theBlueButton includes access to a “continuity-in-care” document. The patient can authorize access to the information between theVA and community providers, facilitating the exchange of information within and across healthcare systems. Most recently, in 2012, Blue Button incorporated the use of “open notes,” encouraging discussion with providers and enhanced patient engagement through allowing patients to view progress notes.14 Bar codemedication administration: Perhaps one of the earliest


examplesof an interoperable electronic nursing interventionwas bar code medication administration. Scanning the patient’s wristband andthen themedicationis an automatedmethodof ensuring that the correctmedicationis being administered tothe correctpatient, at the correct time and in the correct dose via the correct route. Not only havemedicationerrors decreased across theVAsince the inceptionof the bar code system, but severalother beneficialoutcomes have been noted.Real-time documentation allows medication administration data to be readily available to other clinicians. Bar code medication administration has also been associatedwith a reduction innursing time spent on medication administration-related activities. Nurses reported satisfaction with the bar code system because of its safety mechanism, ease of use and efficacy in reducingmedical errors. Clinical workflow: the end-all, be-all:Nurses can be using the


most sophisticated, interoperableEHR, but if clinicalworkflowisn’t taken into consideration when designing the system, significant value is lost. Clinical workflow varies considerably from organi- zation to organization, and even within an organization.When a disparity lies between system design and the real-life day-to-day tasks of care delivery, problems arise. Some challenges nurses encounter that disrupt their workflow include having to log into multiple systems, excessive use of the keyboard to input data, poor screen design for patientmedication profiles, cluttered note screens and orders, increased number of clicks to document a task16


and


the perception that the nurse spendsmore timewith theEHR than with the patient. Systems that are designedwith clinical workflow in mind are more likely to improve nursing care, coordination of care and patient safety.17


Workflow-designed systems make


documentation more streamlined and documentation standards easier to achieve. An issue in clinical workflow design known as “workarounds” can potentially alter patient safety standards. A workaround occurs when a healthcare provider takes a shortcut to save time rather than complete the task using the “best prac- tice” approach. For example, in the case of bar code medication administration, the nurse may scan an unattached patient IDlabel rather than scanning the actual patient ID band on the patient thus increasing the risk for a medication error. A major point in the interoperability improvement processmust include identifying workarounds, addressing the issues and finding solutions.18


What role(s) can nurses play? Nurses can influence interoperability in health information tech- nology (IT) at the bedside and in leadership roles. Being involved in committeesor groups thatdeveloppolicies andprocedures about the use of theEHRwill ensure that the value and quality of nursing care is achieved.Nurses knowpatients and they understand best practice workflowsthat support excellence inpatient care. The feedbacknurses can provide to ensure theEHRis designed with best practice clinical workflows will positively shape the future of interoperability.Nurses


The hospital ED where a 45-year-old man is transferred after a mo- tor vehicle accident has an electronic health record (EHR) in place. However, the hospital’s EHR does not connect (interoperate) with any other EHR. The patient arrives unresponsive with the following vitals: BP 90/40. RR 28, deep respirations noted. Neurological assessment reveals pupils 3/2 with equal but slow reaction to light and stimulation. The patient has suspected broken ribs and femur, along with a deep laceration on the face requiring stitches. CT scan is negative for brain injury or bleed. Labs are sent, but results are delayed because of a logistical error in the laboratory. The pa- tient is stabilized and admitted to ICU for close monitoring. Then the patient begins to decompensate. When labs finally return, blood glucose level comes back in the 500 range and ABG is not- ed for metabolic acidosis. The diagnosis of diabetic ketoacidosis (DKA) is made and treatment begins. After extensive treatment, the patient is discharged home. The patient is seen in the primary care provider’s office, and a copy of that encounter is faxed to the hospital for their records. The paper copy states that the patient has a history of poorly controlled type 1 diabetes mellitus.


1. If the ER had had access to an interoperable EHR: a. Treatment would have stayed the same.


b. A history of type 1 DM would have allowed for a more focused treatment plan.


c. The CT scan wouldn’t have needed to be performed. d. The lab wouldn’t have made an error.


2. The nurse quickly initiates DKA treatment, including insu- lin infusion, fluid replacement and electrolyte balancing measures because the physician used an electronic DKA order set template to write the orders in the EHR. This is an example of:


a. Clinical decision support systems b. Secure information sharing c. Bar code medication administration d. Security measures


3. The patient is at risk for skin breakdown secondary to immobility and his history of diabetes. One clinical deci- sion support system that has been shown to reduce the incidence of hospital-acquired pressure ulcers is:


a. A clinical alert reminder to turn the patient b. Statistics about skin breakdown prevalence


c. Educating nurses about the cost of hospital acquired pressure ulcers


d. A physician order to turn the patient every two hours


4. The nurse uses bar code medication administration to administer the patient’s insulin dose, along with other routine medications. Outside the room, the nurse scans the patient’s ID from a sheet of printed labels, then scans the medications, before going in to administer them. This is an example of:


a. Interoperability making the nurse’s job easier b. A “workaround” c. The five rights of medication administration d. A proficient nurse


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Answers


1. B—Previous medical history may help connect some missing links during what appears to be a straightforward trauma.


2. A—Specific, clinically relevant tools can help providers deliv- er safer and more efficient care.


3. A—Appropriately placed notifications raise awareness about preventable hospital-acquired conditions.


4. B—This is an example of a workaround, or shortcut, which can increase risk for medication error.


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