1

Using HIT to Improve Outcomes for Using HIT to Improve Outcomes for Elderly Nursing Home ResidentsElderly Nursing Home Residents

Wednesday, Sept 26, 2007; 10 – 11:30amWednesday, Sept 26, 2007; 10 – 11:30am

Susan D. Horn, PhDSusan D. Horn, PhDInstitute for Clinical Outcomes ResearchInstitute for Clinical Outcomes Research

699 E. South Temple, Suite 100 699 E. South Temple, Suite 100 Salt Lake City, Utah 84102-1282Salt Lake City, Utah 84102-1282801-466-5595 (T) 801-466-6685 (F)801-466-5595 (T) 801-466-6685 (F)

shorn@isisicor.comshorn@isisicor.com

Using Clinical Decision Support Systems to Measure Quality of Care for Special Populations

2

Research Based FoundationResearch Based Foundation

National Pressure Ulcer Long-term Care StudyNational Pressure Ulcer Long-term Care Study

(NPULS), 1996-1997(NPULS), 1996-1997

• 6 long-term care provider organizations6 long-term care provider organizations

• 109 facilities; 2,490 residents 109 facilities; 2,490 residents

• 1,343 residents with pressure ulcer; 1,147 at risk1,343 residents with pressure ulcer; 1,147 at risk

• 70% female; Average age = 79.8 years70% female; Average age = 79.8 yearsFunded by Ross Products Division, Abbott LaboratoriesFunded by Ross Products Division, Abbott Laboratories

3

Long Term Care CPI ResultsLong Term Care CPI ResultsOutcome: Develop Pressure UlcerOutcome: Develop Pressure Ulcer

GeneralGeneral AssessmentAssessment

IncontinenceIncontinenceInterventionsInterventions

NutritionNutritionInterventionsInterventions

StaffingStaffingInterventionsInterventions

+ Age + Age 85 85

+ Male+ Male

+ Severity of Illness+ Severity of Illness

+ History of PU+ History of PU

+ Dependency in + Dependency in >= 7 ADLs>= 7 ADLs

+ Diabetes+ Diabetes

+ History of tobacco use+ History of tobacco use

+ Dehydration+ Dehydration

+ Weight loss+ Weight loss

+ Mechanical devices + Mechanical devices for the containment of for the containment of urine (catheters) urine (catheters)

- Disposable briefs- Disposable briefs

- Toileting Program- Toileting Program

- RN hours per - RN hours per resident day >=0 .5resident day >=0 .5

- CNA hours per - CNA hours per resident day >= 2.25resident day >= 2.25

MedicationsMedications

- SSRI + Antipsychotic

Horn et al, Horn et al, J. Amer Geriatr SocJ. Amer Geriatr Soc March 2004; 52(3):359-367 March 2004; 52(3):359-367

- Fluid Order- Fluid Order

- Nutritional Supplements- Nutritional Supplements

• standard medicalstandard medical

- Enteral Supplements- Enteral Supplements

• disease-specificdisease-specific• high calorie/high high calorie/high proteinprotein

4

1.1. CNA Daily Documentation and WorkflowCNA Daily Documentation and Workflow» Standardized data in documentation flow sheets; Standardized data in documentation flow sheets;

include best practice elementsinclude best practice elements» Improved communication with clinical team (RN, CNA, Improved communication with clinical team (RN, CNA,

MDS, Dietary)MDS, Dietary)

2.2. Wound Nurse PrU Tracking DocumentationWound Nurse PrU Tracking Documentation» Standardized data in PrU documentation (assessments Standardized data in PrU documentation (assessments

and treatments)and treatments)» Timely access to compiled information Timely access to compiled information

3.3. Clinical Reports: Timely Information for Care PlanningClinical Reports: Timely Information for Care Planning » Identify residents at risk for pressure ulcer developmentIdentify residents at risk for pressure ulcer development» Summarize information for clinical decision-makingSummarize information for clinical decision-making» Shorten response time between identification of resident need Shorten response time between identification of resident need

and interventionand intervention

Scope of HITScope of HIT

5

6

7

HIT RequirementsHIT Requirements

• Ease of use: practical for CNA staff (e.g., pen Ease of use: practical for CNA staff (e.g., pen and paper solution or hand-helds)and paper solution or hand-helds)

• Minimal training (good for turnover)Minimal training (good for turnover)

• Rapid staff adoption (no need to learn how to Rapid staff adoption (no need to learn how to use a computer or alter clinical workflow) use a computer or alter clinical workflow)

• Minimal impact to existing clinical workflow Minimal impact to existing clinical workflow

• CNAs and wound RN up and running in 2-3 CNAs and wound RN up and running in 2-3 monthsmonths

• Low costLow cost

8

•Digital PenDigital Pen» Thin and light device that writes like an Thin and light device that writes like an

ordinary penordinary pen» Includes camera that records pen strokes in Includes camera that records pen strokes in

pen memory that stores up to 200 pagespen memory that stores up to 200 pages» Records position and time 75 times a second; Records position and time 75 times a second;

camera records pen strokes in pen memory camera records pen strokes in pen memory» Used with digitized form, digital pen reads Used with digitized form, digital pen reads

unique pattern of dots to interpret the dataunique pattern of dots to interpret the data•Docking StationDocking Station

» Battery chargingBattery charging» Uploading data from memory to database Uploading data from memory to database

via Internetvia Internet

Example technology #1Example technology #1 Digital Pen Digital Pen

9

Example technology #2 Example technology #2 Facility-developed ApplicationFacility-developed Application

ProfileProfile:: Facility programmers developed application: relational Facility programmers developed application: relational

databasedatabase Hand-held devices for data inputHand-held devices for data input CNA documentation of daily notesCNA documentation of daily notes Wound nurse documentation of PrUWound nurse documentation of PrU Reports to monitor resident changes Reports to monitor resident changes

Project RequirementsProject Requirements:: Incorporate standardized data elements into applicationIncorporate standardized data elements into application

BehaviorsBehaviors Skin observationsSkin observations

Develop AHRQ reportsDevelop AHRQ reports

10

Example technology #3 Example technology #3 Electronic Medical RecordElectronic Medical Record

ProfileProfile:: Add CNA standardized documentation data elements Add CNA standardized documentation data elements

into EMRinto EMR Add Wound RN standardized documentation data Add Wound RN standardized documentation data

elements into EMRelements into EMR

Project RequirementsProject Requirements:: Incorporate standardized data elements into applicationIncorporate standardized data elements into application

BehaviorsBehaviors Skin observationsSkin observations

Develop AHRQ reportsDevelop AHRQ reports

11

Decision Making ReportsDecision Making Reports• Documentation Completeness ReportDocumentation Completeness Report. . Summary of Summary of

CNA documentation completeness ratesCNA documentation completeness rates. .

• Nutrition ReportNutrition Report. . Displays average meal intake, Displays average meal intake, resident diet, supplements, resident weight status resident diet, supplements, resident weight status (presence of weight gain/loss), last diet consult date, (presence of weight gain/loss), last diet consult date, history of pressure ulcer indicator, and presence of history of pressure ulcer indicator, and presence of pressure ulcer. pressure ulcer.

• Behavior ReportBehavior Report. . Displays the total number of times a Displays the total number of times a resident exhibits a behavior by shiftresident exhibits a behavior by shift..

• Priority Resident ReportPriority Resident Report. . Displays residents who are Displays residents who are at risk for pressure ulcer development and high priority at risk for pressure ulcer development and high priority for staff focus.for staff focus.

12

• Nutrition SummaryNutrition Summary» Average meal intake for 4 Average meal intake for 4

weeksweeks» Fluid intake for 4 weeksFluid intake for 4 weeks» Supplement use Supplement use » Dietary consult dateDietary consult date» Weight change since last weekWeight change since last week» Existing pressure ulcerExisting pressure ulcer» History of resolved ulcerHistory of resolved ulcer

• Weight SummaryWeight Summary» Weight 180 days priorWeight 180 days prior» Weight 30 days priorWeight 30 days prior» Weight for each of past 4 weeksWeight for each of past 4 weeks» Weight change since last week Weight change since last week » 5-10% weight loss past 30 days5-10% weight loss past 30 days» >10% weight loss past 180 days>10% weight loss past 180 days» Psychiatric medications receivedPsychiatric medications received

Example: Nutrition ReportExample: Nutrition Report

Stratified by RiskStratified by Risk

Provide ‘BIG picture’ over time, not just snapshot of one shift or one dayProvide ‘BIG picture’ over time, not just snapshot of one shift or one day

13

Nutrition ReportNutrition Report

What are uses of the Nutrition Report?What are uses of the Nutrition Report?

• Identify which meals are not being eatenIdentify which meals are not being eaten

• Promote use of nutritional supplementsPromote use of nutritional supplements

• Identify need for consistent weightsIdentify need for consistent weights

14

• Decreased meal intake Decreased meal intake • Weight lossWeight loss• Increased incontinence episodesIncreased incontinence episodes• Increased behavior problemsIncreased behavior problems• Existing red areas on skinExisting red areas on skin• History of pressure ulcer in last 90 History of pressure ulcer in last 90

daysdays•

Example: Priority ReportExample: Priority Report

Identifies residents at riskIdentifies residents at risk

15

ResultsResults Decrease Pressure Ulcer DevelopmentDecrease Pressure Ulcer Development

Increase Adherence to Best PracticesIncrease Adherence to Best Practices

Increase Staff Accountability and SatisfactionIncrease Staff Accountability and Satisfaction– Inclusion of front-line workers in QI effortsInclusion of front-line workers in QI efforts– Comprehensive documentation at point of careComprehensive documentation at point of care– Communication among care team improvedCommunication among care team improved

Reduce InefficienciesReduce Inefficiencies– # documentation forms for CNAs# documentation forms for CNAs– CNA time looking for documentation bookCNA time looking for documentation book– Time to compile reports for State Regulators and MDS Time to compile reports for State Regulators and MDS – Time for Wound RN to summarize and report dataTime for Wound RN to summarize and report data

Improve State Survey ProcessImprove State Survey Process

Establish a foundation for EHREstablish a foundation for EHR

16

Q4 03 (Pre-Implementation) to Q3 05 (Post-Intervention Review) Combined Facilities Average

0.0

5.0

10.0

15.0

20.0

% H

igh

Ris

k R

es

ide

nts

Facilities Average National Norm

Facilities Average 14.0 13.0 12.9 10.6 9.6 9.4 12.0 9.1 8.7

National Norm 14.0 14.0 14.0 13.0 13.0 13.0 14.0 14.0 13.0

Q3 03 Q4 03 Q1 04 Q2 04 Q3 04 Q4 04 Q1 05 Q2 05 Q3 05

Q4 03 – Q3 05% Change = - 33%

Impact On Pressure Ulcer QMs Impact On Pressure Ulcer QMs Study Facilities CombinedStudy Facilities Combined

Source: CMS Nursing Home Compare; Facility QM data Source: CMS Nursing Home Compare; Facility QM data reportsreports

17

Pressure Ulcer HealingPressure Ulcer Healing

• Analyze PrU assessment and treatment data to Analyze PrU assessment and treatment data to determine those practices that are associated with determine those practices that are associated with faster healing, controlling for resident and initial faster healing, controlling for resident and initial ulcer characteristics.ulcer characteristics.

• Implement findings in standardized wound Implement findings in standardized wound assessment documentationassessment documentation

• Combine tracking outcomes (development and Combine tracking outcomes (development and healing of PrUs) and quality improvement healing of PrUs) and quality improvement (information to improve clinical decision-making)(information to improve clinical decision-making)

18

What is different about this What is different about this approach?approach?

• Integrates sustainable quality improvement into daily Integrates sustainable quality improvement into daily operations. operations.

– Project activities are integrated into versus added Project activities are integrated into versus added on to daily work. on to daily work.

• Streamlines documentation with focus on critical data Streamlines documentation with focus on critical data elements and information flow. elements and information flow.

• Involves front-line staffInvolves front-line staff. . – Establish multi-disciplinary design and Establish multi-disciplinary design and

implementation teams, including CNAs, nurses, implementation teams, including CNAs, nurses, dieticians, wound nurses, MDS nurses, social dieticians, wound nurses, MDS nurses, social services, and restorative care. services, and restorative care.

19

What is different about this What is different about this approach?approach?

• Translates documentation into care Translates documentation into care planning informationplanning information..

– Migrate from a paper/form document environment Migrate from a paper/form document environment toward a data culture environment. toward a data culture environment.

• Translates data into multi-disciplinary clinical reports.Translates data into multi-disciplinary clinical reports. – Migrate from a culture of accessing quarterly Migrate from a culture of accessing quarterly

reports for retrospective analysis to using weekly reports for retrospective analysis to using weekly clinical reports by multi-disciplinary team for clinical reports by multi-disciplinary team for timely resident care planning.timely resident care planning.

20

Clinical StrategyClinical Strategy

• Early identification of high risk residentsEarly identification of high risk residents

• Monitor changes in PrUs, nutrition, Monitor changes in PrUs, nutrition, incontinence, and behaviorsincontinence, and behaviors

• Integrate with guidelines and evidence- Integrate with guidelines and evidence- based practicesbased practices

21

QI Organization StrategyQI Organization Strategy

• Leverage CNA daily and Wound RN weekly Leverage CNA daily and Wound RN weekly documentation to provide data for reportsdocumentation to provide data for reports

• Improve accuracy of CNA observations Improve accuracy of CNA observations

• Electronic checking of data now possibleElectronic checking of data now possible

• Integrate timely information into day to day Integrate timely information into day to day practicepractice

» Easy access to summarized informationEasy access to summarized information

» View resident trends and multiple risksView resident trends and multiple risks

• Multidisciplinary inputMultidisciplinary input