Directly Integrating Health Information Exchange (HIE) Data with the Electronic Health Record Increases HIE Use by Emergency Department Clinicians

Abstract

Objectives: This article (1) develops a Fast Healthcare Interoperability Resources app, Health Dart, that integrates information from Indiana's community health information exchange (HIE), the Indiana Network for Patient Care (INPC), directly with Cerner, an electronic health record (EHR), and (2) evaluates the effect of Health Dart's implementation on HIE use.

Methods: Health Dart was implemented in 14 Indiana University Health emergency departments (EDs) using a stepped-wedge study design. We analyzed rates of INPC use in 286,175 ED encounters between October 1, 2019 and December 31, 2020. Logistic regression was used to model the probability of INPC use given the implementation context, such as user interface (UI) enhancements and the coronavirus disease 2019 pandemic.

Results: INPC use increased by 131% across all encounters (from 3.6 to 8.3%; p < 0.001) after Health Dart implementation. INPC use increased by 144% (from 3.6 to 8.8%; p < 0.001) more than 2 months postimplementation. After UI enhancements, postimplementation INPC use increased by 123% (from 3.5 to 7.8%) compared to 181% (from 3.6 to 10.1%; p < 0.001) in postimplementation encounters that occurred before UI enhancements. During the pandemic, postimplementation INPC use increased by 135% (from 3.4 to 8.0%; p < 0.001) compared to 178% (from 3.6 to 10%; p < 0.001) in postimplementation encounters that occurred before the pandemic. Statistical significance was determined using 95% confidence intervals (α = 0.05).

Conclusion: Direct integration of HIE information into an EHR substantially increased frequency of HIE use, but the effect was weakened by the UI enhancements and pandemic. HIE information integrated into EHRs in the form of problem-oriented dashboards can potentially make information retrieval more efficient and effective for clinicians.

Keywords: COVID-19 pandemic; FHIR; Fast Healthcare Interoperability Resources; electronic health record; emergency departments; health information exchange.

Fig. 1

The Health Dart app within PowerChart, the Cerner EHR, showing HIE information relevant to chest pain. EHR, electronic health record; HIE, health information exchange.

Fig. 2

Software architecture and application workflow of Health Dart. The workflow consists of the following steps: Cerner PowerChart loads Health Dart into a dedicated frame, and passes the provider credentials, along with the patient identifier, to the app (1). Health Dart posts a request (using the HTML POST method) for data to the Back-end for Front-end Service (2). The Back-end for Front-end Service forwards the user credentials and context to the Authentication Processor (3). The Processor checks the request against various business rules, such as whether the user is authorized to use Health Dart and access data about the specific patient. The Processor logs the login request (4) and verifies the credentials (5). The result of the credential verification is returned to the Back-end for Front-end Service (6) that then communicates with the API Server to retrieve data (7) if the user is authorized to use Health Dart and access data. (If that is not the case, the Back-end for Front-end Service returns an error message to Health Dart [not shown].) The API Server comprises a number of APIs, including a commercial FHIR API (Mulesoft, San Francisco, California, United States). The FHIR Server connects to the Indiana Health Information Exchange Database to query the requested resources (8), which provides them to the API Server (9). The API Server communicates them to the Back-end for Front-end Service (10). After performing any transformations needed, the requested content is provided to the app (11). The response body is used by the app to place content in the PowerChart frame (12).

Fig. 3

Monthly rates of HIE use in each Health Dart rollout wave. HIE use is defined as accessing the HIE either through Health Dart or the Web-based application during a patient encounter. Health Dart was implemented in four Wave 1 sites on December 13, 2019; three Wave 2 sites on February 7, 2020; three Wave 3 sites on June 8, 2020; and four Wave 4 sites on August 3, 2020. The rollout study was temporarily paused between Wave 2 and Wave 3 due to the COVID-19 pandemic. A total of 110 encounters had missing data (0.04%). Due to technical limitations, the Health Dart application was available in Cerner Powerchart across all sites in April 2018; therefore, we could not prevent use of the application prior to the study period for each wave. HIE, health information exchange; UI, user interface.

Fig. 4

Rate of HIE use before and after Health Dart rollout at 14 IU Health EDs in four rollout waves. HIE use combined access through the Web-based viewer and Health Dart. ED, emergency department; HIE, health information exchange; IU, Indiana University.