Harnessing the EHR to Transform Nursing
Care and Improve Outcomes
Beyond Documentation
Linda Fahey RN, NP, MSN
Regional Director of Quality & Patient Safety SCAL Kaiser Permanente Southern California
Ann O’Brien RN, MSN, CPHIMS
Kaiser Permanente National Director of Clinical Informatics
Celeste Farugia RN, MSN
Clinical Nursing Director Adult Services & Nursing Quality Kaiser Permanente, Woodland Hills
Welcome
Disclosures
Today’s presenters do not have any relevant financial interests or endorsement of products.
Participants must attend the entire session(s) in order to earn contact hour credit. Continuing Nursing Education credit can be earned by completing the online session evaluation.
The American Organization of Nurse Executives is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on
Accreditation.
Discuss strategies for leveraging the EHR to improve quality, safety and clinical
outcomes.
Outline the components of Kaiser
Permanente's Clinical Transformation
Model and lessons learned in using data to improve care.
Describe how data mining and advanced
analytics can be used to improve clinical practice and highly reliable workflows.
Describe a strategy for transforming care
delivery through the use of enabling technology.
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IOM Future of Nursing Report
HIMSS Position Paper
Transforming Nursing Practice through Technology & Informatics
Health Information Technology (HIT) will be the primary differentiator in transforming care delivery.
With > 3 million members nurses are in a key position to influence the future of healthcare delivery.
Emerging nursing informatics leadership roles are critical to bridge new care models into clinical practice with the right technology solutions. Nurse executives should partner with nursing informatics executives in
leading change and embracing technology that is interoperable, patient-centric, user-friendly and focused on quality outcomes.
Nursing executives should champion the redesign of clinical workflow and processes for the adoption of new technology to support front line staff.
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Kaiser Permanente:
An Industry Leader in HIT
KP HealthConnect
Not just an EHR
Program-wide system that integrates clinical record, appointments registration,
ancillaries and health plan Member access to information and outcomes All Hospitals at HIMSS Stage 7 At the end of 2011, only 1% of U.S. hospitals were at Stage 100% of Kaiser Permanente’s hospitals (36) have achieved Stage 7
HIMSS Davies Award Winner
Recognizes
excellence in the implementation of EHRs
Achieving the goals of safer, high quality and patient-centered care through the innovative, comprehensive and consistent use of information technology
HIMSS Clinical Transformation
Kaiser Permanente
Clinical Transformation Model
• Collaborate to foster knowledge translation • Leverage advanced analytics to extractactionable knowledge • Focus on “Making it Easy to do the Right Thing” • Build evidence out of
practice Set standards based on clinical goals, and evidence-based practice Leverage EHR to optimize workflow and support clinical decision making Develop reports to monitor the practice change Measure the impact of the change through outcomes analysis and research
Ten Most Costly Medical Errors and
Associated Annual Cost
Pressure Ulcers were the most FREQUENT and 2nd most
COSTLY medical error identified.
1. Postoperative infections $3.3 billion
2. Pressure ulcers $3.2 billion
3. Mechanical device or implant complications
(non-cardiac) $1.0 billion
4. Postlaminectomy syndrome $995 million
5. Hemorrhage complicating a procedure $678 million
6. Infection due to central venous catheter $589 million
7. Pneumothorax $569 million
8. Infection from injection/infusion/transfusion/
vaccination $566 million 9. Other complications of device, implant and graft $398 million 10. Abdominal hernia $342 million
The $17.1 Billion Problem: The Annual Cost of Measurable Medical Errors. Van Den Bos, J, Rustagi, K, Gray, T., Halford, M.,
Clinical Transformation Model: Case Study
Optimizing Care for Hospital Acquired Pressure Ulcers
• Collaborate to foster knowledge translation • Focus on “Making it Easy to do the Right Thing” • Build evidence out of
practice Set standards based on clinical goals, and evidence-based practice Leverage EHR to optimize workflow and support clinical decision making Develop reports to monitor the practice change Measure the impact of the change through outcomes analysis and research • Leverage advanced analytics to extract actionable knowledge
Set Standards Based on Clinical Goals,
and Evidence-based Practice
Adopted SKKIN Bundle:
Adapted from Ascension Health Care SKIN
Bundle and The Institute for Health Care
Improvement Recommendations
Incorporated into Program-wide and
Regional Hospital Acquired Pressure
Clinical Transformation Model: Case Study
Optimizing Care for Hospital Acquired Pressure Ulcers
• Collaborate to foster knowledge translation • Leverage advanced analytics to extract actionable knowledge • Focus on “Making it Easy to do the Right Thing” • Build evidence out of practice Set standards based on clinical goals, and evidence-based practice Leverage EHR to optimize workflow and support clinical decision making Develop reports to monitor the practice change Measure the impact of the change through outcomes analysis and research
Leverage EHR to Optimize Workflow and
Support Clinical Decision Making
(SKKIN interventions within the Pressure Ulcer Risk Clinical Practice Guideline)
Leveraging EHR to Optimize Workflow and
Clinical Decision Support
What did we learn?
Conducted “Mini-root cause analysis” on all HAPUs
MIDAS- New on-line reports replaced paper processes
Data defines priority areas needing focus for improvement
How could we leverage the EMR to support clinical decision making?
Analyze data to define priority areas for improvement
Build evidence based practice into documentation and individualize/ personalize care processes
SKKIN Bundle Related Factors from UORs:
#1: Lack of Turning and Repositioning
SKKIN Bundle Related Factors from UORs: #1: Lack of Turning and Repositioning
Leveraging EHR: Optimizing Workflow & Clinical
Decision Support: Turning & Repositioning Best Practice Alert
Implementing the Best Practice Alert:
Engaging Frontline Staff
The Pilot
One page huddle form was developed to explain Best Practice Alert, how it was going to work and who to give feedback to if there were problems.
Staff signed unit rosters to ensure all staff were educated.
All Managers, Asst. Managers and Educators were able to assist staff during pilot.
Informatics specialist and designated leader rounded on staff to get input and work through technical issues during pilot.
Implementing the Best Practice Alert:
Engaging Frontline Staff
Pilot Learnings
Easy to implement
2 minor technical issues identified
The BPA was set to fire every eight hours with physical assessment versus every twelve which was current practice.
Documentation of turning and repositioning would reset the two hour frequency therefore staff had to be cognizant if they turned at 8am but didn’t
Implementing the Best Practice Alert
Engaging Frontline Staff
Staff ‘s perception of the Best Practice
Alert
“Finally, the EMR will support Nursing practice….usually MD’s get the clinical support.”
Heightened awareness of Pressure Ulcers as Regional/Medical Center priority initiative
BPA will ensure outcomes – both patient care and accurate documentation
Implementing the Best Practice Alert
Engaging Frontline Staff
BPA promotes team approach to ensure
optimum care
Two nurses during NKE Plus handoff (Kaiser Permanente’s in- patient room bedside report model of care)
Charge Nurse rounds
CNA hourly rounding
This is changing our culture from a culture of
Clinical Transformation Model: Case Study
Optimizing Care for Hospital Acquired Pressure Ulcers
• Collaborate to foster knowledge translation • Leverage advanced analytics to extract actionable knowledge • Focus on “Making it Easy to do the Right Thing” • Build evidence out of
practice Set standards
based on clinical goals, and evidence-based practice Leverage EHR to optimize workflow and support clinical decision making Develop reports to monitor the practice change Measure the impact of the change through outcomes analysis and research
Develop Reports to Monitor Practice Changes
Clinical Transformation Model: Case Study
Optimizing Care for Hospital Acquired Pressure Ulcers
• Collaborate to foster knowledge translation • Leverage advanced analytics to extract actionable knowledge • Focus on “Making it Easy to do the Right Thing” • Build evidence out of practice Set standards based on clinical goals, and evidence-based practice Leverage EHR to optimize workflow and support clinical decision making Develop reports to monitor the practice change Measure the impact of the change through outcomes analysis and research
Measure Impact the Change Through Outcomes
Analysis & Research: Impact of Best Practice Alert
For Internal Use Only | Page 25
Before and After BPA Compliance 8+ Repositions 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Before BPA average rate
A ft e r B P A a v e ra g e r a te Negative Impact Improvement
What do Nurse Leaders want from the
Electronic Medical Record?
The Electronic Medical Record should serve as an
interactive patient care tool that supports nursing
practice to:
Optimize patient safety.
Ensure accurate documentation that tells the patient’s story.
Provide decision support with interactive care guidelines which promote critical thinking .
Provide support that is intuitive, not complex or time consuming, and does not contribute to alert fatigue.
Embed reminders to prevent delays or omissions in care and create a culture of always
What do Nursing Leaders want from the
Electronic Medical Record?
The Electronic Medical Record should serve as
an interactive patient care tool that supports
nursing practice to:
Create workflow that decreases waste and duplication.
Leverage workflow that drives interdependence amongst all disciplines.
Synthesize and pulling data to assist in creating comprehensive individualized care plans.
Ensure more time at the bedside.
But there are still challenges for the
bedside nurse that impact quality…
Searching for things and information
Rework
Variation
Interruptions
Repetition
Unshared Knowledge
Inadequate information at the point of care
Collecting data that never gets used
Lack of shared knowledge of events, schedules, processes
Lack of “system-ness”
How might we disruptively
innovate and transform the
inpatient work environment
to enable simple, reliable
patient care delivered by
nurses and their
inter-professional partners
through the wise use of data,
analytics and information
technology?
KP SmartCARE Technology Strategy
Vision:
Leverage technology to transform care delivery and improve patient safety and quality outcomes.
Strategy:
Accelerate the adoption of smart, standards-based, interoperable, patient centered technology that will make healthcare delivery safer, more efficient, timely, and accessible.
Execution:
Strategic implementation of key technology initiatives within the clinical setting.
Clinical Transformation
Rapid Sign-On
Eases the burden and repetition of logging-in to the EHR every few minutes
Clinical
Intelligence
Provides cognitive support and real time contextual information Workflow Automation Manage tasks, schedules and events Mobility
Biomedical Device Integration (BDI) captures patient data automatically resulting in real-time, accurate, easily available patient information. BDI is foundational to the KP
SmartCARE Strategy.
Turn Patient C
Lift team is scheduled
Check Patient B’s pain
Last check: level 5 Vital signs checked 10 minutes ago Procedure name
Patient C meds Prep Patient D for OR
15 30 45 2h Ambulate Patient B 2h Turn Patient A
Lift team is scheduled
Blood gas results
Patient C 5 Nurse Name Alerts New Orders Tasks
New Rx for Patient A
Name of Rx and instru ctions From Dr. E
Ambulate Patient D
Every 2 hours From Dr. K
Lab draw for Patient B
Short description Patient Name A-fib, CHF Age 57, Catholic Dr. W, Dr. X Fall risk No Latex Hearing aid
Wound Care (Est 30 mins) New Orders: Last visit from Dr. W:
1. Apply 4X4" duoderm with border to stage 1ulcer on coccyx Change every 3 days and prn per wound care protocol/N. 2. Irrigate stage 3 ulcer on 1t hip with saf-clens.
Apply Kaltostat rope, cover with Combiderm 6X6"; change daily and prn per wound care protocol/N. Administer pain meds 10 minutes before procedure.
30Pain reassessment 22h ! INR > 19.6 Pain meds No food by mouth DNR Vital signs Confirm 45 Catheter 11am 67 120/80 95% 15 Rhonchi 7am 68 120/80 95% 16 Rhonchi 3pm 68 118/82 95% 16 Rhonchi 3am 68 118/82 95% 16 Rhonchi Yesterday, 3pm None Info supporting nurse’s current activity Static info about patient Timely info about patient, regularly updated Customizable area - nurse chooses what info to display Nurse’s activities (synched with mobile app)
Baseline ECG: A-fib. Episodes of rapid ventricular response. Last incident 7pm yesterday. Lasted 10 mins. MD prescribed IV Cardiazem HR: BP: O2: RR: Lung: Xray Physical therapy Respiratory therapy 11am: 2pm: 4pm:
!Therapist running late Update Schedule 3:02 pm
Vital Signs Important Notes
icons indicating patient-specific precautions
Turn Patient C
Lift team is scheduled
Check Patient B’s pain
Last check: level 5 Vital signs checked 10 minutes ago Procedure name
Patient C meds Prep Patient D for OR
15 30 45 2h Ambulate Patient B 2h Turn Patient A
Lift team is scheduled
Blood gas results
Patient C 5 Nurse Name Alerts New Orders Tasks
New Rx for Patient A
Name of Rx and instru ctions From Dr. E
Ambulate Patient D
Every 2 hours From Dr. K
Lab draw for Patient B
Short description Patient Name A-fib, CHF Age 57, Catholic Dr. W, Dr. X Fall risk No Latex Hearing aid
Wound Care (Est 30 mins) New Orders: Last visit from Dr. W:
1. Apply 4X4" duoderm with border to stage 1ulcer on coccyx Change every 3 days and prn per wound care protocol/N. 2. Irrigate stage 3 ulcer on 1t hip with saf-clens.
Apply Kaltostat rope, cover with Combiderm 6X6"; change daily and prn per wound care protocol/N. Administer pain meds 10 minutes before procedure.
30Pain reassessment 22h ! INR > 19.6 Pain meds No food by mouth DNR Vital signs Confirm 45 Catheter 11am 67 120/80 95% 15 Rhonchi 7am 68 120/80 95% 16 Rhonchi 3pm 68 118/82 95% 16 Rhonchi 3am 68 118/82 95% 16 Rhonchi Yesterday, 3pm None Info supporting nurse’s current activity Static info about patient Timely info about patient, regularly updated Customizable area - nurse chooses what info to display Nurse’s activities (synched with mobile app)
Baseline ECG: A-fib. Episodes of rapid ventricular response. Last incident 7pm yesterday. Lasted 10 mins. MD prescribed IV Cardiazem HR: BP: O2: RR: Lung: Xray Physical therapy Respiratory therapy 11am: 2pm: 4pm:
!Therapist running late Update Schedule 3:02 pm
Vital Signs Important Notes
icons indicating patient-specific precautions
Turn Patient C
Lift team is scheduled
Check Patient B’s pain
Last check: level 5 Vital signs checked 10 minutes ago Procedure name
Patient C meds Prep Patient D for OR
15 30 45 2h Ambulate Patient B 2h Turn Patient A
Lift team is scheduled
Blood gas results
Patient C 5 Nurse Name Alerts New Orders Tasks
New Rx for Patient A
Name of Rx and instru ctions From Dr. E
Ambulate Patient D
Every 2 hours From Dr. K
Lab draw for Patient B
Short description Patient Name A-fib, CHF Age 57, Catholic Dr. W, Dr. X Fall risk No Latex Hearing aid
Wound Care (Est 30 mins) New Orders: Last visit from Dr. W:
1. Apply 4X4" duoderm with border to stage 1ulcer on coccyx Change every 3 days and prn per wound care protocol/N. 2. Irrigate stage 3 ulcer on 1t hip with saf-clens.
Apply Kaltostat rope, cover with Combiderm 6X6"; change daily and prn per wound care protocol/N. Administer pain meds 10 minutes before procedure.
30Pain reassessment 22h ! INR > 19.6 Pain meds No food by mouth DNR Vital signs Confirm 45 Catheter 11am 67 120/80 95% 15 Rhonchi 7am 68 120/80 95% 16 Rhonchi 3pm 68 118/82 95% 16 Rhonchi 3am 68 118/82 95% 16 Rhonchi Yesterday, 3pm None Info supporting nurse’s current activity Static info about patient Timely info about patient, regularly updated Customizable area - nurse chooses what info to display Nurse’s activities (synched with mobile app)
Baseline ECG: A-fib. Episodes of rapid ventricular response. Last incident 7pm yesterday. Lasted 10 mins. MD prescribed IV Cardiazem HR: BP: O2: RR: Lung: Xray Physical therapy Respiratory therapy 11am: 2pm: 4pm:
!Therapist running late Update Schedule 3:02 pm
Vital Signs Important Notes
icons indicating patient-specific precautions
Turn Patient C
Lift team is scheduled
Check Patient B’s pain
Last check: level 5 Vital signs checked 10 minutes ago Procedure name
Patient C meds Prep Patient D for OR
15 30 45 2h Ambulate Patient B 2h Turn Patient A
Lift team is scheduled
Blood gas results
Patient C 5 Nurse Name Alerts New Orders Tasks
New Rx for Patient A
Name of Rx and instru ctions From Dr. E
Ambulate Patient D
Every 2 hours From Dr. K
Lab draw for Patient B
Short description Patient Name A-fib, CHF Age 57, Catholic Dr. W, Dr. X Fall risk No Latex Hearing aid
Wound Care (Est 30 mins) New Orders: Last visit from Dr. W:
1. Apply 4X4" duoderm with border to stage 1ulcer on coccyx Change every 3 days and prn per wound care protocol/N. 2. Irrigate stage 3 ulcer on 1t hip with saf-clens.
Apply Kaltostat rope, cover with Combiderm 6X6"; change daily and prn per wound care protocol/N. Administer pain meds 10 minutes before procedure.
30Pain reassessment 22h ! INR > 19.6 Pain meds No food by mouth DNR Vital signs Confirm 45 Catheter 11am 67 120/80 95% 15 Rhonchi 7am 68 120/80 95% 16 Rhonchi 3pm 68 118/82 95% 16 Rhonchi 3am 68 118/82 95% 16 Rhonchi Yesterday, 3pm None Info supporting nurse’s current activity Static info about patient Timely info about patient, regularly updated Customizable area - nurse chooses what info to display Nurse’s activities (synched with mobile app)
Baseline ECG: A-fib. Episodes of rapid ventricular response. Last incident 7pm yesterday. Lasted 10 mins. MD prescribed IV Cardiazem HR: BP: O2: RR: Lung: Xray Physical therapy Respiratory therapy 11am: 2pm: 4pm:!Therapist running late Update Schedule 3:02 pm
Vital Signs Important Notes
icons indicating patient-specific precautions
Measure the impact on clinical documentation
and clinician workflow
Pain Reassessment
Post-Dashboard Run Chart
34
Pain Reassessment within 59 mins Department - 5 Ewa Apr1 - Nov24, 2012 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100% 4 /1 4/8 4 /1 5 4 /2 2 4 /2 9 5 /6 5 /1 3 5 /2 0 5 /2 7 6 /3 6/9 6 /1 7 6 /2 4 7 /1 7/8 7 /1 5 7 /2 2 7 /2 9 8 /5 8 /1 2 8 /1 9 8 /2 6 9 /2 9/9 9 /1 6 9 /2 3 9 /3 0 1 0 /7 1 0 /1 4 1 0 /2 1 1 0 /2 8 1 1 /4 1 1 /1 1 1 1 /1 8 1 1 /2 5 1 2 /2 % of P t R e a s s e s e d w /i n 5 9 m ins
5 Ewa Baseline (Apr-Jul'12) New Median (Aug-Oct'12)
baseline median = 75% new median = 84% Shift 14 data pts above baseline m edian Dashboard im plem ented 8-15-2012
An Integrated Environment for Safe
Patient Care
Goal: Convergence of voice, secure messaging, presence, smaller smarter devices and workflow automation to
improve safety by decreasing the cognitive burden
Development of a strategy
and road map is a key success. Can’t chase the technology.
“Instead of the current model of one patient accessing one provider at a time,
people can access their care whenever and wherever they need it.”
Bernard Tyson COO
Kaiser Foundation Health Plan & Hospital
KP SmartCare Today
Healthcare will be coordinated beyond hospitals and clinics to our daily lives through digital channels, including mobile and social collaboration
Transforming Care to Ensure Patient Safety
Leadership / Governance
Cross functional collaboration
Standardized processes
Real Time, actionable data
Clinical Decision Support
Usability
BioMedical Device Integration
Mobility
Performance Improvement & Removing Waste
Patient & Family Engagement
Automate trigger detection
of adverse events
Role of the Nurse Leader
Define an inter-professional governance model that defines the strategic vision, roles and measures of success.
Drive performance measurement based on evidence based practice and data mining to synthesize new knowledge.
Develop Nursing Informatics Leadership roles to support the integration of clinical practice,
technology and process redesign.
Set clear, measurable clinical outcomes for technology initiatives.
Support and champion cultural transformation as a foundation for new technology.
Contact Information
Linda Fahey RN NP MSN
Regional Director of Quality & Patient Safety
Ann O’Brien RN MSN CPHIMS
National Director of Clinical Informatics Ann.O’[email protected]
Celeste Farugia RN MSN
Clinical Nursing Director ICU/MedSurg Woodland Hills [email protected]
