Special Report: Information technology changes DP
[Editor's note: In this issue of Discharge Planning Advisor is the second part of a special report on health care information technology and how it is changing discharge planning, as well as transforming the entire health care system. This includes the following article on how hospitals redesign care processes using electronic records and another story about a physician sign-off electronic tool. In the June issue, there were stories about the transformation of EHRs in hospitals and a look at how an Australian health system has used electronic discharge summaries as a building block.]
Hospitals can redesign care processes using EHR
Here's how to do it
When hospital leaders consider initiatives expanding their organizations' health information technology (HIT), they might look at the outcomes experienced by a national health care organization called Trinity Health of Novi, MI.
The organization's outcomes as reported in the Joint Commission Journal for Quality and Patient Safety are related to its use of HIT to help redesign clinical practices and to create new efficiencies. They are as follows1:
a 25% reduction in severity-adjusted mortality over three years;
exceeding national average of 97% of CMS quality measures;
a 45% reduction in pressure ulcers;
reduced hospitalizations by managing chronic conditions;
urgent medications given to patients 40% faster;
reduced hospital liability costs.
The sixth-largest Catholic healthcare system in the country has hospitals in seven states from Maryland to California. And the organization has implemented HIT across close to half of its 31 hospitals, says Jane Brokel, PhD, RN, an assistant professor at the University of Iowa's College of Nursing in Iowa City, IA. Brokel studied the health care system's experiences with HIT and published a journal article about it earlier this year.1
"They have made the transition in phases," Brokel says. "They're working on making electronic health records available across all entities."
The organization implemented many of the components and applications of HIT on the same day, using what Brokel calls the "Big Bang" approach.
"They started out with a phase I that put the clinical data repository in place early on," Brokel says. "They set a go-live date, and then set a variety of milestones that management had to meet."
Physicians and the chief executive officer were included in the process of setting milestones, and one of the executives was identified as the accountable executive for a particular project, she notes.
"The accountable executive is accountable for meeting that component of the strategic plan, including the implementation of an electronic health record," Brokel says.
"They considered it at the level of a major building project, so it tapped into all the necessary resources, as would any strategic planning initiative," she explains.
A variety of efficiencies and benefits can be derived from such a major HIT initiative.
For example, medications collected in one location can be reviewed within the next location, Brokel says.
Also, the emergency department physicians' electronic documentation could be made available for nursing units and patient's primary care physicians through remote access to the electronic health record, she adds.
"They'd be sent a message that one of their patients was in the emergency room if they were credentialed with the health system or on staff," Brokel says. "They'd have their password to the electronic system."
Instead of using fax machines, physicians could sign-in and obtain the patient information they needed.
Early on in the process of transition to HIT, the health system invited primary care physicians, hospitalists, nurse case managers, and discharge planners to a couple of focus group meetings, Brokel says.
"We invited a couple of our [HIT] developers from the vendor system to sit in on these focus groups with the clinicians," she adds. "One of the focus groups had all of the individuals who were part of the discharge process."
The meetings discussed research using a discharge planning HIT system and what kinds of information is needed at the time of discharge, Brokel recalls.
"All of that work kind of set the stage and helped the vendor," she says.
The discharge HIT system has evolved into one that assists clinicians with discharging patients from the hospital setting to the next location, whether it is a nursing home or clinic or to home with a home health agency's care.
"It includes discharge instructions, reconciliation of medications, a working diagnosis, and putting all of those key types of care together to prepare for eventual discharge," Brokel says.
"The vendor system that was utilized for the electronic health record had already, very early on, the capability of having discharge orders that could be started early in the patient's stay," she explains.
So, clinicians could see the discharge orders with nursing information, medications, diagnostic orders, and all of it was provided in one view on the screen.
The discharge HIT also includes discharge instructions that can be given to patients. All of the discharge information is packaged together so that the end user does not have to go individually to orders, instructions, or medications to complete the process, Brokel says.
"It links into a pathway," she adds.
The focus group meetings also helped the clinicians design a discharge workflow that allowed them to discharge to multiple settings, Brokel says.
"Initially, they were working together to improve the evolution of some of the HIT," she adds. "They worked with vendors, and then their work became a feature of the EHR that can be applied in all the different ministry organizations."
For instance, clinicians helped to design a discharge workflow that enabled hospitals to discharge to multiple settings, she says.
One system HIT team worked for 18 months with each hospital team before beginning the transition to electronic health records.1
Another benefit is that the electronic data includes all prior education that was completed for that patient, and it shows physicians what the prior home medications were and which inpatient medications were ordered during the patient's stay, Brokel says.
"Then, physicians can make a decision about whether the patient should be discharged with a new prescription," she adds.
The electronic Navigator is a high-level checklist that opens up within the EHR to pull all of the information and pieces together, Brokel says.
"Physicians can see what instructions need to be given, which prescriptions need to be written, and what the physician's final note is," she explains. "They might pull in some lab findings that were key to share with the next provider or show results from specific tests and therapies needed, etc."
Reference
1.Brokel JM, Harrison MI. Redesigning care processes using and electronic health record: a system's experience. Jt Comm J Qual Patient Saf. 2009;35(2):82-92.
Source
For more information, contact:
Jane Brokel, PhD, RN, Assistant Professor, University of Iowa, College of Nursing, 482 NB, 50 Newton Road, Iowa City, IA 52242. Email: [email protected]. Telephone: (319) 335-7111.
System integrates physician sign-out process with EMR
Patient-tracking tool helps with DP
Like many hospital systems, the University of California - San Francisco (UCSF) Medical Center had handled physician sign-outs in a fragmented way: each clinical services area had developed its own way of documenting sign-outs.
"That typically meant on-call residents and interns covered all patients who were scheduled to go home that day," says Russ Cucina, MD, MS, an associate medical director of information technology and an assistant professor of hospital medicine at UCSF Medical Center.
Some areas used Microsoft Word documents; others had Excel spreadsheets; still others used a FileMaker program, Cucina says.
"So, our office of medical education decided that since physician sign-off was a potential error and safety issue, they would make the sign-out standard across all services," Cucina says.
The result was the development of a patient-tracking tool, called Sign-out, Information Retrieval, and Summary (SynopSIS) for the purpose of supporting patient tracking, transfers of care, and daily rounds.1
"It allows us to document the information that's particular to sign-out and that is not found elsewhere in the medical record," Cucina says.
For example, it will include contingency plans, such as what to do if the patient has a fever or is short of breath, Cucina says.
"These are the sort of things somebody covering for you would want to know," Cucina says. "It's the kind of information we intend folks to document in SynopSIS."
Here is how the health care system's changes work:
There are dashboard views of patient's clinical situation.
"We've learned that people like synoptic views," Cucina says. "We made the observation that SynopSIS has grown in its application from a system to providing overnight coverage to a dashboard that gives a summary of a patient's status."
Some care planning information has been summarized in SynopSIS, and that's become a useful tool for discharge planners and case managers, as well, Cucina says.
"Case managers can have a handy snapshot look at patients and their problems and physician plans," he explains. "So, it's quite popular with discharge planners and case managers as a way of supporting their work."
The information included in this snapshot also is available in a daily note, a progress note, physician orders, etc., he notes.
But the other documentation will contain more details than are of interest to discharge planners, so the SynopSIS dashboard is more convenient, Cucina says.
"SynopSIS' distilled view is attractive to case managers and discharge planners," he adds.
Although SynopSIS was created expressly for the purpose of providing a sign-out system, its use in discharge planning is an unintended benefit, Cucina notes.
"At first we had restricted which clinicians would have access to SynopSIS within the electronic medical record," he explains. "After using it for several months, we began to get requests from roles we hadn't originally intended to use it, like nurse case managers, who wanted to gain access to the system."
Physicians can decide the level of SynopSIS detail.
"Physicians have a lot of liberty to decide at what level of detail and what information they'd like put into SynopSIS," Cucina says. "In response to their knowledge of a wider audience, we find that physicians have expanded the amount of information they are putting into SynopSIS because they think it's useful in patient care."
And physicians believe the software program is a good way to collaborate with nurse case managers and others, he adds.
However, the software has limits.
One limit is that it doesn't contain a place for communicating the discharge disposition, Cucina says.
Physicians sometimes add the discharge disposition in anyway, although it would be better if there were an explicit place to create that statement, he adds.
"So we're thinking about making an explicit data point and formulating it in a way that is most useful to discharge planning," he says. "It's still at the conceptual stage, but it might occur in the foreseeable future."
Patient-tracking tool's utility expanded.
"We originally created SynopSIS for teams that had primary responsibility for patients," Cucina says. "But quite quickly as it became successful, there was a desire for consulting services also to use SynopSIS."
For instance, infectious diseases (ID) physicians wanted to have a sign-out process from one ID doctor to another in their role as consultants, he explains.
"However, the dataset that is important to the primary internal medicine team is different from that dataset needed for the primary care doctor," Cucina says. "So, we had to present views within SynopSIS that support primary service and sign-out needs, as well as the dashboard needs of the primary service and also for a consulting service."
The patient-tracking tool did not contain the specialty-specific datasets that various specialist might like to see.
"Having specialty-specific views on the dataset is something we need to create," Cucina says. "But at the same time, we need to make sure we're not rebuilding silos between various services, because we think there is a benefit of multidisciplinary information."
The design challenge is to show clinicians everything they need to see, but focusing the information in the big picture, Cucina adds.
Reference
1. Sarkar U, Carter JT, Omachi TA, et al. SynopSIS: integrating physician sign-out with the electronic medical record. J Hosp Med. 2007;2(5):336-342.
Source
For more information, contact:
Russ Cucina, MD, MS, Associate Medical Director of Information Technology and Assistant Professor of Hospital Medicine, University of California - San Francisco Medical Center, Box 0131, San Francisco, CA 94107. Email: [email protected].
In this issue of Discharge Planning Advisor is the second part of a special report on health care information technology and how it is changing discharge planning, as well as transforming the entire health care system.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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