The role of electronic health records and interoperability in clinical workflows

When you think of electronic health records (EHRs), you may picture a doctor scrolling through their tablet or clicking through the exam room computer when treating patients. Indeed, EHRs are a digital version of a patient’s paper chart. They’re real-time, patient-centered records that offer a far more detailed picture of a patient’s health beyond standard clinical data collected in a provider’s office, and they make this information available to a worldwide network of authorized health care providers.

EHRs provide actionable information about a patient’s total medical history, which can be shared securely and confidentially. As the health industry adopts a more interdisciplinary approach to care, engaging a diverse team of providers and specialists is crucial. EHR systems offer a protected method to share, access, and coordinate valuable patient data.

What are EHRs and why are they important?

EHRs go beyond other types of medical records as they’re designed to be shared among all stakeholders involved in a patient’s care—even patients themselves. They allow a team of providers to coordinate the delivery of different care modalities and help reduce inefficiencies like running duplicate tests, polypharmacy, and taking family histories.

EHRs and interoperability (a system of sharing data electronically) are approaches to managing health information that not only facilitate the secure and seamless exchange of data, but also make sure the data captures a complete portrait of the patient’s care experience.

Health care organizations that utilize EHRs and data interoperability make getting quality care easier, faster, and more efficient. They improve patient engagement and help close gaps in health literacy.

In fact, making EHRs accessible to patients through a portal can be motivating, helping to activate them in their own health and care plans.

EMR vs. EHR vs. PHR—what's the difference?

While some people use the terms EMR (electronic medical records), EHR, and PHR (personal health records) interchangeably, there are significant differences between these record types. Essentially, health records document the broader concept of health and well-being—describing the total condition of the body—and not just data specific to medical diagnoses and treatments.1

What’s an electronic medical record, or EMR?

EMRs contain a patient’s basic clinical data—such as what would appear on a paper chart—and are generally maintained within a single medical practice. They include diagnoses, medications, immunizations, vaccinations, and family medical histories. EMRs enable providers to track patients over time, which makes them more valuable than paper records. They’re used to monitor major changes in health parameters, like blood pressure, and identify patients for preventive visits and screenings. EMRs detail the treatment history of a patient but do not easily “travel” out of the practice.1

What’s an electronic health record, or EHR?

EHRs go beyond the patient’s medical history reported in EMRs to paint a fuller picture of the patient’s health and well-being. EHRs represent a total collection of patient data from all of the clinicians involved in a patient’s care. Furthermore, EHRs differ from EMRs as they can be shared with and accessed by other health care providers that are authorized in a patient’s care, including laboratories and specialists. In other words, EHRs “move” along with the patient through different care modalities, from hospital to nursing home and even across geographies.1

What’s a personal health record, or PHR?

PHRs contain the same information as EHRs but are designed exclusively for patient access. Patients are increasingly involved in their own care, and PHRs allow patients to maintain and manage their health details via a secure and confidential platform. PHRs may collect information from a variety of sources including clinicians, home monitoring devices, and information provided by the patients themselves.2

Health records in action:
A patient’s journey with diabetes

If we look at these health records in action, it may appear like this: A patient experiences symptoms of extreme fatigue and blurry vision. The primary care physician accesses the patient’s EMR to review their medical history, checking for diabetes and related conditions. The patient undergoes blood glucose testing, A1C testing, and other blood tests, the results of which the physician then enters into the EHR system. 

Upon receiving a type 2 diabetes diagnosis, the treating physician refers the patient to an endocrinologist and registered dietitian. The specialists access the patient’s EHR to understand the incident that inspired the referral and the full scope of the patient’s care. New information about the patient’s treatment plan, medications, and follow-up exams is updated in the EHR system. 

The patient is invited to access their PHR via a patient portal, which can be used as a tool to monitor blood glucose, physical activity, and medication adherence. Importantly, relevant patient education resources and tips on healthy living are also accessible via the portal.

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Interoperability

Interoperability is the ability of health information technology systems to work together within and across various health care organizations to share data. These systems usually include cross-platform communication tools and applications. Notably, interoperability allows for data exchange between systems while preserving the integrity of the exchanged information.3

A lack of health care data interoperability is an expensive problem, costing the U.S. health care system over $30 billion a year.3

Because interoperability has such a big influence on how health care is delivered today—as well as on the industry’s financial health—the 21st Century Cures Act and other government standards have compelled health organizations to focus on advancing interoperability. Specifically, that the exchange of electronic health information is secure and accessible for authorized use when and where it’s needed to support the health and wellness of patients.5

Challenges of interoperability

While interoperability has tremendous benefits for coordinating data analytics and clinical decision-making, there are also challenges—especially when implementing these systems. Two prominent challenges include how to manage the increasing amount of data within a health care system and how to get different sources of health information technology to effectively “talk” to one another.

Nearly one-third of hospitals and health care systems report insufficient support for data interoperability endeavors.6 At the same time, these systems also support a diversity of sources and technologies used in gathering and storing sensitive data—including hospitals, clinicians, health plans, patient portals, databases, and the patients themselves—but have limited means of interconnecting these sources.

Technologies advancing interoperability

Today, most providers are bound to episodic data retrieval and exchange within a singular health care system. To tackle data interoperability, health care systems would benefit from leveraging two innovative technologies, SMART® (Substitutable Medical Applications, Reusable Technologies) and FHIR® (Fast Healthcare Interoperability Resources).7

SMART

What are SMART technologies?

SMART was originally designed as a model of “build once, go anywhere” with the goal of building a standard framework for developers in the creation of health care applications.8 With SMART, these applications work seamlessly and securely across the health facility’s EHR system. SMART applications provide clinical care to patients, based on the patient’s profile and care experience.7

FHIR

What is FHIR?

FHIR, or Fast Healthcare Interoperability Resources, is a standard developed for the electronic exchange of health care information. FHIR is part of the Health Level Seven® (HL7) standards meant to address challenges facing digital health record processing, in which EHRs must be made available, discoverable, and understandable.9 FHIR is essentially used to join disparate EHR systems and has promise for the development of application-based approaches to data exchange.

KRAMES PatientEducation_KOF_general

How does FHIR work?

The focus of FHIR is to simplify system integrations in order to improve interoperability. The basic units of interoperability are “resources,” and FHIR is built on the concept of breaking down exchangeable content into resources that may be incorporated into existing systems. As basic building blocks to be interpreted by a range of web and mobile applications, cloud communications, and EHR data sharing, these resources must have a common definition and method of representation, a common set of metadata, and a human-readable part.9,10

Why is FHIR important?

FHIR provides a standardized way to represent and share patient data regardless of how local EHRs represent or store this information. This provides flexibility to facilitate seamless data exchange across a wide variety of use cases within the health care ecosystem. Ultimately, FHIR supports improved patient care by alleviating providers from performing time-consuming administrative tasks like accessing patient data from disparate EHR systems, allowing them to instead focus on the patients’ health needs.

What is SMART on FHIR?

FHIR allows the SMART applications to retrieve and exchange data among authorized EHR systems, alleviating the burdensome task of collecting and consolidating data from disparate sources. SMART interacts with and works on top of FHIR interfaces (hence, SMART on FHIR), ensuring the application adherence to protocols of data exchange.8

What are HL7 standards?

HL7 standards were created to address challenges facing digital health record processing, in which EHRs must be made available, discoverable, and understandable. HL7 applies structure and standardization to data exchange and information modeling used to support automated clinical decision-making and machine-based processing. Today, over 90% of U.S. health care systems use HL7 standards.11

Benefits of true interoperability

True interoperability—within multiple health system locations and, ideally, outside the organization—allows clinicians to gain a full picture of the patient’s medical history and health, and make better care choices for patients, diagnose issues earlier on, and reduce misdiagnosis. Interoperability is designed to improve clinical workflow efficiency, ultimately driving better health outcomes.7

Interoperability furthermore facilitates patient engagement, helping develop a more informed patient. For example, Krames On FHIR® combines SMART and FHIR specifications to support patient education applications that, when launched within the EHR, retrieve information about your patient’s conditions, medications, and procedures while presenting educational resources customized for that patient’s needs. Krames On FHIR then posts back in the EHR system the resources that were shared with the patient, completing the information loop.

KOF Activity History Screenshot

 

Clinical Workflow

An EHR system must be compatible with an organization’s clinical workflow to help providers coordinate care as efficiently as possible.

A clinical workflow involves EHRs in several ways: scheduling patients, managing communications between patients and providers, checking patients in and out, administering certain clinical exams, renewing medications, and even connecting patients to relevant patient education.

Krames On FHIR, for example, launches within the EHR experience to deliver up-to-date, customized patient education, both at the point of care and throughout the patient journey.

EHR integration improves clinical workflow

The ability to integrate patient education resources into the clinical workflow and make them directly available through an electronic system ultimately saves everyone on time and cost: It empowers patients to manage their own health, helping avoid unneeded visits to the doctor’s office. Moreover, greater interoperability benefits the clinical workflow as it allows providers more time to focus on treating the patients and less time in front of a screen searching for and deciphering important health information.

EHR requires habitual use to provide real value

For an application like an EHR to deliver on its stated aims, providers must use it habitually and continuously. In fact, without physicians contributing a complete picture of patient information, a robust EHR system is meaningless. As a clinical workflow touches many different parts of the health care system—clinicians, technicians, informatics, and patient experience teams—the EHR system should facilitate efficiency and efficacy without burdening these teams to access data from disparate sources.

EHR plugins help support clinical workflow

An EHR system alone is not as powerful as an EHR system with complementary solutions that are integrated into the system. These solutions range from administrative functions to patient access and telehealth; they’re typically marketed as add-ons or plugins meant to enhance the functionality of EHRs. Rather than overhaul a complete EHR system, these integrations can be used strategically to improve functionality in areas that need attention, for example, customer relations or practice management.

With 29% of the hospital market, Epic Systems reigns supreme over EHR vendor competitors.12 The Epic App Orchard helps developers pair plugins with their EHR system, including applications to support real-time, evidence-based decision-making, apps that prepare clinicians for procedural changes through roleplay, and others that provide clinical skills guidance for nurses performing an unfamiliar procedure. 

As busy nursing and interdisciplinary care teams treat more patients than ever before—which includes the time-consuming task of arming them with well-researched education—they can access a new, all-in-one solution from Krames and Zynx Health. It delivers relevant, evidence-based Krames education mapped directly to teaching points in Zynx Best in KLAS care plans, pushed to the patient portal via Krames On FHIR—to simplify workflows, improve clinician engagement, and increase care quality.

Implementation

The first step in developing an EHR-friendly workflow is implementing the right tools (and right partners). These should support the increased access and engagement of both patient and provider. For example, Krames On FHIR—pretested and pre-certified with Epic software—integrates directly within the provider’s EHR clinical workflow, delivers robust patient education content, and eliminates unnecessary clicks, apps, and delays.

Best practices

When implementing new technologies that impact system-wide clinical workflows, following best practices can alleviate concerns of losing data and time spent getting the system and staff up to speed. Here’s how to develop an EHR-friendly workflow:

  • Partner with an experienced, proven implementation team as it’s vital to long-term adoption of new EHR systems and workflows.
  • In planning the implementation, rollout, and transition from legacy EHR systems, maintain continuous communication and training to develop a successful clinical workflow.
  • Work with a trusted partner to help you anticipate risks and advise on frequent questions.
  • Create an open feedback loop with end-users to ensure you’re continuously improving the user experience by reducing the number of clicks, improving app launch time, search function, and reducing other areas of friction.

Krames on FHIR implementation case study: Singing River Health System

Singing River Health System, a large health system on the Mississippi Gulf Coast, worked with Krames to follow a smooth implementation process for Krames On FHIR.13 Krames helped tailor a patient education solution to fit the system’s clinical needs while ensuring integration with clinician workflow, connectivity to the patient portal, and access to after-visit summaries. 

Furthermore, Krames tested resource weight on the network and end-user experience, educated Singing River staff on the transition to Krames On FHIR and the application itself, and continued to provide training and develop tip sheets after the system was live. Along with providing tailored and always-up-to-date content, extensive testing and ongoing communication are central to Krames’ implementation process and key to delivering user and patient satisfaction.

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Vendors vs. partners

Simply stated, the difference between vendors and partners is where vendors supply a product or service, partners become an extension of the client’s business. The vendor relationship is straightforward, and, typically, you don’t need strategic advice beyond their service offerings. A true partnership, on the other hand, will recommend a product other than their own if it provides a better solution for your organization.14

Identifying the right strategic partner—or building a true bidirectional relationship with a supplier—requires time and mutual trust.15 Developing a true partnership is worthwhile when investing in a significant project or overly complex technical endeavors, such as integrating a sophisticated EHR system with SMART on FHIR applications.

A true partner aligns you with the right vendors

Krames, for example, partners with various EHR vendors to bring their clients the most capable, comprehensive solutions. Krames helps their clients identify gaps in existing EHR systems and continuously offers updated solutions for a better end-user experience. These solutions include integrating patient education into a telehealth workflow, creating user interface enhancements, optimizing outpatient workflow, and more.

In other words, a partnership with a company like Krames is advantageous to your organization as they work with other trusted vendors to tailor services to your needs. Krames works tirelessly to optimize solutions that reduce the manual effort required by clinicians. Content updates and maintenance patches are automatically pushed out to clients, reducing the burden on IT teams. Krames has been a trusted advisor through countless EHR installations and migrations, helping their clients expedite the deployment process. Their team of experts is with you every step of the way.

Krames On FHIR implementation webinar:
Houston Methodist Health System

Krames_pillar_1200x627_HMwebinar

Clinical leaders and IT specialists from the Houston Methodist Health System worked with Krames in 2019 in completing a system-wide implementation of Krames On FHIR to streamline EHR systems and patient resources across all eight of their hospitals. As an early adopter of Krames On FHIR, Houston Methodist was able to position themselves as an innovator in their market space. 

Houston Methodist’s primary argument for choosing Krames On FHIR included ease of updates (an invaluable solution for their IT department), clinical workflow support (providing tools for clinicians available at their fingertips), and video resources for patients (known to improve patient engagement over material handouts). Based on Houston Methodist’s goals and feedback, Krames then made practical recommendations to their technology road map, establishing best practices and enhancing implementation offerings for future clients.

Technology and telemedicine

The coronavirus pandemic has made the role of technology in health care more prominent than ever. As we’ve previously discussed, electronic health records—and the systems that access them—are integral in delivering coordinated, quality care to patients. But in the wake of COVID-19, additional features like telehealth capabilities are now mandatory for health care systems to provide continuous care in today’s health landscape.

Telehealth

Prior to the COVID-19 outbreak, only 25% of patients reported using telehealth services; less than a year into the pandemic, nearly 60% of patients embraced the use of telemedicine and a third said they would even leave their physician for a provider who offers it.16 If your health care system hasn’t integrated telemedicine into their platform yet, now’s the time.

Krames On FHIR supports access to virtual care. To integrate EHR and features like patient education into a telehealth workflow, Krames has partnered with Epic software. Epic’s telehealth module follows an ambulatory workflow, much like an office visit, and even allows providers to send patient education to MyChart, Epic’s patient portal.

Integration of telehealth

Integrating telehealth capabilities to work with your EHR system requires following SMART on FHIR specifications or partnering with a trusted group to make the integration process as easy as possible. Krames has proven the ease of implementing telehealth following their new release of Krames On FHIR, which in the case of the North Mississippi Health Services, took less than a day to configure the telemedicine feature.16

While many EHR systems currently provide basic telemedicine functions, a self-standing platform like Epic has many more features: appointment scheduling, e-prescribing, sharing lab and imaging results, and accessing devices on the patient’s end to function like clinical instruments, for example, digital stethoscopes and other types of scopes.17

The role of EHR in telehealth

EHR plays a foundational role in the telehealth experience. In fact, Epic’s telehealth module opens a virtual visit directly within a hospital’s EHR system, in which patient information and preferences, along with patient education, are directly accessed and updated. In other words, to access telemedicine, a patient requires access to EHR.

Patient engagement 

For improved care outcomes, patient engagement is a vital aspect of health care delivery. Engaging patients via a patient portal empowers the patient and gives them a role in shaping their own health experience.

Based on EHR integration, patient portals can manage the most up-to-date information on a patient’s health and even suggest customized, sharable patient education resources in a variety of formats (digital, video, print).

Krames On FHIR launches within the EHR experience to deliver award-winning Krames On-Demand® content where it has the greatest impact on outcomes: at the point of care. The value of engaging patients during the act of delivering their care helps physicians bridge gaps in health literacy. What do the patients actually understand about their condition, and why they need to adhere to their prescribed care regimen?

KRAMES PatientEducation_KOF_diabetes

The role of EHR in patient engagement

Health care organizations must keep pace with other industries in delivering a personalized patient experience that coordinates digital and physical touchpoints. This keeps patients engaged with their care plan and your practice, even beyond their visit. Krames mobile-first solutions extend the EHR to patients on their mobile devices—engaging them outside of the exam room and boosting adherence to care plans.

Patient portals based on integrated EHR systems not only provide access to care and resources, but they track important health information and provide context to help a patient understand changes to their health over time. EHR integration improves the engagement factor of patient portals in part by personalizing the data and inviting interaction but also by providing them flexibility with 24-hour access.

Industry standards / accreditation

When it comes to sensitive health data, organizations are right to be concerned about security. Whether you’re looking to implement SMART on FHIR or integrate patient education into your EHR system, ensure the software and health content providers you enlist maintain URAC (Utilization Review Accreditation Commission) accreditation.

URAC accreditation demonstrates a health care organization’s commitment to quality and safety and ensures your organization’s compliance with national industry standards.18

Furthermore, just because EHR allows physicians to use patient data to improve the provision of care, this does not change their obligation to keep health data private and secure.

To address these concerns, EHR systems have built-in safety measures, including access controls like passwords or PIN numbers, encryption of stored data that only authorized individuals can “decrypt,” and an audit trail that tracks who accesses data and any changes made to it.19 If a data breach does occur, providers are obligated by law to inform the patient.19 Furthermore, ISO 27001 Certification demonstrates that products like Krames On FHIR and Krames On-Demand adhere to rigorous international security standards, ensuring the confidentiality, integrity, and availability of valuable health information.20

“Meaningful Use” vs. MIPS

Quality initiatives like “Meaningful Use” are critical for guiding interoperability standards within a health care system and defining how EHR is used. Meaningful Use is a concept that describes the use of EHR in a meaningful way (for example, electronic prescribing) to ensure that the exchange of health information improves the quality of care.21

MIPS, or Merit-based Incentive Payment System, is a value-based reimbursement program that rewards providers based on the quality of care they provide.22 MIPS now encapsulates Meaningful Use objectives to reflect how providers utilize EHR, focusing on interoperability and appropriate information exchange.

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REFERENCES

1 Garrett P, Seidman J. EMR vs EHR – What is the difference? Health IT Buzz Blog. https://www.healthit.gov/buzz-blog/electronic-health-and-medical-records/emr-vs-ehr-difference. January 4, 2011. Accessed March 11, 2021.

2 What are the differences between electronic medical records, electronic health records, and personal health records? Health IT Web site. https://www.healthit.gov/faq/what-are-differences-between-electronic-medical-records-electronic-health-records-and-personal. Updated May 2, 2019. Accessed March 11, 2021.

3 Sullivan T. HIMSS writes new definition of interoperability. Healthcare IT News Blog. https://www.healthcareitnews.com/news/himss-writes-new-definition-interoperability. Published March 22, 2019. Accessed March 20, 2021.

4 Huynh K, Dzabic N. Industry voices—Interoperability can cut health costs by $30B; But this needs to happen first. Fierce Healthcare Blog. https://www.fiercehealthcare.com/tech/industry-voices-interoperability-can-reduce-healthcare-costs-by-30b-here-s-how. Published August 25, 2020. Accessed March 20, 2021.

5 Interoperability. Health IT Web site. https://www.healthit.gov/topic/interoperability. Updated May 9, 2019. Accessed April 1, 2021.

6 Hyle P. FHIR power: Picture-perfect for patient engagement. Krames Blog. https://www.krames.com/insights/fhir-power-picture-perfect-for-patient-engagement. Published January 7, 2021. Accessed March 11, 2021.

7 Collier M. Ignite data interoperability with SMART on FHIR. Krames Blog. https://www.krames.com/insights/ignite-data-interoperability-with-smart-on-fhir. November 27, 2018. Accessed March 11, 2021.

8 McLaughlin G. What is SMART on FHIR? Redox Blog. https://www.redoxengine.com/blog/what-is-smart-on-fhir. Published May 19, 2017. Accessed March 20, 2021.

9 FHIR overview. HL7 International Web site. https://www.hl7.org/fhir/overview.html. Updated November 1, 2019. Accessed March 20, 2021.

10 Bresnick J. 4 basics to know about the role of FHIR in interoperability. Health IT Analytics Blog. https://healthitanalytics.com/news/4-basics-to-know-about-the-role-of-fhir-in-interoperability. Published March 22, 2016. Accessed March 20, 2021.

11 HL7 Introduction: Importance, uses & benefits of developing HL7 Apps. Covetus Blog. https://www.covetus.com/blog/hl7-introduction-importance-uses-benefits-of-developing-hl7-apps. Published October 7, 2019. Accessed March 20, 2021.

12 Landi H. Epic, Meditech gain U.S. hospital market share as other EHR vendors lose ground. Fierce Healthcare Web site. https://www.fiercehealthcare.com/tech/epic-meditech-gain-u-s-hospital-market-share-as-other-ehr-vendors-lose-ground. May 1, 2020. Accessed April 14, 2021.

13 A smooth HIT implementation with continuous communication. Krames case study. https://www.krames.com/hubfs/FHIR_Case%20Study_SingingRiver.pdf. Accessed March 21, 2021.

14 Gray P. Are your suppliers vendors or partners (and why it matters)? Tech Republic Blog. https://www.techrepublic.com/article/are-your-suppliers-vendors-or-partners-and-why-it-matters. Published November 6, 2018. Accessed March 22, 2021.

15 Gunn J. StayWell’s Krames On FHIR app listed in APP Orchard. Krames Blog. krames.com/news/staywells-krames-fhir-app-listed-app-orchard. Published November 15, 2017. Accessed March 22, 2021.

16 Casper S. North Mississippi Health Service’s enhanced telehealth experience for both patients and physicians. Krames Blog. https://www.krames.com/insights/telehealth-patient-education-solutions-right-there-when-seeing-a-doctor-for-remote-care. Published July 22, 2020. Accessed March 22, 2021.

17 How to start doing telemedicine now (in the COVID-19 crisis). Krames Blog. https://www.krames.com/insights/how-to-start-doing-telemedicine-now-in-the-covid-19-crisis. Published April 23, 2020. Accessed March 22, 2021.

18 Accreditation standards and requirements. Case management study guide glossary of terms. https://casemanagementstudyguide.com/ccm-knowledge-domains/principles-of-practice/accreditation-standards-and-requirements. Accessed March 22, 2021.

19 Rodriguez, L. Privacy, security, and electronic health records. Health IT Blog. https://www.healthit.gov/buzz-blog/privacy-and-security-of-ehrs/privacy-security-electronic-health-records. Published December 12, 2011. Accessed March 22, 2021.

20 Gerlock K. ISO 27001 Certification: What it means for StayWell clients. Krames Blog. https://www.krames.com/insights/iso-27001-certification. Published September 23, 2019. Accessed April 2, 2021.

21 Public health and promoting interoperability programs. CDC Web site. https://www.cdc.gov/ehrmeaningfuluse/introduction.html. Updated September 17, 2020. Accessed March 22, 2021.

22 What is MIPS? Practice Fusion Web site. https://www.practicefusion.com/value-based-reimbursement. Accessed March 22, 2021.

FHIR® is the registered trademark of HL7 and is used with the permission of HL7.