Let’s Talk Informatics
Electronic Clinical Documentation
Alyson Lamb & Keltie Jamieson
June 20, 2019
Bethune Ballroom, Halifax, Nova Scotia
Please be advised that we are currently in a controlled vendor environment for the One Person One Record Procurement
project.
Please refrain from questions or discussion related to the procurement for
One Person One Record Clinical Information system.
Informatics…
utilizes health information and health care technology to enable patients to receive best treatment and best outcome possible.
Clinical Informatics…
is the application of informatics and information technology to deliver health care. AMIA. (2017, January 13). Retrieved from https://www.amia.org/applications-infomatics/clinical-informatics
Objectives At the conclusion of this activity, participants will be able
to…
▫ Identify what knowledge and skills health care providers will need to use information now and in the future.
▫ Prepare health care providers by introducing them to concepts and local experiences in Informatics.
▫ Acquire knowledge to remain current with new trends, terminology , studies, data and breaking news.
▫ Cooperate with a network of colleagues establishing connections and leaders that will provide assistance and advice for business issues, as well as for best-practice and knowledge sharing.
1. Understand the vision and guiding principles for clinical standardization
2. Understand the concepts behind clinical standardization
3. Understand the building blocks for clinical documentation
Conflict of Interest Declaration
• We do not have an affiliation (financial or otherwise) with a pharmaceutical, medical device, health care informatics organization, or other for-profit funder of this program.
Agenda
1. Vision
2. Guiding Principles
3. Clinical Standards
4. Understanding of Electronic Clinical Documentation
5. Questions
Right Information, Right Person, Right Time and Place
A single health record for every person in Nova Scotia
A modern, integrated health information system:• Accessible across the continuum of care• Made up of a scalable clinical information system and the right mix of additional systems, applications, and technologies
Patient• Improved service
delivery
• Increased Safety
• Improved Care Experience
Provider• Improved care decisions
• Improved quality of care
• Improved health outcomes
Planner• Improved planning &
monitoring of health services
• Improved population wellness
Public• Increased value from
health care spending
• Increased
sustainability and affordability
Pro
ble
m
Sta
tem
en
tO
PO
R V
isio
n
Planned Outcomes
The health care system in Nova Scotia is facing significant challenges that require changes in how health-related services
are managed and delivered. The underlying health information systems currently deployed in the Province are
fragmented and costly to maintain. The “One Person-One Record” (“OPOR”) strategy requires the Province to replace the
three existing hospital information systems with a core clinical information system (OPOR – CIS).
Until now, the Province’s health information systems have been procured and implemented by functional need, which has
created a complex environment of over hundreds of systems which collect information on patients but are unable to share
it across the continuum due to excessive integration cost and effort.
OPOR Vision8
Anticipated BenefitsOutcomes realized in other jurisdictions
1. Enhance patient safety
60% reduction in serious medication errors (alerts, on line
and available evidence based practice guidelines).
2. Improvement in quality and clinical outcomes
Improved compliance with Accreditation Canada’s
Required Organizational Practices and preventative
management of adverse events.
3. Improved patient experience
Better information available in a timely manner results in
better decisions about care. This can reduce repeat testing
and wait times for patients and shorter length of stays.
4. Improved access to health information
The right and complete information is available for the right
clinician at the right time.
5. Health system use of information
Alignment with CIHI vision (2011) as approved by the
provinces (better healthcare and improved health for
Canadians).
6. Population Health
Guiding Principles
Guiding Principles
Focus on Patient & Family Centred Care: partner with patients
Clinician Driven: by clinicians for clinicians
Based on clinical best practice, evidence, and outcomes
Documentation is an outcome of care
Variation in care should be minimized, intentional and be measurable
Leverage work already done across the organization and by other jurisdictions – not reinventing the wheel
Learn by doing - a continual improvement process
Clinical Standards
Clinical Standardization
Province wide, iterative health care
quality improvement based on clinical
outcomes and variation analysis.
Implementation of new research/
innovation
Continuous Improvement
Improve quality, safety, and patient outcomes
by reducing variations in care, and following
optimized workflows with evidence built in.
Improve value per healthcare dollar spent
Care Transformation
Enable clinical and business
intelligence: better decision-making
(patient to population level).
Clinical Decision Support
Agreement on standard electronic clinical terms,
terminologies, and data view/entry conventions across
specialties, scopes of practice, departments, and
organizations
Technical Standards
Establishment of clinical
standards and protocols for the
management of patients.
Clinical Standards
13
Best Practice Guidelines
Required Organizational
Practices
Quality Initiatives
Hospital Protocols and
Policies
Practice Standards
Standards
of Care
Data
Standards
Clinical
Documentation
Standards
Governance
Project Management
Technology
WorkflowClinical
Doc.Order SetsOrders
Best Practice Content
Med. Mgmt.
Sta
nd
ar
ds
Care Plans
Care Transformation
Evidence Informed, Best Practice
15
Provincial Considerations
16
PersonalizationStandardization
Standardization is the goal….Personalization is human nature
Balance & Measure
16
Clinical Effectiveness
The right thing (evidence informed best practice)
The right person (scope of practice & skilled workforce)
The right time (accessible services at the point of need)
The right place (location of treatment / services)
Clinical effectiveness is defined (UK Department of Health, 1996) as
“the application of the best knowledge, derived from research, clinical
experience and patient preferences to achieve optimum processes and
outcomes of care for patients.
17
18
• “Clinical documentation facilitates the accurate representation of a patient’s clinical status that translates into coded data. Coded data is then translated into quality reporting, statistical reporting, public health data, and disease tracking and trending”AHIMA - http://www.ahima.org/topics/cdi?tabid=overview
US Trend 19
Continuity of Care Document (CCD):
• increase the quality and efficacy of patient transfer between points of care
• modernize communication methods for patient data exchange –interoperability between systems in a multi-vendor model
CCD Templates* include:1.Header2.Allergies3.Problems4.Procedures5.Family history6.Social history7.Payers8.Advance directives9.Medications10.Immunizations11.Medical equipment12.Vital signs13.Functional stats14.Results15.Encounters16.Plan of care
©2018 Healthtech Consultants. All rights reserved. Do not distribute without written permission.
Level of Standardization
20
Strive/Plan for a high level of standardization
Components that can be standardized:
Patient Data
• Demographics• Patient Headers• Allergies• Medications• Health and Social History
Diagnostic Tests & Results
• Lab• Diagnostics
Assessment and Exam Findings (Interprofessional Team)
• Core Corporate Documentation Tools• Progress notes• Standardized Assessments• Speciality Documentation tools
Prescriber/Physician Documentation
• Admission/H&P• Discharge Summary• Consultation Report• Progress Notes• Procedure Notes
Orders
• Order Catalogue• General/Corporate Order Set
Care Planning
• Consults/referrals• Discharge plans• Patient and family education• Problem Lists• Kardex
©2018 Healthtech Consultants. All rights reserved. Do not distribute without written permission.
Patient Data
Demographics
Allergies
Medications
Medical/Health History
Problems
Procedures
Family History
Social History
Advanced Directives
Infection Control
Diagnostic Tests & Results
40%
65%
80%
Level of Standardization - Minimum
©2018 Healthtech Consultants. All rights reserved. Do not distribute without written permission.
Patient Data
Diagnostic Tests & Results
Assessment and Exam Findings
Vital Signs/O2/Pain
Height and Weight
Risk profile
Falls
Violence
Pressure Injury
Aggressive behavior
Mental Health Act Forms/legal
status/forensic status
VTE
Sepsis
Intake and Output
Infusion therapy
Wounds/Drains
Cognitive Status
Functional Status
ADL
Sleep
Elimination (Bowel/Stool Chart)
40%
65%
80%
Physician Documentation
Admission/H&P
Discharge Summary
Consultation Report
Progress Notes
Procedure Notes
Emergency Department
Order Catalogue
General/Corporate Order Sets
Care Planning
Consults/referrals
Discharge plans
Patient and family education
Chronic disease management
Crisis Management
Level of Standardization - Better
©2018 Healthtech Consultants. All rights reserved. Do not distribute without written permission.
Patient Data
Diagnostic Tests and Results
Assessment &Exam Findings
Physician Documentation
Order Catalogue
General/Corporate Order Sets
Care Planning
Program/Service/Specialty Content
Documentation tools
Standardized Assessments
Order Sets
40%
65%
80%
Level of Standardization - Best
North York General Hospital (NYGH) has achieved substantial patient care benefits from the implementation of an integrated record and the utilization of evidence based order sets
Cumulative Capabilities Stage NYGH Case Study
Complete Electronic Medical RecordContinuity of Care Documents sharedData WarehousingData continuity w/ED, Ambulatory, Outpt, Inpt
7 In meeting HIMSS Stage 6 requirements, NYGH has seen significant improvements in their care delivery:
Second best HSMR (hospital standardized mortality rate) in Canada
2,300 medication errors averted in first year of Closed Loop Medication Administration
Physician Medication Reconciliation at discharge has gone from 8% to over 80%
Rates of prevention against Venous Thromboembolism have increased from 50% to 96%
55% reduction in preventable deaths from Pneumonia due to use of electronic diagnosis-specific order sets
45% reduction in preventable deaths from COPD due to use of electronic diagnosis-specific order sets
Average turn around from time antibiotic ordered to first dose administered was reduced by 4 hours (from 291 minutes to 50 minutes)
Other hospitals could realize similar benefits by achieving HIMSS Stage 6
Physician documentationFull Clinical Decision Support 6
Closed loop medication administration 5
Computerized Physician Order EntryClinical Decision Support (clinical protocols) 4
Nursing documentationClinical Decision Support (error checking) e-Medication Administration RecordPACS outside Radiology
3
Clinical Data Repository w/ controlled vocabularyClinical Decision Support (rules)Document imaging
2
LaboratoryRadiologyPharmacyFull Radiology Picture Archiving & Communication
System (PACS)
1
Paper-based workflows 0
NYGH
Source: Jeremy Theal, MD FRCPC, CMIO, North York General Hospital “Patients Benefit when Clinicians, Culture, Evidence and Health IT Connect”, February 26, 2014. HIMSS Presentation
Case Study – North York General
Designing the Clinical Standards Process
• Engagement of clinicians and physicians to drive high levels of clinical adoption
• Leverage standardized clinical content available (don’t recreate the wheel)
• Local input to ensure clinical standards are “right sized”
• Leverage evidence (changes to standard content only if evidence based)
• Optimize time of steering committee and working group members
• Clear approval process
• Documentation of standards
Electronic Clinical
Documentation
Iterative Process – Learn by Doing!
Understand the Clinical Documentation Architecture
What needs to be documented
at a minimum for all
encounters?
Common across all programs?
Unique for programs,
interventions, clinical context?
Content Development – Where to begin?
Data ElementsExample: Lab/DI catalogue,
Vitals
Clinical Documentation
Example: Assessments, Scoring Tools
Care of Diseases, Conditions
Example: Guideline, Clinical Pathway, Order Set
Three Areas of Work
Template 1 Template 2
Common Concepts
Designing using common concepts
Example Detailed Clinical Data Model
Example Detailed Clinical Data Model
Example Detailed Clinical Data Model
Example Detailed Clinical Data Model
36
If Blood Pressure was a building block
37
Blood Pressure Standard
Family History
Step 1 Select the relevant knowledge part(s) from the standard
Step 2Include in form for use in clinical care.
B.P.
FH
ReferralKnowledge Building Blocks
A nice screen/form that I can use ;-)
Building an Orthopedic Referral(simplified example)
Referral
Imaging Results
Imaging Result
Step 1 Select the relevant knowledge part(s) from the standard
Step 2Include in form for
use in the OR.
B.P. FH Triage
Knowledge Building Blocks
A nice screen that I can use
Blood Pressure Standard
Family History Operative Report
Building an OR Report – Knee Arthroplasty(simplified example)
Medical Device
Medical Device
39
Screen designs meet the specific requirements of the groups that will use them, but use consistent data standards.
OR ReportOrtho Referral
Meeting Clinician needs, keeping standards
40
Dashboard / Report / Extract / Summary / Message
Content Standards drive Information Reuse
Standards in the “building blocks” allow information to be shared and reused appropriately, regardless of who recorded it.
Analytics Framework
Data
& M
easu
rem
en
t L
og
ical M
od
el
Define data requirements
Business Value DefinitionsDescribe the need & Identify the desired change,
Understand method of measurement &
Build analytic questions
Create clinical knowledge artifacts
Supporting Master Data *Patient Record Clinical Data
Define measurement rules(How we use the information we have, to build the measurement we need, to support the Business Value defined)
Care Timeline DataPatient Demographic
Master Data
Generate new information
Use new information
Compliance to Standards
AppropriatenessPatient
OutcomesCost Outcomes
Therapy Effectiveness
Foundational Knowledge
Clinical Documentation
Clinical Knowledge Topics
Clinical Decision Support
Evaluation of Standards
Evaluation of CKT
What is a form?ENTRY/DOCUMENTATION & REPORT
What is different about electronic documentation?
Example: Patient is seen at the OAC by Nursing, Physio and Physician
Separate
entry
“forms”/screens/
lego
Nursing Assessment
Physio Assessment
Physician Documentation
Report to
Family Doctor
View/Report for
Nursing
View/Report for Surgeon
Automatically
communicated
Where to Start?
1. Define guiding principles for documentation
2. Data elements• Definition• Minimum/Core• Additional situation based
3. Templates • Assessments• Discharge• Standards• Order sets
4. Analytics• Reports• Evaluation• Clinical Decision Support
THANK – YOU
DISCUSSION/QUESTIONS?
The Let’s Talk Informatics series meet the criteria outlined in the Manipro+ Certification
guide for 1 credit by providing content aimed at improving computer skills as applied to learning
and access to information.
A certificate of attendance will be sent to you to personalize, along with the link for the
evaluation.
Thank you for attending today’s event.