Abstract This paper analyzes the importance of interoperability implementation in electronic healthcare records and how HL7 plays a major in the transition from functional interoperability to semantic interoperability

This paper analyzes the importance of interoperability implementation in electronic healthcare records and how HL7 plays a major in the transition from functional interoperability to semantic interoperability. Interoperability assists in setting standards needed for shared information to be communicated and understood via a secure format. EHR have been a major factor in removing the barriers of exchanging patient care information amongst physicians. Interoperability of EHRs have been theorized to be a significant factor in decreasing the cost and delivery of quality healthcare. Multiple studies were analyzed in order to determine if a fully semantic interoperable system is best for medical devices in health care entities. The shift to an interoperable healthcare system is costly, but research shows that the benefits are significant in reducing the amount of healthcare related errors and waste which spillovers into decreasing the overall cost of healthcare.
Research Question: Does semantic interoperability of EHR systems implemented under development standards such as HL7, increases or decrease healthcare delivery and quality.
Null Hypothesis : Semantic interoperability of EHR systems implemented under development standards such as HL7, does not increase or decrease healthcare delivery and quality.
Alternative Hypothesis: Semantic interoperability of EHR systems implemented under development standards such as HL7, does increase or decrease healthcare delivery and quality.
Most medical devices that are used today are mobile and have internet capabilities via movie networks. These medical devices use IEEE standards in order to generate the data necessary to transmit data for EHRs to health information exchanges via HL7. On of the biggest challenges of the implementation of EHRs is semantic interoperability. For decades, patient data was always paper-based. A digital format of patient information is referred to as EHRs. Electronic health records can be stored, retrieved and shared via a network implemented by information technology. Interoperability is one of the key factors of insuring that EHRs are able to transmit quality information. It allows for a seamless exchange of information that may improve healthcare quality, lower costs, reduce medical and administrative erros. Poor communication and inaccurate information entry and reporting Is the main source of medical error. HL7 is a set of standadrs aims to compact these issues by developing and implanting semantic interoperability.
What are EHR Systems
EHR systems or electronic health records are electronic documents of patient information, health history patient and clinical demographics, lab results, patient x-rays, immunization records, prescription history, and patient alerts and messages from physician. As EHR implementation is rapidly growing, so is the factor of interoperaility. Interoperability allows for the exchange of EHRs between healthcare systems. It also enables patient records to be shared amongst different healthcare professionals at different locations. EHRs can create a wider, seamless flow of information. the objective of EHRs is to facilitate electronic health services that are interoperable among a number of domains such as laboratory, patient administration, and pharmacy. (Figure 2.) It allows patient records and other pertinent information to be readily available. This information is beneficial to making healthcare-crucial decisions.
An electronic health record systems purpose is to eliminate the use of paper based patient records. ‘It is a repository of information regarding the health status of a subject of care in computer process form’ (ISO/ TR 20514). While an EHR does contain the medical and treatment histories of patients, an EHR system is built to go beyond standard clinical data collected in a provider’s office and can be inclusive of a broader view of a patient’s care. EHRs can: (healthit.gov)
• Contain a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results
• Allow access to evidence-based tools that providers can use to make decisions about a patient’s care
• Automate and streamline provider workflow
There are 3 different types of EHR systems:
• Local
• Shared
• Directory service
The shared EHR typically contains summarized information that is of interest to multiple types of providers, whereas a local EHR contains detailed information usually of interest to a single type of provider. (Bird, Goodchild, and Tun). Sammerville and Sawyers 1997 suggest that specification should be implemented in order to be successful other requirements consist of non-functional and functional components.Functional system constraints depicts the level of ability of a system to exchange information between systems.

Figure 2.Electronic Health Recods Systems Workflow

What is Interoperability
Interoperability is defined as the ability of two or more components to exchange information and to use and understand the information that has been exchanged. (IEEEE,1991).
In a healthcare setting, there are 3 levels of interoperability:
1. Functional
2. Structural
3. Semantic
In order for EHR systems to achieve semantic interoperability, it must be able to maximize the ability of the shared information and utilization. In order for interoperability to provide meaningful information that can be understood, it must e semantic. Functional interoperability is the basic exchange of data between information technology solutions. In a functional interoperability bases system, the end user must be able to interpret the data that has been sent. Structural interoperability insures that clinical data remains constant. Unlike functional interoperability, it has the ability to interpret data for the end user. Semantic data is exchanged and interpreted for the end user; therefore, the information can be understood and used in decision making processes. Functional and semantic interoperability are achieved when the same information distributed is the same information being received.
Within an institution, interoperability means that data from different departments or services (eg,pharmacy, radiology, clinical laboratory, pathology)can be interfaced and exchanged. Under a national rapid-learning system, interoperability re?ects the need to have health information exchanged across organizations—not just between private organizations or academic institutions, but also across sectors (public, private, and government). For interoperability to be achieved, data standardization is critical. Data standardization actively assists in the delivery of more ef?cient and higher-quality healthcare and therefore, EHRs will provide a means for aggregating patient-level data into a health information exchange system, or a system of coordinated and connected databases, that can be analyzed to advance health care delivery and quality (Baker ,2015). . In their fullest capacity, EHRs are anticipated to improve clinical documentation and ef?ciency, access to information, and provide a portal for informatics-enabled research. This research can be used to eliminate health disparities amongst difference socio economic statuses within any country. Most currently implemented EHRs adequately collect, document, and display clinical information, but there is a signi?cant challenge in translating this information into useful elements that are readily shared ,interpreted, and analyzed. EHRs are generally not yet interoperable (Miriovsky., Shulman, and Abernethy, 2012). Lack of interoperability standards pose a threat to medical record exchange through the internet. EHRs without standards pose a threat of systematic medical errors. By reducing the need for a custom interoperable system, it is best to just use a commonly adopted and accredited set of standards such as Hl7.
The value of Interoperability
Interoperability equips primary care physicians the ability to make informed decisions faster my accessing medical documents via mobile devices and broadband internet or Wi-Fi. It also, with the help of cloud computing, allows previous medical and prescription history of patients to be access at different geographical locations. Because of interoperability, a PCP can send patient’s prescription to the pharmacy and the sense interoperability is becoming more systematic, the pharmacist can understand and make sense of what information has been sent in order to prepare the correct prescription. The government has played a crucial part in the implementation and the health information exchange (HIE) within the nations healthcare facilities. In 2009 president Obama introduce the HITECH Act due to the implementation of the American recovery and reinvestment act. This pushed for the nation’s healthcare delivery system to shift to digital format of patient care information. As a result of this electronic healthcare record systems were created (EHRs). The HITECH Act allocated around 35 billion dollars in incentives to push for the expansion and adoption of EHR systems in healthcare facilities. This push for adoption of EHR systems not only created the need for security and privacy precautions, but the ability to exchange information back and forth. Thus, the factor of interoperability comes into play when trying to combat this issue.
3 major goals of implementing interoperable EHR systems nationwide is to:
1. Send, receive, fins and use primary data domains to improve healthcare outcomes
2. Expand data sources to improve healthcare and lower costs
3. Improve healthcare through real-time data access

A study conducted by the West Health Institute in 2017 estimated that widespread medical device interoperability can eliminate 36 billion dollars that will be wasted in the healthcare system (Figure 4.). The bulk of this waste (97 percent) relates to the lack of interoperability itself, with the remainder coming from the lack of commonly implemented standards (such as HL7).
HL7 and the Barriers and Challenges Associated with Implementing Interoperability
Information technology infrastructure coincides with business, policy, and administrative aspects of an organizations workflow. Therefore, there are others that need to be aware of the importance of a semantic interoperable system and what needs to be done to implement that system from an administrative perspective. All EHRs must follow a certain data formatting standard. The most common one is Health level 7 or HL7.HL7 is an international standards development organization that serves the healthcare community. It is responsible for developinf specifications that can enable healthcare system applications to exchange a variety of health relate data. These standards are set to assist in developing and increasing efficiency and effectiveness of patient care and healthcare delivery as whole.
One of the main goals/priorities of HL7 is to development and implementation of an interoperable system. The shift from HL7 version 2 to version 3 plans to introduce semantic interoperable capabilities for electronic health records. In order to do this, HL7 plans to ‘develop coherent, extendible standards that permit structured, encoded health care information of the type required to support patient care to be exchanged between the computer applications while preserving the information’s quality (Dolin and Alschuler, 2011).. Finally, finding a compatible EHR infrastructure is one of the most difficult things amongst others such as the lack of planning and sufficient knowledge of administration and other staff. The EHR system must be specific to meeting the needs of the organization. In addition to the knowledge and planning, finding the funds and designing a semantic interoperability EHRs deters health providers from switching from a paper- based system.

Figure 4. HL7 Interface (Source: HL7.org)
Since HL7 and EHRs work together as a collective unit to digitize patient records in a secured and comprehensive format, it also serves the purpose to eliminate data entry error. 35% of errors are made by incorrect data entry. HL7 based EHRs can be set up to notify nurses or healthcare coders where or if pertinent information is missing from the system or has been entered in an incorrect format. For example, if a nurse mistakenly enters in the patient’s date of birth with today’s date, the EHR system should flag it as incorrect.
Interoperability of EHR systems pay a major role in reducing the amount of time needed to manually enter information. Overall, this allows a smoother, faster, efficient workflow and increased quality of patient care, which, in turn, can reduce the amount of patients that are readmitted. As a result, healthcare can be provided at lower costs with the help of interoperable EHRs systems by decreasing the length of admittance times, which means there is increased availability of nurses and doctors. Increased capacity creates an opportunity for providers to right-size their appropriate bed utilization and management metrics which can expand access to care for patients (Sachdeva and Bhalla, 2010). Challenges with usability, productivity levels, interference with patient face time and interoperability are now well-known drivers of user dissatisfaction with EHR (Healthcare data solutions white paper) (Figure .3). The lack of interoperable systems can compromise patient safety, reduce the quality of care, and hinder the progress of achieving better healthcare (Schlabig Williams, 2014).). Lack of interoperable standards in EHRs lead to an increase in wasted funds due to things such as:
• unnecessary repeated medical testing
• drug prescription error
• medical diagnosis error
• time to manually enter data
• decreased response times

Figure 3. EHR Challenges (Source: capturebilling.com)
Cost Benefits
A 2017 analysis by the congressional budget office produced reports that suggested that the agency the department of veteran’s affairs, its use of health IT has reduced its costs and greatly improved the quality of its care. (Congressional Budget Office, 2007). EHealth systems with information exchange functionalities also showed potential impact on quality of care or patient outcomes. From five studies, one had inconclusive results on direct patient care and four presented partial effects, as nursing staff efficiency led to a faster call response, a decrease in unplanned ICU admissions and hospital mortality, improvement of health data quality and more efficient (Reis, Marcolino, Becerra-Posada, Novillo-Ortiz, and Ribeiro, 2017). Being able to Achieve interoperability between varied health information systems is very important, as it will reduce health-associated costs and contribute to more effective patients treatment.. This achievement will also assist in locating where information exchange between entities is flawed. The information can then be used to eliminate wasteful spending such as redundant testing and careless medical diagnosis or prescription errors. The interoperability between health information systems is only possible through the definition of standard messages, which must be adopted by all manufacturers of this type of technology, in order not to put into question the effective functioning of these systems 2. Among the different standards used should be highlighted by its features the HL7 (Health Level Seven) and the DICOM (Digital Imaging and Communication in Medicine) (Walker and Pan,2005.)
A study conducted by the West Health Institute set out to determine the effect of medical device interoperability on health care costs. The study examined the primary sources of waste in health care that could be eliminated with the implementation of medical device interoperability in addition to the waste that is produced from a lack of commonly adopted interoperability standards like HL7. The report’s ?ndings suggest that increased medical device interoperability would reduce waste, lead to improvements in quality and decrease the cost of care overall. One of the main reasons healthcare costs are so high is because of the costs and time required to implement a fully interoperable system.
Switching from a functional to semantic interoperable electronic health record system is key factor in combatting the issue f rising health care costs. In addition to reducing costs, a semantic system decreases the amount of medical errors and time wasted dealing with medical data entry. While semantic interoperability is hard to achieve, organizations such as Health Level 7 are collaborating to create standards to make the exchange of EHRs comprehensive ad rapid, while still maintaining a high level of data quality.
As many studies have shown that though rapid access to clinical information, creating medical devices that are completely interoperable is crucial in shortening patient length of stay which can also lead to a greater capacity for other patients to be started and have faster response times. Therefore, semantic interoperability of EHR systems implemented under development standards such as HL7, does increase or decrease healthcare delivery and quality and the alternative hypothesis can be accepted and the null rejected. HL7 architectural structure is providing these medical devise to be semantically interoperable while also exchanging quality information that is equitable, patient-centered, efficient, and effective in a timely manner. Without interoperability of EHRs the cost of healthcare will remain high and the amount of medical errors will continue to decrease the quality of healthcare in its entirety.