HSS5301 Optimizing inpatient care

Optimizing inpatient care HSS5301

IP settings:

IP EHRs are essential to quality of health care

What makes it difficult?

Number and complexity of IP orders

Acuity of IP problems

Complexity ofIP care teams

Phased implementation is attractive

- Minimal impact on workflow efficiency

Developing IP HER

- Define and agree on the primary goals:

n 1. For guiding project development

n 2. For evaluating project’s success and planning successive refinements

- Experience from Geisinger:

n Began by using OP HER

n Physicians and OP-clinic support staff became familiar with the HER before the hospitals’ nurses

n Proposed 3-phase implementation

u Facilitated information review

u Provider order entry and documentation

u Nursing documentation and medication admin.

Facilitated information review

- Presentation of clinical Ix organized into P lists

n To enable clinicians to review the P’s status in a single overview

u Status icons

u Patient list

- Analysis begins in the admission dep, since hospitals’ DT system is the source of patient lists.

n Review Ix created by the ADT system and how they could be presented to HER users

n Interview all types of clinicians and attended patient rounds.

u To identify the information needs

u To assess the tools that were in use to track P location.

n Review the HER S/W

u Look for the options available for P list organization and display Ix

Presentation of lab tests/results

- Organizes results into clinically meaningful groups

- Easy access of commonly used ordered test panels: eg. CBC, general chemistry

+Provider order entry and documentation

- Geisinger’s exp with OP HER phased implementation

n Request for merger and rapid implementation for both order entry and documentation

- Follow same approach for IP HER

n Provider order entry and documentation are implemented together.

Documentation: template notes

- Begin with those infrequently available in paper chart during P’s hsitap stay

- Start with general outline of master template before developing templates for specific Dx and Px

- Identify appropriate content

n Review P charts

n Review the templates

n Interviewing physicians

- Require validation by

n Clinicians

n Staff from medical records, billing and legal department

Documentation/ effifiency tools:

- Should be more effective to use (easier &faster) to use than writing or dictating

- Focus on the elements that affect decision making

n Hx, physical examination and Px

n Make ref to validated clinical prediction rules (CPRs)

Defaulting

- Provide answers to their usual state

- Time-saving

- Wildcards required (placed for adding free text) [since the form can’t anticipate the availbillty of all possible selections]

Ancillary docuemtnation for improved performance

- Orders and templates for documenting other important p-care actitivies in admission order sets like nutrition assessment, fall prevention, and documentation of advanced directives

Order entry:

- Most important efficiency tool for IP EHRs

- 500 order sets are typically recommended

- Users in focused domains that require numerous orders are heavy users, e.g. PAs(Physicians Assistant) working in orthopedic surgery

- Topics and contents of orders sets are typically defined b clinicians

Appropriate content for specific order sets can be identified by:

- Reviewing the paper order sets

- Interviewing clinicians

- Soliciting suggestions from the best practice recommendations like pharmacy, lab, infection control risk management, utilization management, billing etc.

- Review published sources like clinical practice guidelines, reports of clinical trials etc

Important factors of Order Sts

- Speed

- Simplicity, contributes to speed

- Users need help finding order sets

n Pattern matching v.s. hierarchies

- Users can order multiple needs at once

- Order sets require management after implementation:

n Content review and functional review

Provider order entry and documentation

Order management:

- entered orders must be transmitted with appropriate urgency to providers (nurses and consultants), and ht eancillary departments (e.g. laboratory, radiology)

- the exact status of the order should be readily available, saving time to locate Ix on the status of orders

- digital pagin improve order reporting speed but depends on

n development by enterprise ER vendors

n Effectiveness of expensive paging equipment upgrades,

Verbal orders

- EHRs decrease the need for vebal orders

n Physicians can enter orders personally’s inbacket for signature and automatically report to designed manegers if orders are not signed within 24 hours

Patient education

- 20% of patient discharged from a large teaching hospital suffered a care-realated adverse event following discharge [Forster et al.]

n 2/3 could be prevented or minimized by better communication.

- HER enables hospitals to provide patients with standardized discharge instructions

n Include potential adverse effects of care and contact information in lay languages

Cliician feedback

- the success of inpatient EHRs rely on full involvement of physicians and clincians in every phase of the implementation

n face-to-face multidisciplinary feedback team

- Go-alive support for IP EHRs

n Provide training on all 3 shifts

n 24x7 for 2 to 5 days past go-alive