between computer systems, document architecture, clinical templates, user interface and patient data linkage. Standards center on "push" and "pull" methods for exchanging health information.

Digital Imaging and Communications in Medicine (DICOM): The standard for the communication and management of medical imaging information and related data. DICOM enables the transfer of medical images across systems and facilitates the development and expansion of picture archiving and communication systems.

Direct StandardTM: Defines a set of standards and protocols to allow participants to send authenticated, encrypted health information directly to known, trusted recipients over the internet. Two primary specifications are the Applicability Statement for Secure Health Transport v1.2 and the XDR and XDM for Direct Messaging.

Fast Healthcare Interoperability Resources (FHIR®): An HL7 standard for exchanging healthcare information electronically. The basic building blocks of FHIR are "resources," which describe exchangeable health data formats and elements. FHIR also provides standardization for application programming interfaces (APIs). FHIR provides a number of benefits and improvements as a modern healthcare standard including facilitating interoperable exchange with legacy standards, lower overhead, shorter learning curve, an ability to transmit only the necessary pieces of information, potential for patient mediated data, and an energized community of supporters and implementers.

IHE provides a number of specifications that can be used in the exchange of health information.

PCHAlliance co-sponsors the Personal Health Device (PHD) efforts within the IHE Devices Domain, which are focused on developing IHE profiles that leverage and build upon the Continua Design Guidelines and are also updated to support FHIR. These profiles provide guidance to implement globally recognized, consensus-based approaches to connect and test both personal and clinical devices and integrate them into health information systems. The specifications being developed support both medical devices and mainstream consumer facing apps to enable scalable interoperability of the rapidly expanding connected health ecosystem.

Privacy and Security Standards

Privacy standards aim to protect an individual's (or organization's) right to determine whether, what, when, by whom and for what purpose their personal health information is collected, accessed, used or disclosed. Security standards define a set of administrative, physical and technical actions to protect the confidentiality, availability and integrity of health information.

In the U.S., the Health Insurance Portability and Accountability Act (HIPAA) outlines standards that safeguard the privacy and security of protected health information.

HIPAA Privacy Rule: Establishes national standards to protect individuals' medical records and other personal health information. It applies to health plans, healthcare clearinghouses, and healthcare providers that conduct certain healthcare transactions electrically. The rule applies safeguards to protect the privacy of personal health information, and sets limits and conditions on the uses and disclosures of such information without patient authorization. The rule also gives patients rights over their own health information, including the right to examine and obtain a copy of their records, and to request corrections.

HIPAA Security Rule: Sets national standards for protecting the confidentiality, integrity, and availability of electronically protected health information. Compliance with the Security Rule was required as of April 20, 2005 (April 20, 2006 for small health plans). The rule addresses the technical and non-technical safeguards that "covered entities" must have in place to secure an individual's electronic protected health information. Prior to HIPAA, there were no generally accepted requirements or security standards for protecting health information.

In Europe, the General Data Protection Regulation (GDPR) outlines privacy and security regulations for all processing and storage of data relating to data subjects-or people-in the European Union (EU). This regulation extends to health information and any organization that may process or store data on these subjects, meaning it has extensive reach to many organizations worldwide and related to the sharing of data across organizations.

Identifier Standards

Entities use identifier standards to uniquely identify patients or providers.

Enterprise Master Patient Index (EMPI): A data registry used across a healthcare organization to maintain consistent and accurate data on the patients treated and managed within its departments.

Medical Record Number (MRN): An organization specific code used as a systematic documentation of a patient's history and care during a hospital stay.

National Council of State Boards of Nursing ID (NCSBN ID): A unique identifier automatically generated for each registered nurse and licensed practical/vocational nurse, freely available via the Nursys database and maintained by NCSBN.

National Provider ID (NPI): A unique 10-digit number for a healthcare provider to create a standard identification. These NPIs are included in the free NPI Registry.

Object ID (OID): A globally unique ISO identifier and a preferred scheme for unique identifiers in HL7.

Standards, Implementation Guides and Profiles

Standards on their own are helpful because they describe and constrain what data moves.

Implementation guides describe how to implement these standards for a specific use case. An implementation guide is a companion to a standard that describes how to use a standard to satisfy a specific healthcare use case. It should specify which way a standard is to be applied in a particular use case-how to structure the data consistently and what vocabulary to use. While you can implement a standard in a number of different ways, when using an implementation guide to integrate a standard into a health IT system, the guide directs one way to constrain the standard for a particular situation, removing ambiguity and achieving consistency.

A benefit to the use of implementation guides like IHE Profiles is that they provide a common language for purchasers and market suppliers to discuss the integration needs of healthcare sites and the integration capabilities of health IT products. They provide precise definitions of how to implement standards to meet specific clinical needs. They offer developers a clear implementation path for standards that has been carefully documented, reviewed and tested as well as supported by industry partners. They give purchasers a tool that reduces the complexity, cost and anxiety of implementing interoperable systems. IHE profiles, in particular, organize and leverage the integration capabilities that can be achieved by coordinated implementation of communication standards, such as DICOM, HL7 W3C and security standards.

Testing and Conformance Efforts

The adoption and implementation of standards involves a testing ecosystem that spans standards development, implementation and feedback from real-world testing into the development process to support continuous improvement. There are various different testing and compliance efforts that support advancing health IT interoperability, including:

Conformity Assessment: IHE International administers the IHE Conformity Assessment Scheme, which forms the basis for IHE Conformity Assessment Programs and any official certification of conformance to IHE Profiles associated with such testing programs. IHE International authorizes designated test laboratories accredited under this standard to assess the conformity of products with selected IHE profiles.

eHealth Exchange Testing Program: The program was developed to test compliance for HIE standards as required by the eHealth Exchange Coordinating Committee for onboarding to the eHealth Exchange network. Its purpose is to enable organizations that wish to participate in the exchange to validate the compliance of their health IT with the eHealth Exchange Performance and service specifications.

HL7 FHIR® Connectathons: These events provide hands-on FHIR development and testing opportunities held in conjunction with working group meetings. Participants engage in development and testing, working directly with other FHIR developers and senior members of the FHIR standards development team.

IHE Connectathons: A cross-vendor, supervised and structured testing event where the industry tests implementation of IHE Profiles and other standards to successful standards implementation and use. All tests are evaluated on interoperability and conformance to IHE Profiles found in IHE's technical frameworks. The test floor is overseen by IHE's technical project managers, providing a safe, neutral test environment and an opportunity for industry collaboration and problem resolution.

Office of the National Coordinator for Health IT Health IT Certification Program: A voluntary certification program established by the Office of the National Coordinator for Health IT (ONC) to provide for the certification of health IT. Requirements for certification are established by standards, implementation specifications and certification criteria adopted by the ONC secretary. The program supports the availability of certified health IT for its encouraged and required use under other federal, state and private programs. The program is run as a third-party product conformity assessment scheme for health IT based on the principles of the ISO and International Electrotechnical Commission framework.

Organizations like the Global Consortium for eHealth Interoperability, which was co-founded by HIMSS, IHE International and HL7 International, work to amplify and align the work of organizations like IHE and HL7 to increase adoption of emerging and mature health IT standards. The primary goal of the consortium is to coordinate work with governments and national ministries of health to further align existing and emerging standards and implementation guidance with strategic healthcare policy goals to achieve improved health outcomes for people everywhere.

The Interoperability Ecosystem

The health interoperability ecosystem comprises individuals, systems and processes that want to share, exchange and access all forms of health information, including discrete, narrative and multimedia. Individuals, patients, providers, hospitals/health systems, researchers, payers, suppliers and systems are potential stakeholders within this ecosystem. Each is involved in the creation, exchange and use of health information and/or data.

An efficient interoperability ecosystem provides an information infrastructure that uses technical standards, policies and protocols to enable seamless and secure capture, discovery, exchange and utilization of health information.

Exchange Partners and Data Sources

Historically, the focus was on the exchange of clinical information between providers and hospitals. As the technology has progressed, these exchange partners have broadened to include individuals, such as patients and caregivers, and organizations, such as long-term care, public health departments, community-based organizations and payers. With this expansion, along with the shift to value-based care, has also come a broader range of data types that are available to inform health and care, including device data, patient-generated data and data pertaining to the social determinants of health. Social determinants of health can include data points such as an individual's housing status, access to reliable transportation and level of food security.

Network Architectures

There are three primary types of exchange network architecture used to coordinate the exchange of health information across entities.

Centralized: Patient data are collected and stored in a centralized repository, data warehouse or other databases. The exchange organization has full control over the data, including the ability to authenticate, authorize and record transactions among participants.

Federated (Decentralized): Interconnected but independent databases allow for data sharing and exchange, and grant users access to the information only when needed.

Hybrid: Incorporates variations of federated and centralized architectures to harness the advantages of both. These are becoming common as various combinations of available services are implemented.

An important technical development that has expanded exchange partners and data sources is the emergence of healthcare APIs. APIs outline a set of clearly defined specifications to allow for one software application to build on the data and functionality of another application, without needing to understand its system design. APIs are already ubiquitous in today's web economy, and will play an essential role with respect to fueling healthcare interoperability for person centered care.

Types of HIE Organizations

An HIE organization oversees and governs the exchange of health-related information among organizations according to nationally recognized standards. The purpose of a health information exchange organization is to perform oversight and governance functions for information exchange. There are several different types of HIEs currently operating across the U.S. and its territories:

1. Hybrid HIEs are often collaborations between organizations, such as an ACO and a vendor network, within a state or region. The Kentucky Health Information Exchange is an example of a hybrid model.

2. Private/Proprietary HIEs concentrate on a single community or network, often based within a single organization, and include overall management, finance and governance. Examples may include hospital/integrated delivery system networks, payer-based HIEs and disease-specific HIEs. Some software vendors have also established an HIE network for their clients across the U.S. Additionally, the industry may see other evolving entities such as Accountable Care Organizations (ACOs) supporting information exchange.

3. Regional/Community HIEs are inter-organizational and depend on a variety of funding sources. Most are not-for-profit. Indiana Health Information Exchange and Chesapeake Regional Information System for Our Patients are examples of a regional HIEs.

4. State-wide HIEs are run by the governments of their respective states or maybe the state's designated entity. Some state-wide (and regional) HIEs use an umbrella approach and serve as the aggregator for disparate private health information exchanges. Statewide Health Information Network for New York and Arizona's Health Current are examples of a state-wide HIEs.

U.S. Exchange Initiatives: An Environmental Scan

Many organizations are actively working to achieve ubiquitous exchange. This environmental scan provides a curated review of the current landscape of the U.S.-based networks and frameworks which enable interoperable, nationwide health information exchange via a variety of methods and collaborations.

International Networks Enabling Exchange

Beyond the examples outlined above, various exchange networks and infrastructure have been established globally.

The eHealth Digital Service Infrastructure (EHDSI) facilitates the two primary building blocks of cross-border digital health services in Europe: ePrescription and Patient Summary. ePrescription (and eDispensation) allows EU citizens to obtain their medication in a pharmacy located in another EU country. Patient Summary provides information on important health related aspects such as allergies, current medication, previous illness, surgeries, etc. The digital Patient Summary is meant to provide doctors with essential information in their own language concerning the patient, when the patient comes from another EU country and there may be a linguistic barrier.

An important precursor of major exchange initiatives in Europe have been the European Reference Networks. These are virtual networks involving healthcare providers across Europe. They aim to facilitate discussion on complex diseases and conditions that require highly specialized treatment, providing concentrated knowledge and resources. Coordinators convene virtual advisory panels of medical specialists across different disciplines, using a dedicated IT platform and telemedicine tools.

Argentina's National Interoperability Network uses standards to enable communication between participating health information systems, providing a bridge for identity management across systems, sharing documents and patient summaries, managing ePrescriptions and supporting national registries.

Australia's My Health Record is an opt-out, CDA-based document repository used to store shared health summaries, eReferrals, specialist letters, discharge summaries, event summaries, prescription records, diagnostic imaging and pathology reports. Once patients have their record, they are able to manage access and permissions.

Canada's Health Infoway manages an ePrescribing service, PrescribeIT, electronically shares prescription information from clinicians with pharmacies for dispensing. Another Infoway initiative, ACCESS Health, aims to accelerate citizen access to personal health information and digital health services. The exchange initiative is expected to use a cloud-based infrastructure, a FHIR-based API service and a blockchain-enabled consent service.

Hong Kong's Electronic Health Record Sharing System is the country's equivalent to a regional HIE, managing patient data on care episodes, lab results, radiology studies and drug items. The Hong Kong Hospital Authority launched eHRSS to public and private health sectors using an opt-in patient consent model.

Uses of Information Exchange
Watch the HIMSS TV deep-dive on interoperability.
Ultimately, the goal is to be able to share and access information that informs an individual's full, longitudinal health story. By having and understanding the complete and accurate picture of an individual's health-including their preferences and other determinants of health-includes a number of benefits. Clinicians can better inform care and decision making, patients can become active participants in their care plans, and health IT developers and implementers can leverage evidence to create and adopt systems that support clinical processes and improve care delivery.

A number of benefits can be realized for exchange stakeholders, including:

1. Care coordination: Care coordination often involves a variety of stakeholders, including patients, caregivers and care teams across settings in the management of a patient's health. This is a dynamic process that requires data movement across platforms and among service providers in real time to successfully manage care.

2. Improving business and administrative processes: Having access to health information can eliminate time-consuming tasks within a health system, including processing of intake information, coordination across care teams and reporting needs associated with various regulatory requirements.

3. Increased patient safety and satisfaction: Having a full picture of a patient's health through access to disparate data can better inform clinicians on the patient's medical history, preferences and past encounters. This can help avoid duplicate testing, reduce adverse events, inform care decisions and conduct appropriate follow-up to ensure adherence with care management.

4. Value-based care: Population-level data analysis is an essential component of health systems managing high-risk patient populations, public health systems and other stakeholders working to coordinate care needs for a community. Understanding population data can enable better risk analysis and more cost-effective care. At an individual level, having access to longitudinal health data on a patient can reduce duplicative testing and close gaps in information. A key consideration in the shift to value-based care is the incorporation of non-traditional health data, such as an individual's social determinants of health data (e.g. food security status, housing stability and access to reliable transportation) into patient records. This data can be leveraged by health systems to proactively identify a health risk within a target population and intervene to work toward positive outcomes.

With these benefits in mind, taking a use-case driven approach can frame how information sharing may inform care or business practices and can help frame the potential benefits and drive interoperability forward. The following examples provide a snapshot at how interoperable exchange may occur.

Care delivery data: A physician can query a network or external health system for the appropriate patient data from other sources, such as other clinicians and hospitals. The physician can then select certain patient documents or resources (such as medication lists and reconciliations, allergy lists or lab reports) that they want to access during a patient visit.

Consent management: Where consent is not governed by other laws or regulations, a centralized consent management process can enable consensus among the community's stakeholders for a patient consent model, and provide awareness of a patient's willingness to participate in data sharing activities.

Lab results: HIE services provide physicians with the ability to get results directly via their exchange networks.

Medication reconciliation: Having a longitudinal view of all of a patient's encounters can raise awareness of the potential medications a patient was previously or is currently using. This can allow for appropriate follow up with the patient to reconcile differences in records to produce an accurate picture of their medication lists for future encounters.

Patient intake: Using a query and response process, the patient's health record can be acquired ahead of an appointment for clinician review.

Patient preferences: Exchange networks can enable access to information about a patient's care preferences, such as advance directives, empowering patients to make decisions in their care.

Provider alerts: HIE organizations are able to provide alerts to a clinician on their patients when one presents to the emergency department or is admitted to or discharged from a hospital, to ensure appropriate follow-up can be conducted.

Query services: Physicians may want to obtain more information about a patient that is referred to their office. They can query an exchange network which can in turn query other networks or health systems to assemble a complete, longitudinal health record.

Record locator services/master patient indexes: Many exchange networks enable creation of one continuous community record or search capabilities for patient records, facilitating patient identification across multiple provider settings.

Referrals: Organizations have the ability to send referrals directly through HIE services, along with all appropriate documentation.

Secure messaging: Many use cases require the exchange of patient records or related health information between clinicians in different healthcare settings with different EHRs or IT systems. For instance, providers needing to send referrals can electronically share data, eliminating paper documents and expediting the patient's treatment.

Transitions of care: As patients make the transition from one care setting to another (such as from hospital to a primary care provider or skilled nursing facility), interoperable exchange of relevant documentation from one care setting can be easily accessed at the next.

Workflow Considerations and Guidance

As the HIMSS definition suggests, interoperability goes beyond its technical requirements. Often there are policy changes influencing the value proposition and therefore willingness to exchange. Organizational considerations must align with external organizations and work toward achieving trust across stakeholders to enable meaningful data sharing. The following outlines some of these considerations and the approaches that may be leveraged.

Obtaining Patient Consent

Ensuring and communicating patient consent for data sharing activities is critical to abide by regulatory requirements and maintain the trust of the patient. There are several consent models used in information exchange, dependent on regulatory requirements within a jurisdiction.

No consent: Patient health information at a participating healthcare organization is automatically included in and available for exchange.

Opt-in: No patient data sets are made available for electronic exchange until patients actively express whether they would like to make all, or a pre-defined set, of their information available.

Opt-in with restrictions: No patient data sets are made available for electronic exchange until patients actively give their consent to participate. Patients have the option to:

Allow information to flow only to specific providers/li>

Include only specific categories of data or data elements

Make all of their information available for exchange

Opt-out: All or some predefined data sets are qualified to be included and available for exchange, after patients are given the opportunity to opt out in full.

Opt-out with exceptions: All or some predefined data sets are qualified to be included and available for exchange after patients are given the opportunity to:

Allow the exchange of their information only for specific purposes

Limit exchange of their information only for specific purposes

Limit exchange of their information to specific providers or provider organizations

Opt out in full

Selectively exclude categories of data or specific data elements from the exchange

Regardless of the model leveraged, a patient has the right to revoke their consent at any time, and processes to ensure that preference is communicated and enforced is important for data sharing processes.

Ensuring Privacy and Security

Regulations such as GDPR in the EU, HIPAA in the U.S., and various other national and state laws and regulations set forth privacy and security requirements to safeguard health information when it is created, received, transmitted, or maintained by health systems and other organizations. Privacy and security considerations may include the following:

Executing and implementing data use and reciprocal support agreements (DURSA)-also known as trust agreements-with the health systems and other stakeholders. These agreements set forth who may access and exchange the data. Additionally, such agreements set forth standard privacy and security policies and procedures that govern data protection and use. Further, data is typically encrypted when data is exchanged from one organization to another.

While specific security requirements may differ depending upon the DURSA, a typical DURSA may call for each participant to maintain appropriate administrative, physical and technical safeguards to ensure the confidentiality, integrity and availability of the data, aligned with the HIPAA requirements and any other applicable laws and/or regulations.

Producing High-Quality Data

In order to ensure that the information received from disparate sources can be trusted that it is accurate and complete, there needs to be efforts by organizations to maintain high-quality data. This can be achieved by ensuring that:

1. Data are structured and coded with standardized terminology and styles where possible to be leveraged in a machine-readable format for analysis and interpretation

2. Documentation is robust and complete to communicate the full patient story in a way that provides meaning to the human end user of the information.

Public Policy and Government Efforts

Achieving interoperability to date has required government involvement, guidance and regulation. Public policy efforts have the potential to drive forward frameworks for trusted exchange, align and educate stakeholders on existing and emerging standards and broaden stakeholder participation to ensure an inclusive exchange ecosystem for care coordination and continuity. The following outlines examples of how governments have worked to facilitate exchange both within the U.S. and in countries around the world.

United States Policies and Initiatives

With the goal of achieving ubiquitous, interoperable, nationwide exchange, the U.S. Department of Health and Human Services (HHS) has enacted and implemented a variety of legislation, regulations and guidance to further the adoption of standards-based approaches to interoperability.

21st Century Cures: Key Provisions

Among the health IT provisions outlined in 21st Century Cures, many sections provide directives to the ONC, Centers for Medicare and Medicaid Services (CMS) and other agencies related to improving interoperability.

The draft Trusted Exchange Framework and Common Agreement includes the policies, procedures and technical standards that build from existing health information network capabilities and enables them to work together to provide that single on-ramp to electronic health information regardless of the developer, health information exchange, or where a patient's records are located.

The U.S. Core Data for Interoperability is a "standardized set of health data classes and constituent data elements for nationwide, interoperable health information exchange." A "Data Class" is an "aggregation of various Data Elements by a common theme or use case."

The ONC Interoperability and Information Blocking Final Regulation implements key provisions of the 21st Century Cures Act focused on advancing interoperable exchange; supporting the access, exchange and use of electronic health information; and addressing occurrences of information blocking. The rule calls for accelerated use of healthcare APIs. ONC Certified Health IT must have standardized APIs for patient and population services, and meet specific requirements called out in the API Conditions and Maintenance of Certification. Most importantly, the regulation requires that United States Core Data for Interoperability is available for healthcare providers and patients "without special effort."

The Cures Act tasks ONC with the creation of an EHR Reporting Program as a condition of their certification and maintenance of certification. ONC has a process to solicit feedback from the industry on what criteria and methods of collection should be explored for this program. The program's reporting criteria aims to address the following five categories: security, interoperability, usability and user-centered design, conformance to certification testing, and other categories as appropriate to measure the performance of certified EHR technology.

In parallel with the release of the ONC Interoperability and Information Blocking Final Regulation, CMS also outlined an Interoperability and Patient Access Final Regulation, as part of their MyHealthEData Initiative, focused on driving exchange of and patient access to health information by liberating patient data using CMS authority to regulate Medicare Advantage, Medicaid, Children's Health Insurance Plan, and Qualified Health Plan issuers on the federally facilitated exchanges.

Interoperability Standards Advisory

The Interoperability Standards Advisory (ISA) process represents a single, public list of standards and implementation specifications published by ONC. ONC coordinates the identification, assessment and determination of these recommended standards and implementation specifications for industry use to fulfill specific clinical health IT interoperability needs. Stakeholders are encouraged to implement and use these recommended standards as applicable to their needs.

The ISA is organized into sections with related interoperability needs, each including one or more standards or implementation specifications to accomplish the listed need. Additional characteristics on these standards and implementation specifications are listed to inform stakeholders on maturity and adoption. These include:

1. Adoption Level: Approximate, average adoption level for that specific use case in healthcare within the United States.

2. Cost: Conveys whether a fee is involved to purchase, license, or obtain membership for access or use of the recommended standard or implementation specification.

3. Federally Required Status: Conveys whether a standard or implementation specification has been adopted in regulation, referenced as a federal program requirement, or referenced in a federal procurement (i.e., contract or grant).

4. Implementation Maturity: Conveys maturity based upon its implementation state.

5. Standards Process Maturity: Conveys maturity in terms of its stage within a particular organization's approval/voting process.

6. Test Tool Availability: Conveys whether a test tool is available to evaluate health IT's conformance to the standard or implementation specification.

Advancing Standards for Precision Medicine

This ONC project aims to standardize data found outside of traditional care delivery settings. As part of the precision medicine initiative, it focuses on standards in two areas:

1. Mobile health, sensor and wearable data

2. Social determinants of health data

Interoperability Proving Ground

ONC hosts an open, community platform where individuals and organizations can share and learn from projects occurring in the United States and internationally.

Data: Elemental to Health Campaign

HIMSS and PCHAlliance strongly urge prioritization of necessary funding and technical assistance to implement modern health information and technology strategies to ensure timely interoperability and sharing of public health surveillance data. An important component is the work in partnership with the Association of Public Health Laboratories, Council of State and Territorial Epidemiologists and the National Association for Public Health Statistics and Information Systems that support this multi-year effort to modernize public health data systems, surveillance and analytics at the CDC, and state, local and tribal health departments. Funding included in the Fiscal Year 2020 Appropriations Package and the Coronavirus Aid, Relief and Economic Security (CARES) Act, will help address some of the challenges, but in the long term, we need a predictable and sustained funding source to fully tackle this issue.

State-Level Interoperability Initiatives

In the U.S., state public health agencies manage and track information for immunizations, infectious diseases and vital statistics, however, they often lack adequate funding to ensure their information systems are updated and conform to national standards and profiles. Health information exchanges -which are public or private entities, depending on the state and region-aim to ensure there is robust and standardized data exchange between and among public health entities and state and local health departments.

Global Governmental Policies and Initiatives

At an international level, there are a variety of initiatives being led by health ministries and governments to further country-level and cross-border interoperability efforts.

The Global Digital Health Partnership (GDHP) is a collaboration of over 40 governments and territories, government agencies and the World Health Organization, formed to support the effective implementation of digital health services. Interoperability is one of the various work streams explored by GDHP. The proposed work stream activities focus on the evolving challenges of sharing patient data between care providers, organizations, caregivers and patients. These challenges are partly a technical problem for health systems, clinicians and patients, however they also pose significant risks for patient safety, and detract from high-quality coordinated care and the efficient delivery of services. A GDHP report outlines a variety of government efforts from 15 participating countries.

In Europe, the EU EHR Exchange Format developed the EU's eHealth Network to support the digital transformation of health and care in the EU by seeking to unlock the flow of health data across borders, and support implementation of the Cross-Border Health Care Directive. The recommendation seeks to facilitate the cross-border exchange of EHRs in the EU by supporting member states in their efforts to ensure that citizens can securely access and exchange their health data wherever they are in the EU. It will help citizens to quickly access and share their health data with healthcare professionals, for example, when consulting a specialist or receiving emergency treatment in another EU country.

The backbone infrastructure for the EHR exchange is the EHDSI. The EHDSI consists of services and infrastructure that use information and communication technologies to enable cross-border healthcare services. Initial focus is on enabling the exchange of baseline health information, including:

ePatient Summary to provide access to verified key health data of a patient during an unplanned care encounter while abroad

ePrescriptions to enables patients to receive equivalent medication treatment while abroad to what they would receive in their home country

A number of EU countries are already exchanging the ePatient summaries and ePrescriptions. As part of the EHDSI, Finland and Estonia were among the first to implement infrastructures to support the exchange of patient summaries, leveraging the X-Road platform, a free and open-source data exchange layer solution that enables organizations to exchange information securely over the internet. Future phases will include lab results, medical imaging and reports, and hospital discharge letters.

The European Commission also outlined priorities for 2019-2024 EU Digital Strategy, which included the creation of a European Health Data Space (EHDS) to foster the exchange and sharing of different kinds of health data (electronic health records, genomics, registries, etc.) in Europe. It aims to not only support exchange for the delivery of primary care, as well as, the development of new treatments, medicines, medical devices and services. Beyond the citizens, this would help meet the needs of different users and actors in the health system, while simultaneously protecting citizens' data. The commission is currently working with the member states and stakeholders to define the best governance structure and set up the appropriate infrastructure for the EHDS. Additionally, some existing regulatory gaps regarding member states implementation of the GDPR for the secondary use of data are being addressed.

The European Interoperability Framework (EIF) gives specific guidance on how to set up interoperable digital public services. It offers public administrations 47 concrete recommendations on how to improve governance of their interoperability activities, establish cross-organizational relationships, streamline processes supporting end-to-end digital services, and ensure that both existing and new legislation do not compromise efforts.

In an effort to ensure secure and federated access to genomic data, the European 1+ Million Genomes Initiative aims to create a technical infrastructure to improve disease prevention, allow for more personalized treatments and provide a sufficient scale for new clinically impactful research. In addition to the technical foundation for this effort, the signatory countries will also assess ethical and legal implications of genomics, and data storage, security and ethical uses.

Beyond these broader initiatives occurring across Europe, many countries are also leading specific regional and national efforts to expand exchange abilities./p>

The Nordic Interoperability Project is a consolidated grassroots effort to demonstrate the value for the patient from a seamless cross-border exchange of health data. The consortium includes organizations from all five Nordic countries-Denmark, Finland, Iceland, Norway, Sweden-and works to enable patients to live and act in an open, seamless, cross-border healthcare ecosystem, by showcasing and implementing solutions and innovations from the Nordics. The goal is to enable the Nordics by 2030 to be the most sustainable and integrated health region in the world, providing personalized healthcare for all its citizens.

In Portugal, the Shared Services of the Ministry of Health (SPMS) is a state-owned enterprise that manages the Portuguese Health Ministry Central Purchasing and serves as the national IT authority and the Portuguese representative for eHealth cross-border affairs. SPMS provides shared services in the areas of purchasing and logistics, financial services, human resources, and information and communication technologies to health and care entities to centralize and optimize the procurement of goods and services within the Portuguese National Health System.

In Asia and the South Pacific, many governments are also adopting digital health strategies to encourage interoperable exchange. For example, India's The Ministry of Health and Family Welfare (MoHFW) publishes EHR standards and created a Centre for Health Informatics under the eHealth Division of MoHFW as part of their Digital Health Strategy to initiate several digital health initiatives in the country, and started the National Health Portal as a citizen portal with the objective of improving the health literacy of the masses in India. New Zealand's health agencies, organizations and individuals signed a Commitment to New Zealand Health Interoperability to outline principles to drive the adoption of exchange infrastructures and processes in their health sector.

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Discover key insights about interoperability and better understand how data sharing can make a difference in healthcare.

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2015 HIMSS Impact of the Informatics Nurse Survey

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2015 HIMSS Impact of the Informatics Nurse Survey

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Over 6,000 members belong to the HIMSS (Healthcare Information and Management Systems Society).
The role of the informatics nurse in emerging technologies involves medical device integration to directly capture data from the EHR

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The American Association of Colleges of Nursing (AACN) is the national voice for nursing programs at the bachelor and graduate levels. It provides accreditation for nursing programs and has developed standards and essentials to the delivery of nursing education.

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Quality and Safety Education for Nurses (QSEN)

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Quality and Safety Education for Nurses (QSEN)

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QSEN developed six competencies: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, and informatics. The competencies are divided into three categories: knowledge, skills, and attitudes.

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The “butterfly effect” describes a situation in which a minor change in input (e.g. a butterfly flapping its wings in one part of the world) can have a major effect on output (e.g., a windstorm developing in another part of the world).

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Landmark Events and Pioneers in Nursing Informatics

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Landmark Events and Pioneers in Nursing Informatics

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HIPAA is a privacy and security measure in healthcare. It allows for the flow of health information needed to provide and promote high quality healthcare while protecting the public's health and wellbeing.

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HIMSS Technology Informatics Guiding Educational Reform (TIGER) competencies are designed for practicing nurses. TIGER initiatives represent nurses' efforts to translate high-level initiatives on nursing education reform to a practice level; it is an education reform initiative that strives to foster interprofessional community development and global workforce development by maximizing the integration of technology and informatics into seamless practice, education, and research resource development.

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Week 1: Historical Perspectives of Nursing Informatics

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Week 1: Historical Perspectives of Nursing Informatics

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Nursing informatics refers to the field of applied computer science concerned with the processing of information, such as nursing information. It provides information to make better decisions and improve healthcare. It also deals with resources, devices, and methods to store, retrieve, and use information in healthcare resulting in increased efficiency of healthcare, decreased cost, increased productivity, and increased data collection.

The computer revolution in healthcare led to healthcare information technology (HIT) and electronic health records (EHRs).

Some aspects of healthcare delivery that are affected by electronic processing include documentation of patient care, education for healthcare providers, scientific research for advancing healthcare delivery, administration of healthcare delivery services, reimbursement for patient care, legal and ethical implications, and safety and quality issues.

Increasingly complex patient care requirements and the proliferation of intensive care units requires nurses to become super users of computer technology (i.e. cardiac monitors, ventilators, infusion pumps).

References
Saba, V. K., & McCormick, K. A. (2021). Essentials of Nursing Informatics (7th ed.). New York: McGraw-Hill Education / Medical