How Incorporating EBP & CDS Can Improve Outcomes & Agency Efficiency

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1 9/18/2014 How Incorporating EBP & CDS Can Improve Outcomes & Agency Efficiency 2014 NAHC Annual Meeting Phoenix, AZ Karen Utterback, RN, MSN VP Strategy & Business Development McKesson Extended Care Solutions Andrea Devoti, RN, MSN, MBA CEO, Neighborhood Health 1

2 9/18/2014 Objectives Identify how evidence based practice (EBP) concepts apply to home care and hospice clinical practice Explain national IT standards that include CDS as a component of an EMR, integrated with EBP Discuss one organization s EHR journey using an EMR that integrates CDS and EBP 2

3 9/18/2014 What is Evidence? When a theory or hypothesis is tested objectively such as in an experimental or controlled environment. Measurement of an intervention s effectiveness in achieving an outcome that creates lasting changes. Published in scientific literature such as professional journals, books or government reports. Consensus of experts Level of Evidence 3

4 9/18/2014 What is EBP? Evidence based practice is a problem solving approach to health care that incorporates the conscientious use of current best evidence from well designed studies, a clinician s expertise, and patient values and preferences. Fineout Overhold, Melynk, 2005 All three of these key components must be present for evidence based practice to be effective. EBP Scientific Model 4

5 9/18/2014 Why do we need EBP? Status of America's Health Care 30% of healthcare spending $750 Billion for ineffective or redundant care. BC/BS % of acute care and 56% of chronic care conformed to the medical literature. McGlynn, 2003 Patients have a 50% chance of receiving the most advisable care RWJ, 2010 Why do we need EBP? Medical Mistakes Number 3 killer in the US after heart disease & cancer 10,000 serious complications occur each day 400,000 people a year Over 100,000 a day die Cost: $1 trillion each year McCann,

6 9/18/2014 Home Care & Hospice Impact Patient outcomes are 28% better when clinical care based on EBP rather than tradition Fineout Overholdt, 2012 More care doesn t mean better care Medicare patients in higher spending regions receive more care but outcomes and satisfaction if i is the same. Fischer, et. al, 2003 Home Care & Hospice Impact Basing practice & care on evidence is integrated into the Affordable Care Act (ACA). ACOs are required to promote evidence based medicine and coordinate care through using it. Reimbursement will soon focus on achieving & measuring patient centered outcomes rather than just delivering care & paying per visit. 6

7 9/18/2014 Home Care & Hospice Impact Using evidence based clinical practices does not conflict with being regulatory compliant and licensed, and if it does, the agency should have a process for addressing the issues The POC is developed using physician orders and clinician expertise. Agency policies & procedures should support EBP. Physicians should be open to EBP questions. Assures that the 5 Rights of clinical decision support are consistently present: Right Information to the Right person in the Right format through the Right channel at the Right time Berner,

8 9/18/2014 Clinical Decision Support A sophisticated HIT component doesn t stand alone. Provides knowledge & person specific information, intelligently filtered or presented at appropriate times, to clinicians, staff, patients, & others. Includes tools and interventions: computerized alerts and reminders, clinical guidelines, order sets, patient data reports and dashboards, documentation templates, and clinical workflow tools. Clinical Decision Support Supports clinicians through a logical patient assessment, provides prediction of risk, and makes suggestions based on care guidelines. Hall, 2013 Common features Knowledge based (dx, drug interactions, guides). Rules & relationships that combine knowledge with patientspecific information. Communication mechanism that provides relevant information back to the clinician as care is delivered. Berner,

9 9/18/ Benefits of a EMR with CDS 1. Streamlines workflow 2. Helps increase clinical accuracy & productivity 3. Supports the use & adherence to EBP 4. Helps increase clinician satisfaction & improves retention 5. Helps improve patient outcomes 6. Helps maximize agency resources 7. Helps position the agency for opportunities 9

10 One Organization s EMR Journey and Benefits Using an EMR that Integrates CDS and EBP Andrea Devoti, RN, MSN, MBA, CHCE October 20, 2014 Real title for my portion: How NOT To Do Things 1

11 Neighborhood Health Neighborhood has used an EHR in some i 1995 manner since 1995 Initially just Home Care RNs 2003: Went live on system for entire agency With upgrade in 2003 All staff CNAs on telephony Large learning curve for some Some change management education Went well Lost a few staff 2

12 2013 Beta site for new product Incorporates decision support and evidence-based practice Much discussion by managers and IT regarding how to change product 2013 continued Selected small pilot group Super users Training for them on use Only small group of managers and QI staff trained on Omaha system, basis of program 3

13 2013 continued Trained small group on program changes and flow No training on change theory, evidencebased practice, decision support or assessment Due to some technical issues, we delayed complete integration for a month 2013 continued When resumed, began training a bit differently Still heavy emphasis on hands-on Little on theory or assessment 4

14 Therapy Response Therapy staff did well in general A few struggled, but majority like the system Flows the way the therapists perform their visits Nursing Response Nursing staff who had been with Neighborhood h struggled New staff who knew nothing else did better than existing staff WHY? Sad realization that for the most part, nursing staff had been assessing the OASIS, not the patient 5

15 EBP and CDS only functions properly if you maximize assessment skills of clinician and accurately enter data Our staff lacked skills and knowledge or it was dormant that they needed to succeed Assessment must be done in a logical sequence with one system completed before moving on Brought to light all of our warts Assessment issues Productivity issues Clinical judgment weakness Management failures 6

16 Now We are in a better place But with much pain Productivity it increased Staff on disciplinary process if not making progress Individualized instruction for many, with a trainer going into the homes Reviewing assessment skills as well as documentation Now Patient outcomes improving Accuracy and productivity increasing Staff satisfaction increases once they stop fighting the system Still several projects ongoing 7

17 What are my suggestions before major clinical changes? Assess your staff! Even if you have good outcomes, what kind of assessment skills do your staff have and use? Educate them on the background Who, what, when, where and particularly, HOW We failed to do this What s In It For the Clinicians? Personal time Accuracy Decreased being overwhelmed 8

18 What s In It For The Patients? Clinical assessment of condition Accurate and timely communication between the staff Enhanced care coordination Increased outcomes What s In It For The Organization? Decreased overtime Increased quality More timely billing Hopefully, increased satisfaction and decreased staff turnover 9

19 Will I Do It Again? Yes, but manage differently Projects We Are Still Working On Clinical competence Scheduling efficiency Productivity 10

20 Questions? Carolyn Humphrey, RN, MS, FAAN net Andrea Devoti, RN, MSN, MBA, CHCE President, CJ Humphrey Associates Louisville, KY CEO, Neighborhood Health West Chester, PA References Berner, E. S., (2009). Clinical decision support systems: State of the Art. AHRQ Publication No EF. Rockville, Maryland: Agency for Healthcare Research and Quality. Blue Cross/Blue Shield (2012). Building tomorrow s healthcare system:the pathway to high quality, affordable care in America. reform/pathway.pdf Fisher, E. S., et al (2003). The implications of Regional Variations in Medicare Spending. Part 2: Health outcomes and satisfaction with care. Annals of Internal Medicine, 18:138(4),

21 References Hall, P.B., Poole, R., Hall, C.A. (2013). Bridging the gaps in supportive information systems. Home Healthcare Nurse, 31(8), McCann, E. (2014). Death by medical mistakes hit records. Healthcare IT News. McGlynn, E. A., et al. The quality of health care delivered to adults in the United States. New England Journal of Medicine 348, Resources Carrington, J. M. (2012). The usefulness of nursing languages to communicate a clinical i l event. CIN: Computers, Informatics, Nursing, 30(2), Cipriano, P. F. (2011). The future of nursing and health IT: The quality elixir. Nursing Economics, 29(5), 282 and Harrison, R. L., Lyerla, F. (2012). Using nursing clinical decision support systems to achieve meaningful use. CIN: Computers, Informatics, Nursing, 30(7):

22 Resources Health IT.gov Clinical Decision Support. How-To Guides (5) for Clinical Decision Support (CDS) Implementation. implementation Kohn, L. T., Corrigan, J. M., Donaldson, M. S. (2009). To Err is Human: Building a Safer Health System. The National Academies Press: Washington, D.C. Rosenbaum, L, Shrank, W. (2013). Taking our medicine: Improving adherence in the accountability era. NEJM, 369(8),

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