A Nursing Informatics Leadership Role. Improving Clinical Quality Outcomes through EHR Design, Development, and Utilization

Transcription

1 A Nursing Informatics Leadership Role Improving Clinical Quality Outcomes through EHR Design, Development, and Utilization

2 Lyda Gardiner B.Sc., B.Ed., M.Ed., BSN, RN Practice Director Quality and Performance Innovation - Jacobus Consulting Lyda is a respected quality and clinical informatics leader, with a proven track record of spearheading strategic change to realize the full benefits of EHR enabled systems. Employing proven methodologies such as Continuous Quality Improvement, and innovative approaches such as the development of Quality Informatics roles, Lyda empowers leaders and teams to utilize their EHRs to meet Meaningful Use, Value Based Purchasing, and Accountable Care. Drawing on a strong clinical nursing foundation, deep knowledge of healthcare systems and quality methodologies, Lyda effectively creates solutions that combine operational effectiveness with knowledge and information to ensure effective outcomes and realization of strategic goals and objectives. 2

3 Incentive program goal: EHRs that support high quality care through new EHR-enabled workflows, ensuring accurate, reproducible, high quality data at individual and aggregate level are necessary to measure OUTCOMES OF CARE New workflows and documentation requirements can be difficult for clinicians to adopt and for EHR vendors to support well. Focus on Value Based & P4P payment models & other Quality Outcomes programs will increase the need to extract actionable data from EHRs & other systems & reimbursement of organizations will be based on data submitted from the EHR Accurate patient care documentation across the continuum of care is necessary for reporting OUTCOMES of evidence based care Emerging new payment models for health care will require value over volume. Examples of such payment models include: Health homes Accountable care organizations Medicare s value-based purchasing (pay for performance) programs Core Measures Meaningful Use Inpatient/Outpatient Quality Reporting 3

4 Objectives for Today NI Leaders must develop & use skills in ALL informatics domains to help their organizations successfully implement & manage Quality Outcomes Programs (QOPs) EHR is foundational to successful QOPs which drive healthcare forward through provision of data, information & knowledge Design, Build & Maintenance of HCIS MUST ensure effective data/analytics NI competencies need to develop through all layers of the organization Data, Information, Knowledge, Wisdom Safe, Timely Equitable, Effective, Efficient, Patient- Centered 4

5 Current Health Care Environment 2009 ARRA (American Recovery & Reinvestment Act) : Meaningful Use EHR Incentives Program Foundational to PPACA Improve quality, safety, efficiency Reduce health disparities Engage patients, families in their care Improve Care Coordination Improve Population and Public Health Ensure Privacy/Protection of PHI 2010 PPACA ( Patient Protection and Affordable Care Act) : Accountable Care Organizations (ACO), Value Based Purchasing (P4P) Provide Value Improve Quality, control cost/efficiency Protect Patients Improve Safety, involve patients & families, ensure privacy of PHI Ensure Affordable Care Reduce disparity, improve care coordination, improve pop/public health 5

6 AHRQ: Health IT & EHR are the Foundations for Value & Quality EHR Supports: 1. Quality measurement and improvement based on data from EHR 2. Optimized data collection from the EHR 3. Care coordination EHR provides information across care continuum 4. Provides clinicians & patients with necessary info to optimize care 5. Provides timely feedback to care providers about care 6. Facilitates provision of right care & time, based on most current info 7. Allows for the comparative evaluation of treatments and interventions 8. Allows for the collection of data and information at a population level allowing for effective management of high-impact conditions 9. Data provides information about regional and other disparities in care 10. Value of care measurement provided by an organization, or its component departments, or measure the value of care provided by AC0

7 Value Based & P4P Reimbursement Payment reform that rewards Value rather than Volume of patient care is a primary goal, if not THE primary goal, of today s healthcare reform 7

8 QUALITY How is VALUE defined? OUTCOMES + = VALUE COST EHR IS FOUNDATIONAL TO ACHIEVE VALUE IN HEALTH CARE 8

9 Definition of Value Value may be defined as the health outcomes achieved per dollar spent OR: The Intersection of Quality & Cost Quality Cost Value Equilibrium (optimal) 9

10 Relationship Between Quality and Value Achieving high value for patients MUST become the overarching goal of improved health care delivery Value should define the framework for performance improvement in health care. Rigorous, disciplined measurement and improvement of value is the best way to drive system progress. - The New England Journal of Medicine Michael E. Porter, Ph.D. 10

11 Quality Programs are Focused on Outcomes: Getting the right care To the right patient At the right time Every time to ensure the BEST Outcomes Possible QUALITY Outcomes 11

12 The IOM Dimensions of Quality Care are: Safe Timely Effective Efficient Equitable Patient Centered Quality Care The ability to effectively improve Quality requires: Ability to measure & evaluate Structure, Processes, & Outcomes against Quality Dimensions (use data) Ability to impact outcomes through the use of Evidence Commitment to change when a better way is reliably identified- Continuous Quality Improvement 12

13 Quality Department Functions Methodology Measure/evaluate/improve structure & process Abstract Information from records Measure/evaluate and improve Outcomes and the 6 Dimensions of Quality. Provide data & improvement strategies to nursing, physicians, & other clinical practice areas Report data to population/condition data bases to provide information for condition management Report outcomes for Pay for Performance, and other reimbursement Provide physicians with credentialing and performance data Ensure continuous quality improvement through practice change based on evidence (data, clinical research) Performance Improvement (PDCA, six sigma, lean etc.) Meet Evidence Based Standards for structure, process and outcomes (EBM/P) Support the implementation of new evidence for improved quality Change Management NEED: Effective data gathering mechanism reliable EHR 13

14 Codification & Taxonomy Collection, Organization, Storage & retrieval of Information, knowledge Interpretation Transmission of information Human-Computer Interaction Iterative design processes Ways people generate, use & find information Information Sciences Information & Communications Technology Informatics Storage & Dissemination of data Design and build of systems such as HCIS, Clinical (Business) Intelligence & other systems Data Storage & Retrieval Focus on tools that enable efficient: Capture, Delivery, Transmission, & Use of data, information, & knowledge Effective application of those tools 14

15 Nursing Informatics Full Scope & Practice of Nursing, as defined by ANA NI competencies for bedside nurses, Nurse Informaticians, & Nurse Informatics Specialists (graduate level education) Scope of NI is commensurate with scope of nursing practice & nursing science with a concentration on data, information, & knowledge NURSING PRACTICE INFORMATION SCIENCE INFORMATION TECHNOLOGY 15

16 EXTERNAL FACTORS Value (quality + cost) Focus on QOPs Evidence Based Practice Value Based Payment New models of reimbursement ACO, Medical home Regulatory environment ARRA/MU Clinical Care (Nursing) The Health System Information & Communications Technology INTERNAL FACTORS Increased interdisciplinary practice and patient centric processes Coordination of Care People, Processes, & Technology Culture Practice Goals for each discipline Practice Based Evidence Clinical Informatics Slide 16

17 Practice of Quality Sciences Computer Science Information Science QUALITY INFORMATICS (The study of) information use in understanding and improving health care quality and safety Expert knowledge of all quality and patient safety initiatives Measures, regulatory expert ensures consistency between modules Assists with design/development of EHR Ensures streamlined build to facilitate reporting Works with end-users to ensure accurate, reliable entry of data/information Works with Data Architect build, data marts, reporting/data mining, BI solutions Facilitates BI Maturity Supports Quality department transformation to HCIS Supports Organizational transformation to data driven/quality Driven Organization 17

18 Evidence 2 Perspectives Both Critical for Successful Healthcare Transformation 18

19 What is Evidence Based Practice? The conscientious, explicit, and judicious practice of integrating individual clinical expertise with the best available clinical evidence from systematic research in making decisions about the care of individual patients. DL Sackett The integration of bestresearched evidence and clinical expertise with patient values Institute of Medicine Committee on Quality of Health Care in America 19

20 What is Practice Based Evidence? A structured, systematic approach to utilizing data obtained from your EHR to drive decision making Applies scientific method to the gathering and utilization of organization specific data Aligns data and measurement with organizational strategies and performance improvement goals to result in data driven decision making 20

21 Evidence Based Practice & Practice Based Evidence When practiced together, form the basis of Continuous Quality Improvement Provide data, information & knowledge for Clinical Decision Making, which must be coupled with Expert Knowledge & Experience (Wisdom) Quality Outcomes Programs (QOPs) are structured programs of data collection with defined measures targeted to provide data, information & knowledge about diseases & populations that account for big populations and/or high cost 21

22 Nursing Informatics & Coordination of Care Nurses Most qualified, well positioned, & largest group of contributors to healthcare services Best positioned to support essential clinical transformation efforts through automated clinical tools (EHRs) which will result in new care delivery models As nurses coordinate care HCIS will become THE tool that facilitates effective and efficient coordination through communication Real-time availability of information in the form of CDS (clinical decision support,) all of which will facilitate the real-time coordination of care (CDS combines EBP & PBE) Design and flow of data and information will be critical Build MUST Begin with the end(s) in mind Be well defined and clear as to the outcomes needed both for the patients, and for the system (remember there is EBP with regard to HCIS systems as well as for patient care) 22

23 Coordination of Care (cont.) NI practitioners are Leaders - Designers - Facilitators - Educators - They will help nurses gain competencies necessary to utilize EHR at the bedside to provide the knowledge, information, & communication needed They are the leaders who will help Nurse Executives move the nursing agenda forward with regard to QOPs and delivery of VALUE to all patients Nurses & the nursing profession are positioned as the most qualified to respond to the current health system changes & meet ehealth transformational agendas Amara (2000) 23

24 Key Consideration If reimbursement is now based on VALUE, how do you know it has been delivered? Measure of cost & other financial measures Finance Teams Measure care and treatment OUTCOMES CLINICAL AND QUALITY PROGRAMS & DEPARTMENTS (QOPs) Measure interventions, actions, treatments Rigorously define the way outcome is measured, controlling as many variables as possible to allow the data to be comparable and inferences to be accurate 24

25 Outcomes Are evaluated through measurements designed to provide actionable data measure the impact of a treatment, action or intervention Measures provide data & information Expand knowledge allow quantification, comparisons between organizations & practices There are hundreds of measures, developed by many agencies two examples are NQF over 600 endorsed measures PQRI 153 Quality measures 25

26 Outcomes (cont.) Must be measureable using EHR data Data and information provided must be accurate Must be able to report large volumes of data Data fields MUST be well defined, multiple fields must be captured, specific criteria included or excluded 26

27 Quality Outcomes Programs (QOPs) Measure sets Are used to provide information regarding quality of care provided by an organization May include measures of intervention, treatment, specific practices or other action or activity depending how they are built and utilized Are generally a group of measures related to a specific topic, i.e. AMI, SCIP, etc. The Quality Measures in QOPs measure Structure Process Outcomes Along the 6 dimensions of quality Safe Timely Effective Efficient Equitable Patient Centered 30 25% 24% 21% 30%

28 Quality Outcomes Programs (cont.) Built based on evidence ranging from double-blind clinical trials to expert consensus; provides information on population, disease, interventions, treatments, etc. Organizations may build Practice Based Measures; e.g. measuring fall rates in inpatient medicated populations over age 65 Measures form the basis for reports that are fed to dashboard for PI, Surveillance, QOPs, upload to national databases, & other mandatory reporting 28

29 Outcomes Programs are based on Measures Formal Measures Development Ensures Consistent measurement Defined measurements to allow comparison of data Structured Examples of Measures (see next slides) 29

30 Core Measures 30

31 Measures Common To More Than One Program 31

32 VBP Measures 32

33 Quality Outcomes Programs Joint Commission In-pt/Out-pt Quality Reporting Value Based Purchasing AHRQ In-pt Quality- Pt. Safety & Pediatric Indicators Hospital Quality Association In-pt indicators Hospital Acquired Conditions Long Term Care Hospital Quality Indicators Inpatient Psychiatric Facility Quality Indicators Meaningful Use Stage I, II, & III Core, Menu & Quality Measures National Database of Nurse Quality Indicators Medications Mortality 30 National Quality Forum Clinical Quality Measures OASIS (Home Health Data Set) Hospice Quality Measures Inpatient Rehabilitation Quality Indicators 33

34 Quality Reporting Timeline QOPs 34

35 Quality Outcomes Programs QOPs require organizations to apply a basic CQI approach to systematic change, founded on: Identifying a problem & Determining a measure Collecting Data & Reporting actual results Comparing actual outcomes against goal Comparing goal against benchmark Applying interventions (based on evidence) designed to improve outcomes Legislation and national/state initiatives are requiring CQI & associated methodology through QOPs 35

36 Implementing Automated, Large-Scale Quality Outcomes Programs (QOPs) Current QOPs are frequently managed with manual data extraction from electronic record (NDNQI, CORE Measures, IQR, BH, ARU, etc.) Quality team members manually extract data for representative samples and submit to national databases To effectively implement QOPs and the volumes of data they require, automated data extraction from the EHR is essential How can this be automated from the EHR? Nursing Informatics can lead the way

37 Types of Issues Impacting Automated Data Extraction from EHR for QOPs Key Areas Requiring Nursing Informatics Expertise

38 Data Input Issues Inconsistent build, hybrid records, multiple locations to document the same information Lack of awareness of where reportable data is captured (ALL locations) so changes made accurately Lack of knowledge of which data MUST be captured for QOPs, regulatory, Nursing Initiatives & Nursing Quality Improvement programs therefore needed fields do not exist Lack of effective change control fields providing report data changed by user groups (break reports)

39 Data Input Issues (cont.) Data quality assurance Lack of information about data quality in the EHR Accurate documentation capture (frequency) rates Optimized system build opportunities Recognized source of truth (required fields for data capture) Related to end-user documentation reliability To be sure information is pulled correctly & accurately for reports Validity data captured in measures reports provides the correct data for the measure Narrative data reduces ability to report discrete, comparable data Hybrid record data captured on paper must be manually abstracted cannot be automatically reported Reliability Information to be documented is captured as expected

40 Ensure EHR build supports automated QOPs consistently Effective data extraction begins with EHR DESIGN & BUILD Sophisticated tools & software for data extraction / reporting will not work if data fields are Not present Not used or inconsistently used Too many places data can be entered into the system (documented) Data is captured in narrative or other formats that cannot be reported NI Leaders MUST be PROACTIVE in their knowledge and anticipation of required data for QOPs such as MU, VBP, etc. PBE data fields for nursing or organization s CQI programs Anticipation of future data needs Ensure optimization or other efforts don t negatively impact automated QOP date reporting NI leaders MUST coordinate with all experts throughout the system to ensure System design & build reflect the MOST EFFICIENT way to gather actionable, reportable data for QOPs Synchronization with clinical workflow, data collection does not cause artificial or extra work for clinicians in the form of data collection

41 Reportable Data Identify data needed from the system prior to build if possible in order to measure outcomes Build and develop the EHR knowing new requirements for reporting will continuously occur Content of future QOPs (future requirements) already available NI should already be working w clinical leaders to implement & have in place prior to required reporting MU criteria including Quality Measures Quality Indicators CORE Measures, other data sets NDNQI measures nurse sensitive indicators Other patient care indicators defined by external agencies or your organization for Performance Improvement purposes (Quality Dept, Clinical Outcomes Dept) TJC measures of success Measures identified for any type of audit

42 Design and Build Design EHR to capture data currently available OR needed to meet QOPs, other legislated requirements Facilitate Performance Improvement as part of Nursing s CQI Methodology NI Practitioner MUST have a much broader focus and greater knowledge of where All data is housed How it is developed Accuracy, reliability & validity (does it capture data needed for reporting quality measures) 42

43 Data Output (Extraction) Issues Multiple documentation locations to find the same information Lack of designated source of truth Insufficient knowledge of measurement & evaluation (data & information needed for data to wisdom continuum) & CQI techniques Lack of change control - user group makes changes w/out evaluation by team with ability to evaluate impact at all levels of the EHR, including disabling reporting No records of what and when changes were made (these can impact how far back certain types of data can be extracted) How / where data is stored, how long it is available for reporting

44 Ensure the EHR supports QOPs with automation (Roadmap for QOPs) 1. Develop coordinated reporting plan Organizational Reporting & Data Access Develop leadership dashboard Develop department specific reporting & dashboards (PBE) Build reports for critical/repetitively needed data/information Quality abstracted data, Case Management data, NDNQI etc. Start with small projects: facts, data, and information 2. Change Control 3. Coordinate like groups with regard to reports 4. NI or other informatics practitioners learn about reporting & data storage, formats of data entry to support large scale reporting 5. Determine/anticipate additional reporting needs and work with IT to meet needs (may be over time)

45 LOBI Ladder of Business (Clinical) Intelligence: Closely parallels the Blum Model and makes the case for PBE/C(B)I Enabled Intuition Understanding Knowledge Information Data Facts

46 Data Plan/Program Data Structure and Repository Assessment Roadmap for QOPs (cont.) Adequate for high volume reporting Organized approach for high volume reporting Management, storage & retrieval mechanisms in place Develop Data Strategic Plan 1, 3, 5 years Develop necessary expertise Data Architect Quality Informatics Data Management Plan: must align w/ financial/operational goals: start small if necessary Data infrastructure prepared for expanding data needs Data repository/data warehouse Availability of data, purging, other storage activities CI/BI Quality Informatician Data quality entry to storage, to retrieval

47 CI - Clinical (Business) Intelligence CI/BI system purchase is unnecessary in the beginning Can grow one from SQL/data repository & other tools Need to develop expertise within the organization Need nursing/quality informatics expertise Eventually Data Architect, Data Strategy & Plan Most EHRs can report big volume data as needed for successful PBE, QOPs, Financial metrics, etc. CI/BI system may be added later, generally ROI is realized from organized data management & reporting for QOPs, CQI etc. & facilitates CI/BI development

48 Develop Methodologies To Ensure Safe Succession Safeguard knowledge about how the system was developed, decisions made, build strategies Keep records of changes and iterations Document required quality measures and other quality information in a spreadsheet record such as core measures 48

49 Outpatient Quality Reporting Program (OQR) 49

50 Record of Information Needed for QOP Implementation/Management 50

51 Design/Develop Structured Data Cont d 51

52 Change Control Process Effective process MUST be in place to ensure the overall integrity and continuity of the EHR Generally a committee collectively the members hold the total knowledge about the EHR Changes formally presented to committee required information about the change documented and archived (may be several processes) Change evaluated against Quality, PI, Financial and other reporting to ensure appropriate changes made to system, reporting if necessary Changes approved Changes trained, competencies documented if necessary Changes moved from test to live

53 QOPs & Nursing Informatics: Goals are Aligned QUALITY OUTCOMES PROGRAMS inherently move across the data-wisdom continuum (can be structure, process, outcome) QOPs provide PBE (practice based evidence) & are based on EBP & provide information on 2 levels Improve practice at the organizational level Provide data for future research studies on the EBP level Together the data and information from both PBE and EBP, when combined with other data create information and knowledge which coupled with the wisdom of nursing, or when appropriate - of interdisciplinary teams forms the basis for decision making about the care provided by the organization

54 QOPs & Nursing Informatics: Goals are Aligned (cont.) Create an EHR that facilitates movement along the Data-Wisdom Continuum fluidly and continuously The EHR provides data, information, and knowledge of your Organization Patient populations Clinical practices QOPs QOPs, NI Practice, Wisdom, & Experience of organizational and clinical leaders facilitates highest quality patient outcomes, and results in: Provision of healthcare VALUE to patients DOMAIN of Informatics to ensure the system is designed and developed to ensure these goals can be achieved - because The DATA to WISDOM continuum is the heart of Informatics

55 Data are discrete entities that are described objectively without interpretations e.g. Vital Signs in a single moment of time Information is data that are interpreted, organized or structured e.g. Chronological Set of Vital Signs Knowledge is information that is synthesized so that relationships are identified and formalized e.g. synthesis of the observed trend with nursing knowledge Blum, in Nelson 2002 Added by Gardiner 2011 Wisdom is the appropriate use of knowledge to manage and solve human problems. It is knowing when and how to apply knowledge to deal with complex problems or specific Proprietary & Confidential 55 human needs (Nelson, 1989, 2002)

56 NI Leadership Improving QOPs through EHR Design & Development Nursing Informatics can lead the way Nursing Informatics Leaders Must Have a good understanding of healthcare and its impact on nursing Understand flow of information across the EHR and how it can support coordination of care Have a good understanding of measures, reporting, data quality assurance, data storage, and management Have a good understanding of Nursing across its breadth and depth needs, opportunities for EBP & PBE to improve care, the organization, and nursing as a profession Nursing Informatics Leaders must consistently employ Quality/CQI methodologies Nursing Informatics Leaders must have all the skills in every Informatics domain

57 Current Trends & Practices NI in large IDNs lead or participate in QOPs, PBEs, especially related to nursing & teach NI competencies in these areas to bedside caregivers NI Practitioners Are: Becoming highly competent / knowledgeable of global healthcare issues, reform, EBP/PBE & making sure nursing leaders have broad perspective to effectively lead nursing both primary nursing & care coordination roles Excelling in CQI & PI methodologies & applying to their practice regularly Helping bedside RNs become aware of information / knowledge availability & utilization of PI e.g. Kaiser UBTs (PDC/SA from an older era), Cleveland Clinic etc. Leading the way in providing tools and systems that enable nurses as knowledge workers

58 Needed for Care Coordination & Transformation More than ever, NI leaders must support the transformation of nurses & their leaders into Information Users: Sophisticated in their desire for data, information & knowledge Able to apply their wisdom and experience, making the best decisions for Their Patients Nursing Their Organization

59 Critical Success Factors For NI To Lead Quality Outcomes Improvement Clear Knowledge and Understanding of all aspects of Healthcare Informatics Clearly Defined Informatics Program - System-wide and interdisciplinary Recognize EHR as foundational for healthcare into the foreseeable future Ability to perform in all 3 domains of informatics in BOTH Nursing & Clinical Informatics Ability to translate data & information into knowledge & supply it to the disciplines & organizational leadership for application of wisdom & attainment/improvement of outcomes Ability to apply Informatics wisdom to data, information and knowledge to drive informatics outcomes Quality team - partner and support 59

60 Critical Success Factors For NI To Lead Quality Outcomes Improvement (cont.) Clear Understanding of Healthcare beyond department specific understanding New healthcare environment Changes to Payment Models ARRA and other EHR incentives Advances in technology SMART rooms and other tools Advances in social media and other uses of information in healthcare Regulatory impact and requirements Issues in Professional Practice Clearly defined job expectations Clearly defined and practiced accountability Clear understanding of the roles of care coordination & nursing in this critical healthcare function 60

61 Needed for Success: Better Understanding of the Role of the EHR New ways of thinking and doing (Innovation) KNOWLEDGE especially about the EHR New Roles & Practice Models Evidence to guide practice Understanding that change is needed to incorporate new and better knowledge into practice 61

62 IMPROVE CLINICAL QUALITY OUTCOMES THROUGH NURSING INFORMATICS LEADERSHIP OF EHR DESIGN, DEVELOPMENT & UTILIZATION 62

63 Questions? 63

64 References: Amara, 2000 in Remus and Kennedy.. Nursing Leadership Vol 25, #4, 2012 Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academic Press Englebardt, Sheila PhD RN CAN; Nelson, Ramona PhD RN BC. Healthcare Informatics: An Interdisciplinary approach. Philadelphia, PA: Elsevier Health Sciences, Print. Gartner, 17 September ITScore Overview for Business Intelligence and Performance Management. Analysts: Bill Hostman,m John Hagerty Institute of Medicine Committee on Quality of Health Care in America (Sackett, D L, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM. London: Churchill Livingstone; 2000, 2001). Quality Informatics* Wikipedia Nursing Informatics The intersection of Nursing Science, Information Science, and Computer Science ANA (American Nurse s Association) AHRQ Quality Informatics* Wikipedia The New England Journal of Medicine: Perspective: What Is Value in Health Care? Michael E. Porter, Ph.D.N Engl. J Med 2010; 363: December 23, 2010 White, Kenneth R., and John R. Griffith. The Well-managed Healthcare Organization. Chicago, IL: Health Administration, Print. Proprietary & Confidential 64