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Commitment to Results: Optimization & Essential Clinical Dataset

Session #307 - February 15, 2019

April Giard, VP, Chief Clinical Integration Officer (CCIO), Northern Light Health Darinda Sutton, VP, Chief Nursing Officer (CNO), Cerner

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April Giard DNP, PMH-NP, NEA-BC

Has no real or apparent conflicts of interest to report.

Darinda Sutton MSN, RN-BC, FACHE

Has no real or apparent conflicts of interest to report.

Conflict of Interest

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I. Learning Objectives

II. Background of Problem – US and International

III. Essential Clinical Dataset (ECD) Collaborative

– Membership

– Collaborative Structure

– Methodology, Timeline & Approach

IV. Northern Light Health (NLH)

– Analysis of Current state vs. ECD

– Shared Governance approach

– Implementation and adoption

– Outcomes

– Key findings and considerations

V. Results across Early Adopters

VI. Conclusion

Agenda

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1. Explain the three-pronged methodology for determining the

Essential Clinical Dataset (ECD)

2. Define the ECD process for nursing admission history

documentation

3. Describe how the ECD can be used as a foundation for nursing

documentation optimization for your organization

Learning Objectives

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• Challenges with usability post implementation phase

• Studies around nursing documentation within the EHR

• Impact of EHR customization

• Perceptions of the EHR on workflows

• New era of optimization

Chang, H., Lee, T., Liu, C., & Mills, M. (2016). Nurses’ experiences of an initial and re-implemented electronic health record use,

CIN: Computers, Informatics, Nursing, 34(4), 183-190.

Strauss, B. (2013) The patient perception of the nurse-patient relationship when nurses utilize an electronic health record

within a hospital setting. CIN: Computers, Informatics, Nursing, 31(12), 596-604.

Background of Problem

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“ONC is focused on working with CMS to minimize

clinician documentation burden, increasing the

usability of electronic health records, and promoting

interoperability of health IT.”

The standardization of nursing documentation in a

way that is evidence-based, standardized across

settings, and allows for the reuse of data elements

will be critical for continuity of care across the

interdisciplinary care team.

Currently, variation in the length, content, and value

of data collected in nursing assessment is significant

and often unnecessary

Rebecca Freeman, PhD, RN, PMPFormer CNO Office of the National Coordinator for HIT

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• The Joint Position Statement between the Canadian Nurses

Association (CNA) and the Canadian Nursing Informatics Association

(CNIA) published in March 2017 recognizes the need for “a

standardized approach to nursing documentation in all clinical

practice settings across Canada”.

International Agenda item

• Australian Nursing Informatics Position Paper August 6, 2017

Element 7:

“Nurse informaticians insist on the adoption of nationally agreed nursing data standards…..for improved data integration, information sharing, performance monitoring, data analytics, patient safety and quality.”

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• Most organizations have over-designed their EHRs resulting in a lot of “noise” and non-value added data elements

• There is not an established standard for the essential clinical data that needs to be documented in an EHR

• Anticipated Outcomes of the Collaborative:

– Organizations will use the ECD as the foundation for EHR optimization

– ECD will establish a national (international) standard that is EHR agnostic

ECD Collaborative – Why?

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ECD Collaborative Members

190+ Facilities 25,000+ Beds

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Three pronged approach

Final ECDPractice Based

Evidence

Regulatory: CMS, TJC, DNV, MU 1-

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Evidence Based

Practice

Review of

literature for

content, not

process or

workflow

United

States,

Federal

Regulatory,

not state or

global

Environmental

scans of 12

clients’ production

data for frequency

of data element

and utilization

metrics

June

2016

Aug.

2016Nov.

2016March

2017

Collaborative

Admission

History &

intake

content

validation –

Initial review

Regulatory

requirements

review by Collaborative

for all workflows

Literature

Review for

evidence

synthesis

ECD Program

Kickoff :• Charter

• Membership

July 19,

2016

Initial Webex meeting

with Collaborative: • Methodology Overview

• Literature Review

“starter” articles

provided

July 28,

2016

8 hr.

Regulatory

Educationa

l Session

Sept

Oct

2016Collaborative

Report out

Regulatory

requirements for all workflows

Dec ’16

Apr

‘17

Data Extraction

for Practice

Based Evidence:• Admission History

and Intake from 12

Collaborative PROD

domains

Adult ECD Timeline: Admission History & Intake

Adult ECD Timeline: Admission History & Intake

March

2017

July 6,

2017

Aug

Nov

2017

Internal

Cerner

working

group

organized

Admission

History ECD:

collaborative

review and sign

off

March

2017

Mar

May

2017

Collaborative

validation of

Individual

Admission

Dataset

May

Jun

2017

Comparative

Analysis • Across

Collaborative

Clients

ECD V#1

Defined:

Jun

Jul

2017

Early Adopters

begin ECD

analysis against

current process

to determine

Facility ECD

Nov

2017

First 2 clients

LIVE in

PRODUCTIO

N

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Client # of Electronic

Forms

# of Sections # of Questions

#1 4 36 318

#2 5 23 230

#3 3 26 280

#4 2 29 278

#5 2 25 208

#6 13 57 986

#7 4 51 371

#8 6 22 265

#9 1 21 194

#10 8 66 530

#11 2 29 299

Baseline Variation –Adult Admission History Intake Assessment

Cross Map - Admission History questions

Client 1 Client 2 Client 3

Client 1Client 1

DTA Utilization

Client

2Client 2

DTA Utilization

Client

3

Client 3

DTA Utilization

Client frequency8 of 12 facilities included the question

Utilization average>60% avg. charting of that question

Frequency and utilization algorithm

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• Now what…

• NLH shared governance approach

– Compared ECD to NLH current state

– Validated unique state regulations or local requirements

– Rules or reports associated with the question being removed

• Secondary use of the data

Applying the ECD across a Health System

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Key for current Admission History review

Keep - Essential Clinical Data

Keep - NLH local decision –

even though ECD recommended to remove

Remove as recommended by ECD

Remove: Not addressed by ECD - Confirmed as non-essential

by NLH

Move: Collaborative identified as Essential – NLH determined

collection location should be elsewhere

Question regarding workflow, and process need to investigate

before final decision was made

MOVEMOVE

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Collaborative Category: General

Preferred Name:

Confirmed Registration

collects and displays

Legal Guardian:

Confirmed Registration

collects and displays

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Northern Light Health Outcomes

ECD Results: # of eForms # of Sections# of

Questions

Admission ECD 1 8 39

NLH ECD 1 12 65

Northern Light Health

ECD:

• Baseline = 278

• Removed = 213

• Kept = 65

76%

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AverageActive Time

• …translates to about

• 311 hours per year

• given back to each nurse.

AverageClicks

• …translates to about

• 247,985 clicks per year

• each nurse doesn’t exercise.

11%

12 %

Northern Light Health OutcomesEfficiency Measures –Since Implementation

Outcomes: Secondary Use of Data

42% (52) questions were used downstream in one, or more, of the following categories seen in the graph above.

Questions

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NLH Nurse Perception Pre and Post Implementation

5%

20%

31%28%

16%18%

35%

23%

18%

6%

0%

5%

10%

15%

20%

25%

30%

35%

40%

0 to 10 min. 11 to 15 min. 15 to 20 min. 21 to 30 min. Greater than 31 min.

Time to Complete

Pre Post

Pre: 56% of staff felt they could complete the Admission History within 20 minutes

Post: 84% of staff felt they could complete the Admission History within 20 minutes

28%

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NLH Nurse Perception Pre and Post Implementation

1%

19%

26%

37%

18%16%

46%

30%

5%2%

0%

10%

20%

30%

40%

50%

Strongly Agree Agree Neutral Disagree Strongly Disagree

Satisfied with the Process

Pre Post

Pre: 20% of nurses were satisfied with the Admission History documentation process

Post: 62% of nurses were satisfied with the Admission History documentation process 42%

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NLH Nurse Perception Pre and Post Implementation

1%

16%20%

42%

21%

14%

48%

24%

13%

1%0%

10%

20%

30%

40%

50%

Strongly Agree Agree Neutral Disagree Strongly Disagree

Free of Duplication

Pre Post

Pre: 17% of nurses felt the Admission History documentation was free of duplication

Post: 62% of nurses felt the Admission History documentation was free of duplication

45%

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• Challenged the “because we have always done it”

– Asked WHY five times

• Policy driving practice with no relevant reason or evidence

• Local critical thinking and judgement applied when reviewing ECD

• The process was just as valuable as the outcome

• Did not find any items other departments needed to take on

NLH Key Findings and Considerations

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Baseline vs. 30 days post ECD

Total Questions:

Reduced an average of 100 Questions

Total Time: (h:mm:ss)

Reduced an average of 0:2:21 minutes

Total Clicks:

Reduced an average of 37 clicks

Results Across 10 Early Adopters

49%

31%

41%

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• Impact for Nursing

– Satisfaction

– Efficiency

– Foundation for optimization of nursing documentation

– Bottom line impact – Time and Efficiency

– Reducing the Documentation Burden

• Next steps

– Implement across all client base

– Continue with other ECD initiatives

• Non-US progress

• Non Cerner EHR applicability

• US national task forces

Conclusion

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Questions

April Giard DNP, PMH-NP, NEA-BC

VP and Chief Clinical Integration Officer

agiard@northernlight.org

• Darinda Sutton MSN, RN-BC, FACHE

VP and CNO Cerner

darinda.sutton@cerner.com

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