Background: An electronic health record (EHR) can be more beneficial than a paper record for improving patient outcomes and healthcare givers decisions (HealthIT.gov, 2015). However, generic vendor documentation templates, vendors’ lack of EHR customized documentation templates for the organization, and social or technical systems flaws can lead to insufficiencies within the EHR.
Purpose: This workflow redesign project identified ways to improve and optimize patient care and reduce inefficiencies by developing a standardized EHR documentation template for observation patients using social, technical, and regulatory requirements. The use of technology can support more efficient work, promote safer care delivery, streamline work processes, provide point-of-care decision support (McGonigle & Mastrian, 2015; Osheroff et al., 2012), and improve cost savings (HealthIT.gov, 2014).
Setting: The organization where this redesign project was implemented was an urban hospital with 864 beds that provides care for an underserved population. Patients placed under an observation status can be placed in the emergency services observation unit or a general medical-surgical unit.
Method: The Model for Improvement and a Plan-Do-Study-Act (PDSA) cycle was completed to analyze nursing workflow and create a standardized documentation template for patients placed under an observation status.
Results: Five nursing staff members were surveyed on pre-implementation documentation as well as post-implementation documentation. Results showed that the standardized observation assessment improved the amount of time spent on documentation.
There are numerous documentation elements that need to be present in the electronic health record (EHR) to meet regulatory standards. The meaningful use criterion must be incorporated for the Medicare (EHR) Incentive Program which is administered by the Centers for Medicare & Medicaid Services (CMS) (HealthIT.gov, 2013). The purpose of meaningful use is to improve care coordination as well as population and public health. Meaningful use can help lead to better clinical outcomes and increased efficiency (HealthIT.gov, 2014).
The organization where this redesign project was implemented was an urban hospital with 864 beds which serves an indigent population. Patients with an observation status can be placed in the emergency services observation unit or a general medical-surgical unit. Depending on the unit of placement, either the ambulatory EHR documentation (which includes the observation documentation) or inpatient EHR documentation is used. Observation status is defined by the Centers for Medicare & Medicaid Services (CMS) as well-defined services that include ongoing short-term treatment and reassessment to see if further inpatient hospitalization is needed (CMS, 2014). Documentation for every patient placed under observation status should be standardized regardless of unit location. Part of stage one for meaningful use implementation was to electronically capture health information in a standardized format (HealthIT.gov, 2013). Both the medical-surgical units and the emergency services observation unit utilize an EHR; however different systems are used for the inpatient and emergency observation unit, so this new template design will ensure documentation is standardized.
The use of the EHR can not only improve caregivers’ decisions but also patient outcomes (Blumenthal & Tavenner, 2010). The EHR has the potential to be more beneficial than paper records as it can improve the safety and quality of patient care; care coordination; accuracy of diagnoses; health outcomes; practice efficiencies and cost savings; and can increase patient participation in care. However, it does not do this in every instance (HealthIT.gov, 2015); Laramee, Bosek, Kasprisin, & Powers-Phaneuf, 2011). The EHR can potentially support the capture, retrieval, and use of data, information, and knowledge within an organization.
EHRs are utilized to facilitate the sharing of information across different groups of healthcare providers with the goal of more effective, safe patient care. The quality of nursing care can be dependent on the information available to end-users at the point of care (Choi & Kim, 2012). However, many of these IT implementations lack end user engagement (Cresswell, Morrison, Crowe, Robertson, & Sheikh, 2011). Poorly designed EHR technology can lead to errors, lower productivity, or possibly removal of the technology. Short-term solutions such as workarounds can be designed to function around poor EHR technology (McGonigle & Mastrian, 2015). Workarounds created in response to an ineffective work process or poorly designed documentation or interventions can weaken the documentation and make it less beneficial (Osheroff et al., 2012).
Healthcare organizations should be designing technology to fit individual characteristics rather than training individuals to adapt to poorly designed technology (Zhang, 2005). The EHR should increase end-user usability/engagement, increase efficiency and productivity, decrease medical errors, and increase ease of learning. To do this health information systems need to be developed using human-centered methods and techniques that are specifically designed for healthcare domains.
Standardizing the documentation for observation status patients can ensure that the regulatory requirements, meaningful use requirements, and any coding and billing elements are included in the documentation. Involving nursing feedback in the standardization process is important as nurses play an important role in determining how care can be delivered in a safe, effective, and efficient way (Osheroff et al., 2012) including the documentation of care provided. The standardized documentation will improve nursing workflow and productivity as well as improve nursing communication for the emergency services observation patients that are transferred to an inpatient unit.
Documentation redesign will involve change and the Model for Improvement to facilitate change will be the framework for this quality improvement change. The Model for Improvement consists of three fundamental questions to drive the improvement process which is followed by the Plan-Do Study-Act (PDSA) cycle (Langley et al., 2009). The first component asks the questions (a) What are we trying to accomplish? (b) How will we know that the change is an improvement? (c) What changes can we make that will result in improvement? The second component of the model is the PDSA cycle (Moen, Nolan & Provost, 2012). The PDSA cycle can help develop tests and implement changes by providing a framework for efficient trial-and-learning methodology. The cycle begins with plan and ends with action based on the learning gained from the Plan, Do, and Study phases (Langley et al., 2009). Table 1 depicts the Model for Improvement and PDSA Cycle #1 for this workflow redesign project.
Table 1: Model for Improvement and PDSA Cycle #1
Measurements obtained were based on the current workflow and the changed workflow. A baseline measurement of nursing productivity/workflow was collected with the current documentation templates. This was collected by measuring the time in minutes it takes for the nurse to complete the required initial assessment documentation using the current template for the emergency services observation unit and medical-surgical observation patient. After the workflow redesign design was validated and implemented, the nursing productivity/workflow was measured by the time in minutes and mouse clicks needed to complete the standardized initial observation assessment. The required number of mouse clicks the nurse used to document the assessment was evaluated with the current template design and the future template design.
The initial review showed that the emergency services unit had approximately thirty (30) documentation elements in the initial observation admission assessment documentation compared to over one hundred (100) documentation elements in the medical-surgical unit initial admission assessment documentation. Nurses on the medical-surgical units are spending three times as much time on their initial admission documentation compared to the emergency services unit.
Steps in Workflow and Design
Organizational procedures, regulatory standards, meaningful use, and coding/billing requirements were used to design a new documentation template which front-end users (nurses) validated for design and usability. The nurses reviewed the proposed template in a test environment and provided feedback. Once the design was validated it was presented to the stakeholders to be implemented. After initial implementation the nurses provided feedback on necessary changes needed to further improve the efficiency of the standardized observation template. There are different documentation procedures for the emergency services observation unit and the medical-surgical inpatient units for observation patients and the assessment workflows also differ for each of the areas.
Nursing staff in the emergency services observation unit and medical/surgical observation units were interviewed to identify individual tasks and documentation necessary for patient care. By interviewing and observing clinical staff, an understanding of the process before the implementation of the new EHR documentation template can be accurately identified (Osheroff et al., 2012). Since more than one discipline are typically involved or impacted by documentation in the EHR, a workflow map will be created to identify specific improvement goals and objectives.
Focus groups consisting of nurses from the emergency services observation, medical, and surgical units were held to gather qualitative data on the current documentation pre-implementation of the standardized template. Included were reports on time to complete assessment documentation, barriers to the EHR documentation, and suggestions for improvement. This same group was utilized again post-implementation of the standardized documentation template and the same questions were asked.
Initial workflow review of the initial admission assessment noted that on the emergency services unit approximately twenty minutes is needed to complete admission assessment documentation compared to forty-five or sixty minutes on the medical-surgical inpatient units. The difference in the amount of documentation and the time to complete the documentation supported standardizing the workflow. Not only do the emergency services and medical-surgical units use different EHR systems, they have different admission assessment documentation requirements and workflows, (such as time in minutes), to complete the initial admission assessment.
There was a change in the EHR documentation, the workflow (related to time in minutes), and the organizations procedures on documentation for both the emergency services unit and medical-surgical units. There are many potential approaches to implementing a change in workflow or process. Knowledge of subject matter is often an important aspect for change. Other approaches include supporting change with data; developing a change; testing a change; implementing a change (Langley et al., 2009). The knowledge acquired from the workflow analysis guided the workflow redesign project using the Model for Improvement Plan-Do-Study-Act (PDSA) cycle.
With this workflow redesign project the model for improvement questions were answered. The goal was to accomplish standardization of observation documentation; the change was effective as evidenced by the creation of a standard documentation template utilized in all areas for observation patients. The changes to improve the documentation included collaboration between many departments and end users, to create an efficient and standardized documentation template. These departments involved included nursing leadership, hospital leadership, information technology, and education. Measures used to determine the effectiveness of this workflow redesign project included staff qualitative feedback, decrease in the time spent on documentation and a decrease in the number of documentation elements required (Langley et al., 2009).
This workflow redesign project was completed on the pilot unit which was the emergency observation unit. Five nursing staff members were surveyed on pre-implementation documentation. All five nurses responded but only three answered all questions completely. Feedback from the nursing staff pre-implementation of the observation assessment documentation had an average of thirty-seven minutes spent on initial assessment documentation. Post-implementation the same five nurses were surveyed using the same questions used during pre-implementation. Only two nurses responded to the survey. The feedback from the nurse had fifteen minutes spent on the initial observation assessment. This showed that the standardized observation assessment improved the workflow of time spent on documentation. Comparison of the emergency observation unit and the medical-surgical inpatient units showed an obvious difference in the number of minimum clicks needed for an admission assessment. Post-implementation the nursing staff on the pilot unit were asked how the observation documentation was working for them. The reported feedback from the staff post-implementation of the new template staff included “they liked the new template”, “it was easier to use”, “it flowed easier”, and “overall it was preferred”. Figure 1 shows the time spent on documentation assessments pre- and post-implementation.
Figure 1: Time spent on documentation assessments pre- and post-implementation
The emergency observation unit nurses provided feedback on their pre-implementation documentation and the standardized observation documentation via qualitative feedback. The time in minutes it took to complete an admission assessment was charted to show the improvement in efficiency after implementing the standardized documentation.
The standardized documentation was implemented on the emergency services observation unit on July 20, 2015. During this time staff in the informatics department was on the unit to assist with any transition concerns. Staff, (providers, nurses, patient care techs, and health unit coordinators), had been trained on the new documentation template using a test environment in the current EHR. This allowed staff to review and document in the EHR on test patients so they could be more comfortable with the change and more confident with the new documentation was implemented. Having the end-users involved in the implementation ensured the observation documentation could meet their needs and they had the opportunity to provide feedback on improvements or changes needed for their overall operation (Osheroff et al., 2012).
The new documentation was validated by the end-users and the next step will be to implement the standardized observation assessment on all the medical-surgical floors. This implementation will be delayed for a few months as the facility moved to a new campus. Prior to implementing the standardized documentation throughout the facility, the emergency services observation validated the template. After the documentation was utilized and any necessary adjustments were made, implementing on the medical-surgical units will be proposed to leadership. The proposed time for implementation for the medical-surgical units is May 2016.
Once the standardized documentation is implemented on all the medical-surgical units data will be compared. Data collected includes the total number of documentation elements (clicks) nurses select with the new documentation and the time in minutes it takes for nurses to complete the admission assessment documentation. The nurses will be asked the same qualitative questions administered prior to the new standardized documentation to compare the data.
As needed, additional PDSA cycles were and will continue to be completed to ensure that the standardized documentation is working efficiently and has been validated and updated by the end-users. Procedures on assessment documentation will be updated to reflect the standardized documentation for all patients placed under an observation status. The proposed timeline for completion of the redesign project is June 2016.
Limitations to this pilot implementation included time spent on documentation for initial observation assessment was self-reported rather than observed and incomplete responses on pre and post questionnaires. Self-reported assessment times are not as accurate as direct observation to determine time spent on documentation. Incomplete responses limited the data collected to determine if an improvement had been made with the standardized documentation. A challenge for the project was difficulty in getting an automated report for the number of clicks used. A focus group of five nurses was surveyed prior to implementation but having direct observations would have allowed for a more accurate before picture (Osheroff et al., 2012). The focus group of nurses had three out of five nurses who answered all questions pre-implementation and the focus group of nurses had two out of five nurses who answered the questions post-implementation. The number of clicks needed to complete an assessment was hand-counted. The information technology (IT) department was unable to run an automated report to get the minimum number of clicks needed to complete assessments on the pilot unit. Hand counting the number of clicks was limited based on the actual patient assessment. The number of minimum clicks the nurses was required to select was counted. However, depending on the patient assessment there may be many more clicks left uncounted. The minimum number of clicks was if the patient assessment was within defined limits (WDL). If any further documentation was needed to accurately chart the assessment this was difficult to capture since each patient requires a different assessment and exhibits unique complaints.
The EHR can be more beneficial than the paper record for improving patient outcomes and healthcare giver decisions. In this organization, standardized observation documentation was necessary to improve and optimize patient care and inefficiencies. An observation assessment template was developed and implemented on the emergency observation unit. Overall feedback from the pilot unit summarized that the template was easy to use and preferred over the previous charting. The pilot data and feedback showed that the workflow redesign project improved workflow and will benefit all observation patients in the organization once implemented on the medical-surgical inpatient floors. This standardized observation assessment template was one way the organization could provide more efficient documentation and streamline work processes.
Christina Noah, DNP, MSN, RN, CEN.
Dr. Noah is currently the Unit Manager for the Psychiatric Emergency Department at Parkland Hospital in Dallas, Texas.. Dr. Noah received her Bachelor of Science in Biomedical Science from Texas A&M in 2001, her Bachelor of Science in Nursing from Baylor University in 2004, her Master of Science in Nursing from University of Texas at Arlington in 2013, and her Doctorate of Nursing Practice from Texas Tech University Health Sciences Center in May 2016.
Laura Thomas, PhD, CNE, RN.
Dr. Thomas is currently an Assistant Professor at Texas Tech University Health Sciences Center School of Nursing. Dr. Thomas received her Bachelor of Science in Nursing from Texas Tech University in 2004, her Master of Science in Nursing from Lubbock Christian University in 2007, and her PhD in Nursing from Texas Woman’s University in 2014.
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