By Rhonda Spellmeier MBA, BSN, RN, HIE Workflow Specialist

Quality is the bedrock of healthcare. Everyone, including clinicians, administrators, payers, and patients wants to ensure the care being provided is appropriate, effective, and efficient. With the explosion of electronic health record implementations in the last fifteen years, quality is still at the forefront of our priorities. What’s changed is the need to broaden our perspectives to include how workflow and health information exchange play a crucial role in quality improvement.

Vast amounts of electronic health information are available to support quality improvement in all aspects of the healthcare continuum. In a systemic review of studies, Menachemi, et al. found that usage of health information exchange resulted in benefits such as fewer duplicated procedures, reduced imaging, lower costs, and improved patient safety. In another literature review, Holmgren, et al. concluded that widespread HIE is vital to providing a full picture of patient health at the point of care and can also slow medical cost by reducing readmissions. It may also reduce administrative burden on patients by allowing data to flow between unaffiliated care providers across the continuum of care. The COVID-19 pandemic also highlighted the importance of readily available patient and population level health data.

HIE is a simple concept on its surface. Health data is electronically created and shared among disparate providers, payers, public health, policy makers, and patients. However, there are many variables that impact the success of data sharing, including technology and user needs, completeness of information, and organizational workflows. All these variables can negatively affect health information exchange, resulting in massive amounts of information remaining unused at the point of care, where quality matters most.

Below are some workflow considerations to help facilitate Health Information Exchange and quality improvement at your organization.

• When considering the data you are sending to the HIE, ensure documentation is interoperable and complete.
  • Patient matching is dependent upon accurate registration. Create a policy for consistent naming conventions, entering complete demographics, and searching by DOB before creating a new MRN.
  • Know consent policies for your EHR and include them in staff education. Many EHR’s, states, and regulatory entities may require patient consent for their data to be sent to an HIE. Ensure staff responsible for gathering this consent are informed of the process and the workflow includes consent. Consider adding HIE to your Consent to Treat forms.
  • Ensure transmission of data to the HIE is automated and not dependent upon manual sending processes.
  • End users should be documenting relevant data in fields that are populated to the Continuity of Care Document. Ensuring this happens may mean moving data fields to the clinician workflow rather than expecting the clinician to utilize an unfamiliar or cumbersome workflow.
  • Be aware of the triggers in your EHR that send a document to the HIE. If documentation is not complete before the trigger occurs (i.e. discharge) consider adjusting the trigger or the reasons for the incomplete documentation.
• When planning to utilize HIE data to improve care, implement the following workflow tips.
  • Educate staff on HIE regarding expectations, regulations, data that is available, and what can be done with the data. Designate HIE Super Users and Champions.
  • Ease of access is crucial.
    • Bidirectional interfaces between the HIE and EHR can allow the end user to “pull” data back into the EHR rather than logging into a separate system.
    • For end users who access HIE via our web-based portal, ensure the website link is readily accessible and logins are created for relevant end users. Provide initial and ongoing training.
  • End User considerations are vital.
    • Providers are often targeted users, but proxy users, such as nurses, medical assistants, HIM, and quality are often overlooked as end users who benefit from access to outside medical records.
    • HIE Portal access may be more appropriate for certain users than accessing records via the EHR.
• Bidirectional access considerations.
  • Ensure your EHR is connected to the HIE with a bidirectional interface. If your organization attests to either the Bidirectional Exchange of Data or TEFCA measures under CMS or MIPS Promoting Interoperability, you must show you can and are sending and receiving data.
  • Thoroughly understand and test the process for querying and downloading records within your EHR before implementing organization wide. Be aware of what data is truly available to query and what data is not.
  • Ensure end users know where to find the outside records once they’ve been downloaded to the patient’s chart in the EHR.
  • Create policies and procedures for who can access outside records, patient match, and reconcile the data into the patient record. Address when these records should be accessed, i.e., on an acute care admission, follow-up after ER visit, etc. Consider starting with patient encounters that are covered under the Promoting Interoperability program requirements then expanding to other patient encounter types as HIE becomes more commonplace at your organization.
  • Be aware of the audit process in your EHR and how it applies to your HIPAA and privacy policies.
• Web-based portal access considerations.
  • Ensure adequate internet access and speed.
  • Maintain logins regularly. Add HIE access to your onboarding and offboarding checklists to ensure those who need access have it and those who leave your organization do not.
  • Develop policies and procedures detailing when data can be exported from the web portal and how to make it part of the patient’s medical record. Two common methods are printing and scanning into the EHR or printing to PDF and uploading as an attachment into the EHR.
  • Ensure end users who may view the data once it’s uploaded into the EHR know where to find it.

Utilizing HIE to improve healthcare quality is an evidence-based practice. Technology, completeness of information, and workflows are all potential barriers to the success of health information exchange adoption. By addressing these variables, especially workflow considerations, your organization can optimize the use of external data to improve patient outcomes and clinician satisfaction.

Menachemi, Nir, et al. “The benefits of Health Information Exchange: An updated systematic review.” Journal of the American Medical Informatics Association, vol. 25, no. 9, 28 Apr. 2018, pp. 1259–1265, https://doi.org/10.1093/jamia/ocy035.

Holmgren, A Jay, et al. “Health Information Exchange: Understanding the policy landscape and future of Data Interoperability.” Yearbook of Medical Informatics, vol. 32, no. 01, 6 July 2023, pp. 184–194, https://doi.org/10.1055/s-0043-1768719.