9/10/2013 1 Presenters: Karen Utterback, MSN, RN – VP Strategy and Marketing, McKesson ECSG Karen S. Martin, MSN, RN, FAAN – Health Care Consultant, Martin Associates Lois Glanz, BSN, RN – Clinical Information Specialist, UnityPoint at Home 505. Combining Technology and Evidence‐ Based Practices to Improve Outcomes Organizations can manage the challenge of data and information h ith t h l th t f d li i lt d d exchange with technology that uses reference and clinical standards, along with the Office of the National Coordinator for Health Care Information Technology requirements. Use of health information technology (HIT) and electronic health records (EHRs) to achieve the Triple Aim of reducing costs, improving clinical outcomes, and improving customer experience is the focus of current health reform efforts. Home health and hospice organizations must participate in meaningful use of HIT to foster reliable exchange of information among practitioners and patients. Participants will learn how their agency can use standard clinical terminology and evidence‐based agency can use standard clinical terminology and evidence based practices within an EHR system to comply with meaningful use standards, reach organizational goals, and improve patient care. Track: Health Information Technology Audience: | HH | HOS | NUR |
Transcript
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Presenters: Karen Utterback, MSN, RN – VP Strategy and Marketing, McKesson ECSGKaren S. Martin, MSN, RN, FAAN – Health Care Consultant, Martin AssociatesLois Glanz, BSN, RN – Clinical Information Specialist, UnityPoint at Home
505. Combining Technology and Evidence‐Based Practices to Improve OutcomesOrganizations can manage the challenge of data and information
h ith t h l th t f d li i l t d d exchange with technology that uses reference and clinical standards, along with the Office of the National Coordinator for Health Care Information Technology requirements. Use of health information technology (HIT) and electronic health records (EHRs) to achieve the Triple Aim of reducing costs, improving clinical outcomes, and improving customer experience is the focus of current health reform efforts. Home health and hospice organizations must participate in meaningful use of HIT to foster reliable exchange of information among practitioners and patients. Participants will learn how their agency can use standard clinical terminology and evidence‐based agency can use standard clinical terminology and evidence based practices within an EHR system to comply with meaningful use standards, reach organizational goals, and improve patient care.
Track: Health Information TechnologyAudience: | HH | HOS | NUR |
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Today’s ObjectivesSummarize current health IT trends
Describe the value of standard clinical terminology and reference code sets, evidence‐based practice (EBP), and clinical decision support systems (CDS)
Describe one organization’s journey to an EHR supported b d d l l l dby standard clinical terminology, EBP, and CDS
Identify ways homecare and hospice organizations can be involved in health IT Initiatives
A Key to the Triple Aim:System Integration and Execution Goals of the Triple Aim:
Improve health care quality and experienceImprove the health of populationsReduce the per capita cost of health care
Requires system integration and execution: T h i l d d i d Technical standards to support patient‐centered careElectronic Health Records (EHRs)Meaningful Use – Stage 2 and beyondClinical Decision Support SystemsEvidence‐based clinical practice
IHI 2013
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Knowledge ‐ Statistics, Evidence and Mistakes ‐ is the enemy of disease…The third revolution in healthcare will be driven by knowledge, technology and patients.”
Sir Mur Gray, Chief Knowledge Officer of Britain's National Health Service
Federal Health IT Strategy
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Meaningful Use Why :
T t d ti f l t i h lth d i To promote adoption of electronic health records in support of the Triple Aim through:
Complete and accurate informationBetter access to information for providers and patientsReducing costs of care
How:Through a set of CMS defined standardsThrough a set of CMS defined standards
Govern the use of EHRs Allows eligible providers to earn incentive payments by meeting specific criteria
Technical Standards Supporting Meaningful Use
Standard clinical terminology, i.e., Omaha SystemStandard clinical terminology, i.e., Omaha SystemSNOMED (normalizing clinical concepts)LOINC (Logical Observation Identifiers Names and Codes)ICD CM9/10 (diagnosis coding)HL‐7 (Health Language 7)HL 7 (Health Language 7)HTMLTransport Protocols (example ‐ SOAP)xds.b, xca, SAML (document registry)
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A Standard Clinical Terminology
Security and Identity
PersistentInfo
Documents
DynamicInformation
AccessWorkflow Quality
EHR: From A High Level
Dynamic f
Clinical ContentClinical Content
Medic
ation
List
Mgm
t.
Aller
gy L
ist M
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Prob
lem L
ist M
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Publi
c Hea
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epor
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Document Sharing:C S
Patie
ntID
Mgm
t
then
ticat
iondit
Tra
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Medic
al Su
mma
ries:
ASTM
-HL
7 CC
D
Radio
logy/
Imag
ing
Scan
ned
Docu
ment
s/PDF
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Lab
Resu
lts
Patie
nt C
reat
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umma
ries
Docu
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Ava
ilabil
ity N
otific
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Bios
urve
illanc
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Secu
rity P
olicie
s
Cons
umer
Auth
entic
ation
Bed
Avail
abilit
y Che
cking
Labo
rato
ry Or
ders
& Re
sults
Diag
. Ima
ging
Orde
rs &
Resu
lts
Home
Car
e Or
ders
Quali
ty R
epor
ting
Internet
Information Management
Resource Locator Services
- Community Sharing- Pt-to-pt networking- Media interchangeNo
de A
uAu
d
Transaction
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Example of Technical Protocols: Document Registry: NwHIN SAML Headers
Example of the SAML headers that the XDS Toolkit emits to interact with the US ONC CONNECT j I l i h b h d i ll i h CONNECT project. I cannot claim they are correct but they do interact well with CONNECT.
instructions– Clinical summaries– Exchange key clinical information
– Privacy and security
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Right information to the Right person in the Right format through the Right channel at the Right channel at the Right time
Clinical Decision Support Is a sophisticated HIT component doesn’t stand alonep p
Common featuresKnowledge‐based (diagnosis, drug databases including interactions, side effects and monographs)Rules & relationships that combine knowledge with patient‐specific information specific information Communication mechanisms that provide relevant information to the clinician as care is delivered.
Berner, 2009
A critical feature supporting achievement of the Triple Aim!
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Benefits of CDS inside the EHRStreamline workflow and productivityStreamline workflow and productivity
Improve clinical accuracy through EBP
Increase clinician satisfaction
Improve patient outcomes
Benefits of CDS inside the EHRStreamline Workflow and Productivity by:f y y
Organizing and presenting information in an familiar order and workflow
Supporting informed decisions & actions through a variety of rules and tools
Cuing the clinician as to what has been accomplished and what is yet to be done
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Benefits of CDS inside the EHRIncrease Clinical Accuracy through EBPIncrease Clinical Accuracy through EBPMatching patient information with evidence, guidelines & requirementsProviding discrepancy or omission alertsProviding follow up remindersSupporting decisions and recognizing varianceSupporting decisions and recognizing variance
Easy access to information – EBP, tips, etc. Suggesting alternativesCollecting explanation of variance
Benefits of CDS inside the EHRIncrease Clinician SatisfactionIncrease Clinician Satisfaction
Putting information where clinicians need it
Keeping track of tasks and progress toward completion
Providing support for completing complex procedures
Placing the patient at the center of care
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Benefits of CDS inside the EHRImprove Patient Outcomesp
Suggesting individualized care plans based on EBP
Providing visibility to an interprofessional care plan
Recommending specific actions, reminders and evidence while tracking progress
Providing support for patient engagement
Applying currentApplying currentconcepts to homecare & hospice
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Standardized Terminologies
Standardized point‐of‐care terminology: A structured language consisting of terms, definitions, and codes that clinicians use to guide and document practice (i.e. Omaha System)
Standardized reference terminology: A structured Standardized reference terminology: A structured language consisting of terms, definitions, and codes that clinicians do not see, but software developers use to promote interoperability/exchange of data (i.e. SNOMED CT, LOINC)
Omaha System
bl l f hProblem Classification Scheme (assessment)
Intervention Scheme (services)Problem Rating Scale for Outcomes Problem Rating Scale for Outcomes (evaluation)
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Omaha System Model of the Problem Solving Process
Copyright: Martin KS. (2005). The Omaha System: A Key to Practice, Documentation, andInformation Management (Reprinted 2nd ed.). Omaha, NE: Health Connections Press.
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Evidence‐based Practice
Evidence‐based practice is a problem‐solving approach to health care that incorporates the conscientious use of current best evidence from 1) well‐designed studies, 2) a clinician’s expertise, and 3) patient values and preferences. Fineout‐Overhold, Melynk, 2005
All three of these key components must be present for evidence‐based practice to be effective.
The EBP Paradigm Fineout‐Overholt, el al, 2005
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Why Standardized Terminologies and EBP?
National, State & Local Perspective Helps decrease variability across clinicians & providers Supports accurate and comparable benchmarkingHelps achieve efficient & effective patient outcomesH l d tHelps decrease costsMeets accreditation & licensure standardsHelps decrease adverse eventsCan positively affect Home Health Compare Scores
Why Standardized Terminologies and EBP?
Positioning your Organization for SuccessStandards are mandatedBasing practice & care on evidence is expected by the Affordable Care Act (ACA)ACO i d id b d ACOs are required to promote evidence‐based medicineChanging focus to value based purchasing
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Why Standardized Terminologies and EBP?
Clinical Perspective Research studies show that use leads to:
Diffusion of InnovationInnovators‐2.5% (venturesome, like novelty)5 ( , y)Early adopters‐13.5% (opinion leaders who are well connected)Early majority‐34% (learn mainly from those they know well)Late majority‐34% (look to majority; “safe” to try)Laggard‐16% (reference point in past; may be obstructionists to valid change)
Everett Rogers, 1995
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Delays to AdoptionClinicians’ PerspectiveClinicians Perspective
Lack of knowledge/awarenessWasn’t a part of their clinical educationToo difficult or time‐consumingEBP isn’t easily accessible when needed EBP isn t easily accessible when needed Change is difficult
Delays to AdoptionOrganizational PerspectiveOrganizational Perspective
Time, energy and focus is consumed insuring regulatory compliance“That is why we hire licensed professionals”“Isn’t that why we have OASIS?”Isn t that why we have OASIS?Software doesn’t include itChange is difficult and expensive
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The Journey to an EHR supported by standard clinical terminology , EBP and CDS
• Iowa’s largest provider of integrated home health
UnityPoint at Home – Who We Are
g p g
• Provide an evidence‐based integrated chronic care disease management education and certification program for its entire clinical workforce
• Transitioned to an electronic point of care pdocumentation system in 2004
• Part of a Pioneer Accountable Care Organization
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• Point of Care• Increased efficiency• Improved workflow
Our Electronic Health Record Journey•Telehealth monitoring
•Non‐video and video monitoring•Intake workflow • Improved workflow
• Increased accuracy
• Electronic Scheduling• Improved Care Coordination
• Physician Portal• Improved
Intake workflow •Centralize intake across sites
•Electronic Supply ordering•Patient supplies at POC•Delivered to patient’s home
•Smartphone•Improves communication•Most recent data on the server
• Improved communication
• Improved work flow
• Wound Advisor• Extends the reach of wound specialists
Multiple co‐morbities
The Complexity of Home Care
Partnering to prevent 30 day re‐hospitalizations
Complex case management
Difficult social situations
Medication use and poly‐pharmacy
The realities of end‐of‐life care
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First reviewed in 2002
Our Omaha System Journey
We valued the:Patient‐centerednessSimplicityRespect for the evolving technology landscape, i.e. mapping to SNOMED, LOINC, ICD 9/10CMProblem Classification SchemeThe Problem Rating Scale for OutcomesgApplicability to all health care professionalsUse across care settings and internationally
We were concerned that it was not embedded within our electronic medical record
Now is incorporated in our electronic medical record
Our Omaha System JourneyNow is incorporated in our electronic medical record
Supported by EBP and CDS Affords us a patient centered interprofessional care plan
NursingTherapy (PT, OT, SLP)Social workersS i it l d i th i tSpiritual care, massage and music therapistsExtensible to physician and other mid‐level practicitioners
Beginning roll out with home health and infusionPediatrics and hospice will follow
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Access at the point of care
Our Omaha System JourneyAccess at the point of care
Essential that all care team members have access to the care plan at the place of care
Working from a single integrated care planFor example – a Neuro‐musculo‐skeletal function problem will have different interventions for each professional with a common end goal and visibility by all
Noted improvementBefore the use of an EHR with CDS and EBP
Our Omaha System Journey
Before the use of an EHR with CDS and EBPProfessional specific care plans difficult to view by other disciplinesDifficult to access a common patient‐centered problem listRevisits not always focused
With an EHR with CDS and EBPProfessional specific care plans that contribute to i t di i li linterdisciplinary care planWorking with patient‐centered problem list Revisits focused on patient’s problems – efficient use of clinician time.EBP interventions are suggested to clinician as care plan is built
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More documentation does not equal better documentation
Less Can Be Moreq
More accurate charting focused on patient specific problemsIndividualization occurs naturally based on the assessment findingsInterventions provided based on best and evidence‐b d ibased practice
Including appropriate care team participants
The Problem Rating Scale for OutcomesHelping the care team determine readiness for discharge
Training plan – 9 sites
Implementing an EHR with CDS and EBPg p 9
Provided Omaha System basic workshops in preparationEstablished field staff champions
Implementation plan – Covering 9 physical locations
Implementing an EHR with CDS and EBPImplementation plan Covering 9 physical locations
Each site trained individuallyUse case studies to support the system training with the goals of:
Developing consistency in the care planning processDeveloping consistency in scoring the Problem Rating Scale for Outcomes
Workshop attendeesWorkshop attendeesChampions and supporting staff
Metrics once fully implemented
Implementing an EHR with CDS and EBPMetrics once fully implemented
Patient outcomes using CDS and EBPImprovedAchieved more quickly
Clinician satisfactionLess training time to learn EHR systemI d fid i l ti b t i t tiImproved confidence implementing best interventionsIncreased collaboration regarding patient problem list due to interdisciplinary care plan.
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• Omaha System based on a standardized terminology
Preparing for Meaningful Use ‐ Stage 2 and Interoperability
y gy• Including respect for reference codes, SNOMED, LOINC, ICD‐9/10 CM
• Enabling us to share meaningful data
I i bilit t hi iti t• Improving our ability to achieve positive outcomes
• Support our value to Accountable Care Organizations
How you can be a part of what is happening with technology to position us to achieve the
Triple AIM for Health Care
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There are many activities underway and open to your
Health IT InitiativesThere are many activities underway and open to your involvement, check out these sites for opportunities:
http://www.HealthIT.govhttp://www.healthit.gov/policy‐researchers‐implementers/health‐it‐strategic‐planninghttp://wiki.siframework.org/http://www.healthit.gov/policy‐researchers‐implementers/long‐term‐post‐acute‐careYour System, State or Regional HIE
Let whoever is in charge keep this simple question in her head (not, how can I always do question in her head (not, how can I always do this right thing myself, but) how can I provide for this right thing to be always done?”
Florence NightingaleNotes on Nursing: What it is and What it is Not
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What You’re Doing & Questions
Contact InformationKaren Utterback, MSN, RN
VP Strategy and Marketing, McKesson Extended Care Solutions Group [email protected]
Karen S. Martin, MSN, RN, FAANHealth Care Consultant, Martin Associatesmartinks@tconl.comwww.omahasystem.orgwww.healthconnectionspress.com
Lois Glanz, BSN, RNClinical Information Specialist, UnityPoint at [email protected]
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References Abrahamson KA, Fox RL, Doebbeling BN. (2012). Facilitators and barriers
to clinical practice guidelines use among nurses. American Journal of Nursing 112(7), 26‐35.
Berner ES. (2009). Clinical decision support systems: State of the art. Rockville, Maryland: Agency for Healthcare Research and Quality. AHRQ Publication No. 09‐0069‐EF.
Blue Cross/Blue Shield (2012). Building tomorrow’s healthcare system: The pathway to high quality, affordable care in America.p y g q y,http://www.bcbs.com/why‐bcbs/health‐reform/pathway.pdf
Bowles KH, Potashnik S, Ratcliffe SJ, Rosenberg M, Shih N‐W, Topaz M, Holmes JH, Naylor MD. (2013, June). Conducting research using the electronic health record across multi‐hospital systems. Journal of Nursing Administration, 43(6), 335‐360.
References Carrington JM. (2012). The usefulness of nursing languages to
Castillo RS, Keleman A. (2013) Considerations for a Successful Clinical Decision Support System. CIN: Computers, Informatics, Nursing 31(7), 319326.
Cipriano PF. (2011). The future of nursing and health IT: The quality elixir. Nursing Economics, 29(5), 282 and 286‐289.
Fineout‐Overholt E, Melnyk B, and Schultz A. (2005). Transforming health care from the inside out: Advancing evidence‐based practice in the 21st century. Journal of Professional Nursing 21(6), 335‐344.
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ReferencesHarrison RL, Lyerla F. (2012). Using nursing clinical decision support
systems to achieve meaningful use. CIN: Computers, Informatics, ( )
y g fNursing, 30(7): 380‐385.
Humphrey CJ, Utterback K. (2012). The role of evidence‐based clinical practice in emerging home care models. Caring, 31(10), 26‐30.
Institute For Healthcare Improvement. (2013). Triple Aim Initiative. http://www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx
Kohn LT, Corrigan JM, Donaldson MS. (2009). To Err is Human: Building a Safer Health System. The National Academies Press: Washington, D.C.
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Increasing nurses’ access to evidence through a Web‐based resource. Journal of Nursing Administration 42(11) 531 535 Journal of Nursing Administration, 42(11), 531‐535.
Martin KS, Utterback KB. (2014). Home health and related community‐based systems. In R Nelson, N Staggers, Health informatics: An interprofessionalapproach. St. Louis: Elsevier. (147‐163).
Martin KS. (2005). The Omaha System: A key to practice, documentation, and information management (Reprinted 2nd ed.). Omaha, NE: Health Connections PressConnections Press.
Omaha System Website: www.omahasystem.org
Rogers EM. (1995). Diffusion of Innovation (4th ed.). New York: The Free Press.
