Organizing Clinical Information Systems to Manage and Improve Care

Jennifer Allan, BSN, RN Methodist Healthcare System Jane Englebright, PhD, RN Columbia/HCA Healthcare Corporation Our Documentation System 1994 to 1996

• Four sites using a computerized clinical documentation system – Two using NANDA format – Two using NIC format • One site on paper Unresolved Problems Included:

• Increased charting time, increased cost • Ambiguous, complex care plans • Hundreds of documentation screens • Physician dissatisfaction with • Physician dissatisfaction with medical record • Fragmented, duplicative and conflicting information in the medical record “Fix” the System or De-install!

• Meet legal, regulatory & clinical requirements • Decrease documentation time • Reduce costs • Eliminate repetition • Streamline record • Automate reports • Introduce interdisciplinary documentation • Lay foundation for quality monitoring • IMPROVE CARE Two Early Rewrites Used Established Nursing Taxonomies

Advantages Disadvantages

NANDA Well known to Foreign to non- nurses nurses Non-exclusive diagnoses NIC Facilitates Long look-up for charging and interventions acuity Does not tie to care plan Review of Literature

• NIC (Nursing Intervention Classification) • NANDA (North American Nursing Diagnosis Association) • Charting by Exception • Focus Charting • Problem Oriented (SOAP) • Practice Guidelines No current methodologies supported our vision:

Concepts from NANDA, Our NIC, Charting by Goals Exception, Systems Theory

Patient Centered Documentation © Methodist Healthcare System of San Antonio, Ltd.. Patient Centered Documentation • Single standard of care • Standards of practice for each patient care area • Rapid charting • Detailed patient assessment information • Automated connections between phases of care process • Clinical guidelines Any patient entering the MHS system at any level : Receives the same Standard of Care

Consistent Standards of Practice at all facilities across all “like” patient care areas Patient Centered Documentation

The foundation of the system is the Standards of Care for the Methodist Healthcare System Patient Centered Documentation Each patient care area within all facilities has identified standards of practice for defined patient populations

• Common interventions – Shift Assessment –Vital Signs – Discharge planning Patient Centered Documentation

Intervention Data Yes Custom screens Required developed No No Separate Minimum intervention or Expectation delete

Yes

Bundled Intervention Bundled Intervention = Care Area Statement • Unless otherwise documented the following assessments and interventions have been verified: • If on bedrest, patient turned q2h • Assisted with personal hygiene q24h • Linen changed as needed to maintain hygiene and comfort • Privacy provided Patient Centered Documentation Developmental Age Guidelines will be a component of each patient’s care. •Infant • Young Adult • Toddler •Middle Age • Preschool • Older Adult • School Age • Developmentally • Adolescent Delayed Patient Centered Documentation

Admission Admission Care Plan Triggers Assessments

Nursing Standard of Care Patient Type PT Standard of Patient Age Group RT Practice Age Guidelines Dietician Problems Individualized Plan of Care

Standard of Care

Standards of Practice Age Guidelines

Interdisciplinary Plan of Care Problems from Interdisciplinary Physician Orders Assessments Plan of Care

Patient Problems

Unit Care Guidelines Standards of Practice Age Guidelines Standard of Care Patient Centered Documentation Problem List

• Interdisciplinary • Systems framework • Actual problems for this episode of care • Potential problems requiring intervention Problems, Guidelines and Interventions

Problem/ Guideline Intervention Order Neurological None Neuro Assess High Risk Fall Fall Fall Precautions Precautions Chemotherapy Chemo None Patient Centered Documentation

Documenting Care

• Documentation screen mirrors care plan • Detailed documentation of abnormal assessment findings • Abbreviated documentation of routine care Patient Centered Documentation Back to Basics

• Quality measurement tool • Regular measurement of performance of care standards • Patient interviews and observations Pilot Study 1997

• 4 med/surg units •Time spent • 3 months documenting • Incremental overtime • User satisfaction Documentation Time

40 35 30

25 Nurses per shift 20 Mean charting minutes 15 per patient 10 5 0 Apr-97 May-97 Jun-97 Jul-97 * No change in ADC or Acuity Incremental Overtime

16 14 12 10 Mean Hours of 8 Incremental Overtime 6 Per Shift 4 2 0 Apr-97 May-97 Jun-97 Jul-97

An 8.2% Decrease in Salary Per Patient Day Nurse Satisfaction N = 30 18 16 14 12 10 Apr-97 8 Jul-97 6 4 2 0 1 23 Satisfied4 5 Very Dissatisfied Satisfied Nursing Administration Took Ownership!!

• Strategic objective for all five in system • System design process and organizational structure defined • Specific goals and expectations established for system • Resources allocated across system Synchronization required to meet goals • Charting philosophy • How documentation is • How documentation is accessed electronically done and on paper Challenges

• Large investment in current systems • History of not working together • Different levels of experience with computer systems • Multiple specialty programs • Resistance to change Goals

• Clear and concise medical record • Meet or exceed regulatory requirements • Improve staff efficiency • Improve patient care processes and outcomes • Enable clinical research Organizational Structure Clinical Informatics Coordinator Roles

Hospital A Hospital B Hospital C Hospital D

Med/Surg/ Jennifer ICU Rehab/SN Linda U/Psych Ancillary Cindy

Maternal/ Jean Child Clinical Information System Accountability Structure

Nurse Executive(s)

Steering Committee

PCM Coordinators

Clinical Medical Advisory Legal and User Groups Education Managers Committee(s) Risk SMEs Organizational Structure Steering Committee

• Oversee documentation and policy development • Insure appropriate experts have input • Mediate conflicts • Maintain focus on strategic objectives Ground Rules

• 80/20 Rule • Interdisciplinary commitment to no duplicate documentation • All data collected must be used for some purpose • One discipline cannot “dump” data collection responsibility on another Developing Clinical Documentation Largest User Group

Multidisciplinary Regulatory & Legal Clinical Input Review

Approval

Implementation Iterative Process

Next User Group

Multidisciplinary Regulatory & Legal Clinical Input Review

Approval

Implementation Implementation • March 1998 installed in 4 sites already using electronic documentation • September 1998 installed in 750 bed facility with no electronic documentation 25000 1.20

1.00 20000

0.80 15000 0.60

10000 0.40

5000 0.20

0 0.00 Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- 98 98 98 98 98 98 98 98 98 98 98 98 99 99 99 99 99 99

OT Hours OT Hours per Adj Pt Day Working Together Pays Off

• Design: • Maintenance: 5 FTEs for 6 5 FTEs for 5 months hospitals Evaluating Care

Initial Assessments Care Plan

High Risk Screens QI Reports Screening Tools Consult Reports Worksheets Chart Audits: Admission Assessments

MICU

100

95

90

% Completed 85

80 Mar Apr May Jun Jul Evaluating Care

Daily Documentation Medical Record Notes Graphs Profiles Variances Audits QI Reports Revenue Support Chart Audits:

Daily Documentation Daily Documentation

MICU

100

90 Care Area 80 Statement 70 Care Plan Evaluations % Completed 60 50 Mar Apr May Jun Jul Example: Restraints

Daily Documentation of Immobilization & Restraints

Report on Each Item of Immobilization & Restraint Protocol

Report to Managers for Trending and Follow-Up MSTH Nursing “LIVE” RESTRAINT Dates: 01/01/99 to 12/14/99 Acct # N350409782 77 M

Date Time Dang Self Grossly Explain Mental Restraint Circ Skin Order / Others Innap. Beh To Pt Status Type/ Loc Check Cond. Ver. ______10/09 1600 Y Y Y Combat Posey Vest/ Y N Y Bilat Ankles

10/09 1915 Y Y Y Combat Posey Vest / Y N Y Bilat Ankles

10/09 2000 Y Y Y Combat Posey Vest/ Y N Y Bilat Ankles

10/09 2100 Y Y Y Combat Posey Vest/ Y N Y Bilat Ankles Example: High Risk Falls

Q 8 Hour Documentation of Immobilization & Restraints

Daily or Shift Report of Fall Risk Score, Bedcheck, Education

Report to Managers for Trending and Follow-Up Figure 11

Methodist Hosp/Children's Hosp FALL RISK REPORT LOCATION: H.ORTH

PATIENT: UNIT #: AGE/SEX: 86 F ROOM/BED: H.334 A ACCT #: DATE TIME SCORE BC # SIDERAILS INSTRUCTION

12/13/991237 8 Y 4 Y 12/13/991700 8 Y 4 Y 12/14/990250 8 Y 4 Y

PATIENT: UNIT #: AGE/SEX: 60 F ROOM/BED: H.314 A ACCT #: DATE TIME SCORE BC # SIDERAILS INSTRUCTION

12/13/991942 5 N 4 Y 12/14/990231 5 N 4 Y 12/14/990745 5 N 4 Y

TOTAL # OF DOCUMENTATIONS: 124 Example: Nutrition

Nutrition Eval Dietician Nutrition Intervention Completes Nutritional Risk Problem? Added to Eval Assessed on Care Plan Admission

Problem, Goal, and Interventions Nutritional Risk to Care Plan Report to Dietician Daily Monthly QA Report METROPOLITAN METHODIST HOSPITAL 1999-2000

% @ Potential for Nutritional Risk by Priority Based on Total Admissions

40% 38% 34%

37% 42% 100% 46% 80%

60% 52% 55% 57% 55% 6% 8%50% 8% 0% 0% 0% 0% 0% 0% 40% 48% 0% 0% 0% 0% 0% 0% 20% 8% 8% 0% 0% 0% 0% 0% 0% 0% 8% Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May

Potential High Risk Potential Moderate Risk Potential for Status Change Regulatory Requirements • Three JCAHO surveys with results of each benefiting all five hospitals • Several state health department visits with results of each benefiting all five hospitals Example: Glucose Monitoring

Computer generates trended results report, charge, & audit

Nurse documents patient Initial audits revealed results and a 20% error rate!! QC Process Improvement: Glucose Monitoring

Step 1: 20% Monthly feedback to Error Rate staff and managers

Step 2: 1.5% Policy revisions Error Rate Step 3: 0.8% Documentation inservices Error Rate Education/Resource Savings

• Consolidated orientation & training • Shared staffing across units and facilities • Common training for agency, PRN, and students Physician Satisfaction

• Similar chart format at all hospitals • Only pertinent data on daily reports • Less bulky charts • First page of discharge report contains physician data • Fewer complaining nurses to work with!! Key Success Factors

!A documentation methodology !A design framework !An organizational structure Patient Centered Documentation

! Documentation time " Consistency and ! Size of medical record completeness of interdisciplinary record ! Physician complaints " Nursing satisfaction ! Costs " Usefulness of clinical ! Lost revenue data for process improvement, evaluation and strategic planning Based on the demands placed on this system during its first year, we are confident that we have developed a methodology that is flexible enough to meet new demands as they arise. ✡■❙ ✱◆❅▲▼❉❏ ■▲✟ Organizing Clinical Information Systems to Manage and Improve Care

Jennifer Allan & Jane Englebright

Handouts 1. Fall Risk Report 2. Restraint Use 3. Nutrition Services Evaluation: Daily Screening Report 4. Nutrition Service Validation: Monthly Monitoring Report 5. Chart Audits

1 RUN DATE: 12/14/99 Methodist Hosp/Children's Hosp NUR LIVE RUN TIME: 1112 FALL RISK REPO RT BY LO CATION

LOCATION: H.ORTH

PATIENT: UNIT #: AGE/SEX: 86 F ROOM/BED: H.334 A ACCT #: DATE TIME SCORE BEDCHECK # SIDERAILS INSTRUCTION

12/13/99 0030 8 Y 4 Y 12/13/99 1237 8 Y 4 Y 12/13/99 1700 8 Y 4 Y 12/14/99 0250 8 Y 4 Y

PATIENT: UNIT #: AGE/SEX: 60 F ROOM/BED: H.314 A ACCT #: DATE TIME SCORE BEDCHECK # SIDERAILS INSTRUCTION

12/13/99 0045 5 N 4 Y 12/13/99 0800 5 N 4 Y 12/13/99 1942 5 N 4 Y 12/14/99 0231 5 N 4 Y 12/14/99 0745 5 N 4 Y

PATIENT: UNIT #: AGE/SEX: 41 M ROOM/BED: H.301 B ACCT #: DATE TIME SCORE BEDCHECK # SIDERAILS INSTRUCTION

12/13/99 0145 2 N 2 Y 12/13/99 0730 2 N 2 Y 12/13/99 2017 2 N 2 Y 12/14/99 0149 2 N 2 Y 12/14/99 0830 2 N 2 Y

SCORES: 0-2 LO W RISK: P a tie n ts id e n tifie d w ith s c o re s o f 2 o r le s s w ill h a v e n o s upplem ental p ro b le m s a d d e d to p la n o f c a re . 3-6 HIGH RISK: For patients identified with scores 3-6, add problem : High Risk For Fall (s c re e n 3 -6 ) to th e p la n o f c a re . > 6 EXTREMELY HIGH RISK: For patients identified with scores >6, add problem : High Risk F o r F a ll (s c re e n > 6 ) to th e p la n o f c a re

TOTAL # OF DOCUM ENTATIONS: 124

2 RUN DATE: 12/14/99 MSTH Nursing **LIVE** RUN TIME: 1030 Audit of Level III Immobilization

Report Date(s): 01/01/99 to 12/14/99 RESTRAINT

Location: N.3E Age/Gender: 77 M Acct # N350409782

(From Shift Assessment) (From Documentation Level III)

Date Time Level III Protocol Dang Self Grossly Explain Mental Released Restraint Restraint Circ Skin Order /Others Inapp.Beh To Pt . Status & ROM Type/Location Type/Location Checks Cond. Ver. Reorder

10/09/99 1600 Y Y Y COMBATIVE POSEY VEST/BIL ANKLES SOFT/BIL WRIST Y N Y

10/09/99 1915 Y Y Y COMBATIVE POSEY VEST/BIL ANKLES SOFT/BIL WRIST Y N Y

10/09/99 2000 Y Y Y COMBATIVE POSEY VEST/BIL ANKLES SOFT/BIL WRIST Y N Y

10/09/99 2100 Y Y Y RESTLESS POSEY VEST/BIL ANKLES SOFT/BIL WRIST Y N Y

10/09/99 2200 Y Y Y RESTING POSEY VEST/BIL ANKLES SOFT/BIL WRIST Y N Y

10/09/99 2300 Y Y Y RESTLESS POSEY VEST/BIL ANKLES SOFT/BIL WRIST Y N

10/10/99 0010 Y Y Y RESTING POSEY VEST/BIL ANKLES SOFT/BIL WRIST Y N Y

10/10/99 0200 Y Y Y RESTLESS POSEY VEST/BIL ANKLES SOFT/BIL WRIST Y N Y

10/10/99 0400 Y Y Y RESTLESS POSEY VEST/BIL ANKLES SOFT/BIL WRIST Y N Y

10/10/99 0500 Y Y Y RESTLESS POSEY VEST/BIL ANKLES SOFT/BIL WRIST Y N Y

10/10/99 0600 Y Y Y RESTLESS POSEY VEST/BIL ANKLES SOFT/BIL WRIST Y N Y

10/10/99 2100 Y Y Y RESTLESS SOFT/BIL WRIST SOFT/BIL ANKLES Y N Y

10/10/99 2300 Y Y Y RESTLESS SOFT/BIL WRIST SOFT/BIL ANKLES Y N Y

10/11/99 0200 Y Y Y RESTLESS Y SOFT/BIL WRIST SOFT/BIL ANKLES Y N Y

10/11/99 0424 Y Y Y RESTLESS Y SOFT/BIL WRIST SOFT/BIL ANKLES Y N Y

Total of 16 occurrences between 01/01/99 to 12/14/99.

Total of 4 patient(s) on Level III between 01/01/99 to 12/14/99.

3 RUN DATE: 12/09/99 Metropolitan **ADMISSIONS** PAGE 1 RUN TIME: 1050 NUTRITION SERVICE EVALUATION

REPORT FROM: 12/08/99 THRU: 12/09/99 0-2 = LOW 3-6 = MED 7+ = HIGH

ADMIT SKIN DEC. WGT AMT TPN LOCATION ACCT.# NAME AGE SEX DATE REFER N/V INTACT INTAKE SWALLOW G/L LOSS WGT FT-IN TUBE SCORE

M.304 89 F 12/08/1999 U 52 4 7 3 M.326 90 F 12/08/1999 Y 75 5 4 2 M.403 47 F 12/08/1999 Y 5 3 2 M.509 68 M 12/08/1999 Y S 84 5 4 3 M.517 26 F 12/08/1999 Y S Y 68 4 11 Y 4 M.518 28 F 12/08/1999 Y 78 5 1 1 M.524 18 F 12/08/1999 Y 77 4 11 2 M.628 62 F 12/08/1999 Y Y 42 5 8 3 M.632 48 M 12/08/1999 Y 104 5 8 1 M.635 79 M 12/08/1999 S Y 74 5 8 5 M.706 72 F 12/08/1999 Y 44 5 5 1 M.716 47 M 12/09/1999 Y 137 5 7 1 M.732 73 F 12/08/1999 Y 95 5 5 2 M.SIC 61 M 12/09/1999 U 89 5 10 3

4 RUN DATE: 12/09/99 Metropolitan **ADMISSIONS** PAGE 1 RUN TIME: 1052 NUTRITION SERVICE VALIDATION

REPORT FROM: 11/01/99 THRU: 11/30/99 0-2 = LOW 3-6 = MED 7+ = HIGH

ADMIT DISCH FNS SKIN DEC. WGT AMT TPN LOCATION AGE SEX DATE DATE VAL DATE TAT VALIDATE REFER N/V INTACT INTAKE SWALLOW G/L LOSS WGT FT-IN TUBE SCORE M.528 77 F 11/09/1999 11/12/1999 11/10/1999 1 N S Y L 10 67.9 5 3 7 M.517 58 F 11/17/1999 11/18/1999 Y S 56.3 5 3 4 M.515 51 F 11/05/1999 11/06/1999 Y 60.4 5 0 1 M.506 81 F 11/12/1999 11/16/1999 11/13/1999 1 Y S Y 45.4 4 11 5 M.628 72 F 11/01/1999 11/08/1999 11/02/1999 1 Y U Y Y 51.7 5 5 Y 10 M.513 55 F 11/03/1999 11/13/1999 11/06/1999 3 Y S Y 64.7 5 1 5 M.515 32 F 11/04/1999 11/06/1999 S Y 59.9 5 4 5 M.204 44 F 11/04/1999 11/08/1999 Y 70.5 5 2 1 M.616 60 F 11/01/1999 11/12/1999 11/02/1999 1 Y Y 46.3 4 11 0 M.505 62 M 11/01/1999 11/01/1999 S Y 81.3 5 3 5 M.255 40 F 11/02/1999 11/04/1999 11/03/1999 1 N Y 63 5 2 1 M.508 87 M 11/01/1999 11/02/1999 U 86.3 3 M.702 90 F 11/01/1999 11/02/1999 U 5 4 3 M.615 86 F 11/01/1999 11/13/1999 11/02/1999 1 Y Y 39.1 5 0 2 M.518 52 M 11/11/1999 11/12/1999 S Y 163 5 5 5 M.705 79 M 11/01/1999 11/14/1999 11/02/1999 1 Y Y 64.1 5 5 0 M.303 88 F 11/01/1999 11/11/1999 11/03/1999 2 Y U 50.2 5 0 3 M.621 41 F 11/01/1999 11/05/1999 11/02/1999 1 Y Y Y Y 82.4 5 2 3 M.518 77 M 11/01/1999 11/03/1999 11/02/1999 1 Y Y 73.3 5 9 0 M.712 77 F 11/02/1999 11/04/1999 11/02/1999 0 Y Y 93.6 5 8 0 M.601 41 F 11/02/1999 11/04/1999 G 8 69.7 5 5 2 M.729 70 M 11/08/1999 11/13/1999 11/09/1999 1 Y Y S 85.4 5 11 3 M.503 49 F 11/09/1999 11/10/1999 S Y 84.5 5 0 5 M.731 70 F 11/02/1999 11/05/1999 11/03/1999 1 Y Y Y 76.4 2 M.502 47 M 11/02/1999 11/06/1999 11/05/1999 3 Y Y 81.1 5 3 0 M.506 87 F 11/02/1999 11/05/1999 11/03/1999 1 Y Y 50.9 5 0 Y 5

5 6 7 Age/Sex: Attending Page: 1 Unit # Account # Admitted: Location: Meth Hosp/Children’s Patient Care *Live* Printed 01/31/00 at 1601 Status: Room/Bed NURSE MANAGER DETAIL CHART AUDIT Period ending 01/31/00 at 1601

ADMISSION HISTORY AUDIT 01/30 1557 CFK 01/31 0045 SES 01/31 0800 WSH 01/28 0350 AMS NEUROLOGIC/ MUSCULO N N N ADMIT HISTORY DOCUMENTATION: CARDIAC ~WDP: Y Y Y 01/28/00 CIRCULATION TO EXTR N N N 0145

ADMISSION ASSESSMENTS AUDIT SHIFT ASSESSMENT AUDIT 01/28 00432 DLG (continued) 01/30 1557 CFK 01/31 0045 SES 01/31 0800 WSH ADMIT ASSESSMENT DOCUMENTATION: RESPIRATORY ~WDP: N N N 01/28/00 GASTROINTESTINAL ~W N N N 0400 GENITO/URINARY ~WDP Y Y Y GYN ~WDP: Y Y Y QUICK START AUDIT SKIN ~WDP: N N N 01/28 0245 MYW Admit Location: MEDSURG CARE PLAN REVIEW Age of Patient: 65+ YRS 01/30 0100 CFK Problems reviewed / reprioritized. Agree with prioritization CARE AREA STATEMENT AUDIT as currently listed Y 01/31 0054 SES 01/28 0622 AMS 01/28 1500 CAF 01/28 2247 NC 01/29 0643 JLO 01/29 1414 SND Problems reviewed / reprioritized. Agree with prioritization CARE AREA SIGNATURE SIGN OFF: as currently listed Y . HNUR.AMS HNUR.CAF1 MNUR.NC HNUR.JLO1 HNUR.SND 01/29 2213 SND 01/30 0530 BJR 01/30 1400 CFK 01/31 0457 SES CARE PLAN PRIORITIZATION ACCURACY CARE AREA SIGNATURE SIGN OFF: 01/30 0100 CFK 01/31 0054 SES . HNUR.SND HNUR.BJR HNUR.CFK TRA.SES 1. STANDARD OF CARE: STANDARD OF CARE AA SHIFT ASSESSMENT AUDIT 2. DEVELOPMENTAL AGE DEVELOPMENTAL AGE AA 01/28 0432 DLG 01/28 1008 CAF 01/28 1600 NC 01/29 0012 JLO 3. Problem: Altered Problem: Altered NEUROLOGIC/ MUSCULONNNN AA CARDIAC ~WDP: N N N 4. Problem: Impaired Problem: Impaired CIRCULATION TO EXTR Y N N N AA RESPIRATORY ~WDP:NNNN 5. Problem: Impaired Problem: Impaired GASTROINTESTINAL ~ Y N N N AA GENITO/ URINARY ~WDPYYYY 6. Problem: Impaired Problem: Impaired GYN ~WDP:YYYY AA SKIN ~WDPNNNN 7. Problem: Actual / H Problem: Actual / H AA 01/29 0812 01/29 1725 SND 01/30 0029 BJR 01/30 0854 CFK 8. Problem: Low Risk Problem: Low Risk NEUROLOGIC/ MUSCULONNNN II CARDIAC ~WDP:NNNY CIRCULATION TO EXTRNNNN Monogram Initials Name Nurse Type User Key RESPIRATORY ~WDP:NNNN GASTROINTESTINAL ~NNNN GENITO/ URINARY ~WDPYYYY GYN ~WDP:YYYY SKIN ~WDPNNNN