Let’s Talk Informatics

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

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


Patient Data

Demographics

Allergies

Medications

Medical/Health History

Problems

Procedures

Family History

Social History

Advanced Directives

Infection Control


40%

65%

80%

Level of Standardization - Minimum


Patient Data


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


Patient Data

Diagnostic Tests and Results

Assessment &Exam Findings


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




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


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.