Electronic health records (EHRs) have become increasingly popular among healthcare organizations. The transition from paper to computers hasn't necessarily been smooth or easy. At times the implementation of this technology has been frustrating, discouraging, and emotional. But, despite the occasional setbacks, nurse managers should embrace EHRs as a technology that can propel patient safety in an organization.
One advantage of the EHR is the opportunity to use (near) real-time clinical data to trend, evaluate, and monitor goals and outcomes; eliminating the lag times between patient encounter and the availability of data.
EHRs at work
Banner Health uses clinical data to drive patient safety in obstetrics across its hospital system. One of the more recent examples of improvement while using EHR technology has been a reduction in the rate of elective deliveries that are less than 39 weeks gestational age.
To assist with this improvement effort and its monitoring, Banner Health developed a clinical dashboard that's updated daily from computerized medical records. It allows clinicians and managers to monitor results in (near) real-time. The robust clinical data dashboard was developed using the following seven-step process:
* define the terms
* identify discreet data fields in the EHR
* define data display
* validate the data
* develop the reporting format
* ensure appropriate access
* provide timely feedback.
Define the terms: To avoid the “garbage in/garbage out” syndrome, ensure everyone is speaking the same language. If different definitions are floating about there's often cascade effect. One term may be dependent on the understanding of another term. At Banner Health, for example, the terms “elective” and “scheduled” were used interchangeably. However, a patient might be scheduled for an induction at less than 39 weeks with a legitimate medical reason. In addition, clinicians were using “induction” and “augmentation” inappropriately. To correct this situation, a team of obstetrical providers and nurses developed the criteria and definitions for these terms, obtained consensus from key stakeholder groups, and educated clinicians about the differences.
Identify discreet data fields in the EHR: The EHR has a wealth of minable information if the clinicians use it correctly. Data entered from drop down lists, yes/no option buttons, and check boxes are all obtainable. Once key fields are identified, users must be educated on how and why they must be used. We made certain the most common maternal and fetal indications for elective delivery were included in checkbox format to ensure ease of use.
Define the data display: Clinical data should be displayed in a format that makes the most sense for that measure. Sometimes the number of occurrences is most meaningful, such as the number of deliveries per day. Other times a rate may be more helpful, such as the rate of cesarean deliveries. In the example of elective deliveries at less than 39 weeks, Banner Health chose to display the number per day and the rate per month. When using a rate, a numerator (elective deliveries less than 39 weeks) and denominator (total number of deliveries) need to be identified.
Validate the data: Know that the first thing people do with data is scrutinize it. Be prepared. Validating data to ensure it's being entered correctly in the chart, pulled properly in a query, and organized appropriately will minimize challenges to the figures. Banner Health utilized the skills of a core group of quality nurses for this process. They ran queries and asked the quality staff to validate the data. This process uncovered some problems in Banner Health's system and gave them the opportunity to correct concerns before any issues arose.
Develop the reporting format: Involve information technology data experts to explore the best options to ensure managers have timely and easy access to this information. Some options to achieve this goal may include a daily e-mailed report, a link to the report through a facility's intranet, or a clinical dashboard. Banner Health chose to present its information on a dashboard that can be viewed with an overall system score, as well as individual facility scores. This enabled facilities to compare each other's results, identify who was having success with this measure, and learn strategies from one another to improve this patient safety measure.
Ensure appropriate access: Data can help drive practice changes when the right people in an organization have access. For example, it may be important for a chief nurse officer to know what the elective delivery rate is at a facility, but it's the nurse managers and physicians in the unit who impact any outcomes. Some data may be appropriate for anyone in an organization to view; other data may need to be filtered by position and/or department. At Banner Health, everyone can see the elective induction rate for each facility. Only nurse managers or their designees are able to see more detailed information about patients.
Provide timely feedback: The advantage of (near) real-time data is the ability to give timely feedback so that outcomes can be impacted sooner. Auditors (nurse managers, department chairs, quality managers) must have a process in place for reporting any outliers they may find. At Banner Health, auditors first review the record to make sure everything was documented appropriately. The nurse manager should immediately follow-up with the department chair or the delivering provider to understand why an elective delivery occurred and to reinforce the policy regarding elective deliveries at less than 39 weeks. The record may also be peer reviewed for additional follow-up with the delivering provider.
When Banner Health started reporting early elective deliveries, the voluntary induction rate was 0.73%. With the advantage of (near) real-time information, they were able to drop this rate to 0.39% within 6 months and continue to see improvement.
Banner Desert Medical Center, one of Banner Health's busiest perinatal units, struggled with reducing their elective induction rate at first. Over the past 6 months, their elective induction rate has dropped from 0.69% to zero. “The Perinatal Dashboard is used to drive improvement opportunities to reduce variation in our workflow processes,” explained Kathleen Walker, senior nursing director of Women's and Infants Services.
Carol Myers, quality nurse specialist at Banner Desert Medical Center, explained, “I use the dashboard for elective deliveries to see how often the elective box is being checked since this results in reported rate. I review all deliveries less than 39 weeks for medical indication. There are elective deliveries not captured in the dashboard and cases where the elective box is checked and there is a medical indication. I follow up accordingly. However, I am seeing far less electives per screening. Hard stops and awareness has made a difference in our rate.”
Banner Health is using (near) real-time clinical data for measures that are helpful to nurse managers, such as improving timeliness of documentation, reducing the use of expensive adhesion barriers, and monitoring the management of medication administration and its effects. This technology allows nurse managers the opportunity to monitor clinical data in (near) real-time, to improve quality on their unit, and to mentor their staff in patient safety. By embracing EHRs, facilities will be better prepared to improve patient outcomes across the medical board.