FROM DATA TO KNOWLEDGE: INTEGRATING ELECTRONIC HEALTH RECORDS MEANINGFULLY INTO OUR NURSING PRACTICE

Rayne Soriano MS, RN

Manager of Nursing Informatics and Clinical Transformation Program

Kaiser Permanente

OBJECTIVES Describe the drivers of health information technology

(HIT) and electronic health records (EHRs).

Describe the importance of nursing documentation in the implementation and adoption of EHRs.

Explore ways in which nurses contribute to the goals and benefits of HIT through meaningful use of the EHR.

Review major components in EHRs where nurses contribute data for coordinating safe, efficient, and high quality patient care.

Identify challenges in the nurses’ communication and documentation environment.

Identify opportunities to learn more about HIT, EHRs, and nursing informatics.

TRENDS IN NURSING • Registered Nurses constitute the largest healthcare profession in the US;

with an estimated 2.6 million RNs actively working in 2011

• About 60% of RN jobs are in the acute care setting

• Employment is expected to increase by 22% from 2008-2018; much faster than any other career in the United States

• Key drivers of professional opportunity include the technology explosion, an emphasis on health/disease prevention, and the increasing elderly population with longer life expectancies and multiple chronic diseases

• Career paths for registered nurses are many and varied; in practice, education, research, consultation, and management; along with a variety of healthcare settings across the entire care continue continuum.

The Advisory Board Company, 2011

GOING LIVE: IT’S ONLY THE BEGINNING

Progressive Stages of Change

COMMITMENT EXPLORATION RESISTANCE DENIAL

Indifference

Avoidance

Cooperation

Excitement

Confidence

Frustration

Negativity

Skepticism

Curiosity

Asking questions

Somewhat optimistic

Fear Optimism

(loss of control) (embrace opportunity)

Time

BENEFITS OF THE EHR

Improve quality and convenience of patient care

Increase patient participation in their care

Improve accuracy of diagnoses and health outcomes

Improve care coordination

Increase efficiencies and cost savings

THE BENEFITS ARE REAL

CHALLENGES IN THE NURSES’ ENVIRONMENT • Documentation is burdensome and overwhelming

• Interruptions and lack of knowledge are pervasive

• There is huge memory load on the nurse; need for real time contextual information at the point of care

• The environment does not support efficiency

• Technology is not fully integrated

• Documentation tools do not support documentation at the point of care or documentation as an automatic product of care

• Lack of appropriate infrastructure to support technology at the bedside

UNINTENDED CONSEQUENCES

NURSING TIME IMPACT

MEANINGFUL USE

The American Recovery and Reinvestment Act of 2009 authorizes the Centers for Medicare & Medicaid Services (CMS) to provide incentive payments to eligible professionals (EPs) and hospitals who adopt, implement, upgrade, or demonstrate meaningful use of certified electronic health record (EHR) technology.

“MEANINGFUL USE” IS USING CERTIFIED TECHNOLOGY IN EHR IMPLEMENTATION TO:

Improve quality, safety, efficiency, and reduce health disparities

Engage patients and family

Improve care coordination, and population and public health

Maintain privacy and security of patient health information

Stage 2 MU ACO’s

“Stage 3 MU”

3-Part Aim

Registries to manage patient populations

Team based care, case management

Enhanced access and continuity

Privacy & security protections

Care coordination

Privacy & security protections

Patient centered care coordination

Improved population health

Registries for disease

management

Evidenced based medicine

Patient self management

Privacy & security protections

Care coordination

Structured data utilized

Data utilized to improve delivery

and outcomes

Data utilized to improve delivery

and outcomes

Patient informed

Patient engaged, community resources

Stage 1 MU

Privacy & security protections

Basic EHR functionality,

structured data

Utilize technology

Access to information

Transform health care

Meaningful Use as a Building Block THE DETAILS

PROTECTING HEALTH INFORMATION AND THE EHR

HIPAA

Passwords and Authentication

Copying and Pasting

Printing PHI

Email

Social Media

Mobile Communications

HIPAA’S OTHER SIDE

NURSES AND CLINICAL DOCUMENTATION Patient safety through timely and

accurate documentation

Data leading to process improvement and improved patient outcomes

Reports and analytics based on clinical documentation (Pain, Falls, Pressure Ulcers)

Patient engagement through the plan of care

Patient education optimized

Physician writes order 1 Medication Administration pre-EHR

2 UA Transcribes order

3 Nurse reviews and initials order

4 UA faxes order to Pharmacy queue (UA faxes other orders separately to Dietitian, RT, PT)

Pharmacist reviews and approves order to fill 5

Pharmacist enters order in PYXIS 6 Approved order makes its way to RN for administration 7

Patient receives medication 8

Elapsed Time = 1-2 hours

Physician/provider enters order into EHR. Orders transmit with real time allergy alerts

1

Order verified by pharmacist; seen simultaneously by the RN 2

Medications released 3

RN administers med, uses bar code scanner to ensure right patient, right drug, right time, and right dose.

4

Medication Administration with the EHR

Elapsed Time < 15 minutes

CLINICAL DECISION SUPPORT

Definition

Knowledge based computer program designed as a direct aid to clinical decision- making at the point of care.

CLINICAL DECISION SUPPORT – FROM DATA TO KNOWLEDGE Passive (user initiated)

Requires clinician to access tools and information (e.g., clinical practice guidelines and algorithms/protocols)

Information is made available upon request

Active (automatic)

The system processes data entered by the nurse.

Information interacts with clinical data.

Triggered by data like abnormal lab results, allergies, and vital signs.

BENEFITS OF CLINICAL DECISION SUPPORT

Supports achievement of meaningful use

Improves clinical outcomes via increased knowledge

Decreases length of stay

Decreases morbidity and mortality

Reduces adverse drug event

Assists in avoiding medical errors

Decreases healthcare costs

Increases user satisfaction

CASE STUDY: KAISER PERMANENTE PRESSURE ULCER PREVENTION

TEN MOST COSTLY MEDICAL ERRORS AND ASSOCIATED ANNUAL COST Pressure Ulcers were the most FREQUENT and 2nd most COSTLY

medical error identified.

1. Postoperative infections $3.3 billion

2. Pressure ulcers $3.2 billion

3. Mechanical device or implant complications

(non-cardiac) $1.0 billion

4. Postlaminectomy syndrome $995 million

5. Hemorrhage complicating a procedure $678 million

6. Infection due to central venous catheter $589 million

7. Pneumothorax $569 million

8. Infection from injection/infusion/transfusion/

vaccination $566 million

9. Other complications of device, implant and graft $398 million

10. Abdominal hernia $342 million

The $17.1 Billion Problem: The Annual Cost of Measurable Medical Errors. Van Den Bos, J, Rustagi, K, Gray, T., Halford, M., Ziemkiewicz E,, Shreve, J Health Affairs 30, No 4 April 2011

KAISER PERMANENTE CLINICAL TRANSFORMATION MODEL

• Collaborate to foster knowledge translation

• Leverage advanced analytics to extractactionable knowledge

• Focus on “Making it Easy to do the Right Thing”

• Build evidence out of practice

Set standards based on

clinical goals, and evidence-based practice

Leverage EHR to optimize

workflow and support clinical decision making

Develop reports to

monitor the practice change

Measure the impact of the

change through outcomes

analysis and research

LEVERAGING THE EHR TO OPTIMIZE WORKFLOW AND SUPPORT CLINICAL DECISION MAKING

(SKKIN interventions within the Pressure Ulcer Risk

Clinical Practice Guideline)

SKKIN Bundle built into our Electronic Health Record

SKKIN BUNDLE RELATED FACTORS: #1: LACK OF TURNING AND REPOSITIONING

LEVERAGING THE EHR: OPTIMIZING WORKFLOW & CLINICAL DECISION SUPPORT: TURNING & REPOSITIONING BEST PRACTICE ALERT

For In

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9

REPORTS TO MONITOR PRACTICE CHANGES TURNING & REPOSITIONING DOCUMENTATION COMPLIANCE:

IMPROVING OUTCOMES

MOVING TO REAL TIME INFORMATION

COMMUNICATION IS KEY TO SUCCESS

Keeping up-to-date

Sharing best practices

Giving feedback and getting involved

CONCLUSION

The EHR is a transformational tool with benefits beyond what paper could ever do

The use of nursing knowledge and data is key to achieving meaningful use

As nurses, we are the key to the realization of EHR benefits through accurate and timely documentation at the point of care

Data can change behavior

RESOURCES

Health IT.gov: http://www.healthit.gov/

American Nurses Informatics Association: https://www.ania.org/

American Nurses Association: http://www.nursingworld.org/

The TIGER Initiative: http://www.thetigerinitiative.org/

QUESTIONS?