Hitting a Grand Slam 4 Trends that Streamline Clinical Operations & Save Financial Resources Carolyn J. Humphrey, RN, MS, FAAN President, CJ Humphrey Associates The Four Trends Evidence based Clinical Practices Clinical Decision Support Systems Electronic Health Record (HRT) and Information Technology (IT) national events are impacting providers and professionals Importance of standardization to support patientcentered care and care giver communication and collaboration Today s Objectives Translate evidence based practice (EBP) terms and concepts to homecare and hospice clinical practice Recognize how a clinical decision support system (CDS), using EBP, can: Improve patient outcomes; Increase clinician accuracy & productivity, & retain clinical staff; Streamline QR 1
Take Home Identify creative approaches to maximize your IT Investment & increase QR Efficiency in your own agency. Analyze themes and action plans identified by participants. Healthcare Today Knowledge Statistics, Evidence and Mistakes is the enemy of disease The third revolution in healthcare will be driven by knowledge, technology and patients. Sir Muir Gray, Chief Knowledge Office of Britain s National Health Service An EBP Refresher Evidence based practice is a problem solving approach technical care that incorporate the conscientious use of current best evidence from well designed studies, a clinician s expertise, and patient values and preferences. Fineout Overhold, Melynk, 2005 All three of these key components must be present for evidence based practice to be effective. 2
Fineout Overholt, el al, 2005 The EBP Paradigm Nurses Know EBP Nurses use EBP in their education & current practice Why EBP? Our National Health 30% of healthcare spending $750 Billion for ineffective or redundant care. BC/BS 2012 54% of acute care and 56% of chronic care conformed to the medical literature. McGlynn, 2003 Patients have a 50% chance of receiving the most advisable care RWJ, 2010 98,000 people die each year from preventable medical errors Nat Ac Press, 2009 3
Local Perspective Why EBP? Decrease variability across clinicians and providers Accurate & comparable benchmarking Achieve efficient, effective patient outcomes Decrease costs Meet accreditation & licensure standards Decrease adverse events Positively affect HH Compare Scores Positing for NOW! Why EBP? Basing practice & care on evidence integrated into Affordable Care Act (ACA). ACOs are required to promote evidence based d medicine and coordinate care through the use of t Focus on achieving patient centered outcomes rather than just delivering care Telehealth and other enabling technologies. Regulations We have to follow the regulations Regulations were never meant to tell clinicians how to practice. Increasingly, agencies will be licensed on their hi use of best practice. Using evidence based clinical practices does not conflict with being compliant and licensed, and if it does, everyone in the agency should know the procedure to move the issue forward. 4
Physician s Orders Clinicians develop their skilled Plan of Care in conjunction with physician orders. Agency policies & procedures support EBP. Physician s should be open to EBP questions. EBP in the Real World Referrals During a Visit Physician Communications The New Healthcare System National Health Goals The Triple Aim Better patient health (improved patient p ( p p outcomes) Better care (increased standardization, use of evidence based practice, clinician collaboration) Lower costs (more efficiency, quantifiable data for reports) 5
Current & Future Demands of a EHR Published Scientific Literature National Guideline Centers EBP Centers & Resources Statistical Analysis Regulatory CMS, etc. Government Health Resources National & International Sources Homecare & Hospice Associations Specialty Professional Organizations Specialty Disease Organizations Scope of Practice Documents 16 April 16-17, 2013 McKesson Homecare National Users Conference 2013 How EHRs Work Meaningful Use Using certified electronic health record (EHR) technology to: Improve quality, safety, efficiency, and reduce health disparities Engage patients and family Improve care coordination, and population and public health Maintain privacy and security of patient health information Compliance should result in: Better clinical outcomes Improved population health outcomes Increased transparency and efficiency Empowered individuals More robust research data on health systems 6
Why Meaningful Use Matters Automation of workflow and processes What you do with the available information is what matters, meaningful use Automation of individual care settings Incentives to drive adoption of setting specific applications Connectivity between stakeholders You can t share what you don t have Interoperability between disparate systems is key It s about them get them involve Transforming the role of patients Standard Language Federally required Patient Assessment standards: Clinical LOINC Endorsed Vocabulary Content: International ti Classification of Functioning, i Disability and Health (ICF) for the functioning and disability domains SNOMED CT for exact and usefully related content matches HL7 (Health Level Seven ), Version 2.4 and higher messaging and Clinical Document Architecture (CDA) RxNorm Standardized nomenclature for drugs and drug delivery devices Interoperability Ability for diverse systems and organizations to work together, including the ability to exchange information and use the information that has been exchanged. Improve Care Coordination Improve patient outcomes Continuity of care plan 7
Skilled Nurse Assessment identifies low risk for falls Interoperability Therapist Assessment identifies risk for falls Low Physician/Nurse Practitioner identifies Risk for falls = Low SNOMED CT MAPPING MECHANISM At low risk for fall [439430008] SNOMED CT Patient Engagement Patients as Partners Patient Portals Consistent Messages from all providers Continuing reinforcement & feedback Develop relationships Consistently higher compliance Better outcomes 2010 2013 Rules, Regulations & New Funding 2014 2016 Mandates, Pilots & Exchanges 2017+ New Normal Moving Forward 8
Meaningful Use Defined Phase 1 CPOE (for Medications) Drug to Drug and Drug to Allergy interaction checks Demographics, gender, race, ethnicity, DOB, preliminary cause of death Problem List Medication list Medications allergy list Vital Signs Clinical Decision Support Calculate and transmit CMS quality measures Electronic copy of health records Electronic copy of discharge instructions Clinical Summaries Exchange key clinical information Privacy and Security Clinical DS Definition Provides knowledge and patient specific information, intelligently filtered or presented at appropriate times to enhance health. Variety of tools to enhance decision making in the clinical workflow. Tools can include computerized alerts and reminders to care providers and patients; Include clinical guidelines; condition specific order sets; focused patient data reports & summaries; documentation templates; diagnostic support, and contextually relevant reference information, among other tools. A Year in the Life of a Chronically Ill Patient 6 Social Workers 13 Meds 5 Hospital Admissions 6 Weeks SNF Care 37 Nurses 22 2 Nursing Homes 4 Occupational Therapists 5 Physical Therapists 19 Clinic Visits 6 Community Referrals 2 Home Care Agencies 5 Months of Home Care 16 Physicians Source Archer, B 2011 9
Improve Patient Outcomes CDS Can Personalized Assessments & Care Plans Avoid multi physician, multi pharmacy use Interdisciplinary care plan not multidisciplinary. Focus on patient s complete health & well being. Self management support Monitoring & empowerment Telehealth CDS Can Increase Clinician Accuracy & Productivity Respects training & practice patterns. Reminds things planned but don t have to remember; Alerts, visit schedules, etc. Provides information when clinicians are unsure; Can hover over areas for reminders EBP, tips, etc. Present EBP alternatives to support their decision making Corrects errors clinicians have made; Like spell check, EBP reminders, etc. Streamline Quality Review CDS Can Dynamic comprehensive assessment = accurate & consistent documentation. Reduce time spend auditing and reviewing clinical documentation. Required documents for billing result from the assessment & care planning process. Queues up documents for review based on clinical variation and deviation from EBP Supports exception based review 10
CDS Can Position the Organization for Opportunities Provides holistic view of patient care. Efficient sharing with other providers and payers. Identifies those at risk for high utilization Evidence based practice guidelines Improved efficiency, cost benefit, provider & patient satisfaction Timely initiation of services Transition to appropriate level of care The 5 Rights of CDDS CDS Should provide Right Information to the Right person in the Right format through the Right channel at the Right time What You re Doing 11
Let whoever is in charge keep this simple 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 Nightingale Notes on Nursing: What it is and What it is Not References Abrahamson, K. A., Fox, R. L., Doebbeling, B. N., (2012). Facilitators and barriers to clinical practice guidelines use among nurses. American Journal of Nursing 112(7), 26 35. Berner, E. S., La Lande, T. J. (2007). Overview of clinical decision support systems. Springer Science+Business Media, LLC DOI 10.1007/978 0 387 38319 4_1. Blue Cross/Blue Shield (2012). Building tomorrow s healthcare system: The pathway to high quality, affordable care in America. http://www.bcbs.com/why bcbs/health reform/pathway.pdf Buerhaus, P.I., DesRoches, C., Applebaumn, S., Hess, R., Norman, L.D., Donelan, K. (2012). Are nurses ready for health care reform? A decade of survey research. Journal of Nursing Economics, 30(6), 318 329. References Carrington, J. M. (2012). The usefulness of nursing languages to communicate a clinical event. CIN: Computers, Informatics, Nursing, 30(2), 82 88. Cipriano, P. F. (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 21 st century. Journal of Professional Nursing 21(6), 335 344; Health IT.gov Clinical Decision Support. How To Guides (5) for Clinical Decision Support (CDS) Implementation. http://www.healthit.gov/policy researchers implementers/cdsimplementation 12
References Kohn, L. T., Corrigan, J. M., Donaldson, M. S. (2009). To Err is Human: Building a Safer Health System. The National Academies Press: Washington, D.C. League, K., Christenbery, T., Sandlin, V. (2012). Increasing nurses access to evidence through h a Wbb Web based resource. Journal of Nursing Administration, 42(11), 531 535. McGlynn, E. A., et al. The quality of health care delivered to adults in the United States. New England Journal of Medicine 348, 2635 2645. Robert Wood Foundation (2010). Quality & equality in U. S. Health Care: A message handbook. http://www.rwjf.org/files/research/71813.pdf 13