THE NEXT FRONTIER OF UNDERSTANDING NURSING TIME IN THE EMR

THE NEXT FRONTIER OF UNDERSTANDING NURSING TIME IN THE EMR Presentation ID: 484 Nikki Polis PhD, RN SVP and CNE Methodist LeBonheur Healthcare Interim CNO LeBonheur Children's Hospital Memphis, TN Darinda Sutton MSN, RN-BC VP and CNO Cerner Kansas City, MO April 16, 2015 10:45 AM - 11:45 AM.

Disclosure Darinda Sutton is employed by Cerner Corporation. Nikki Polis does not have any relevant financial interests presenting a conflict of interest to disclose. AONE and the ANCC do not endorse any commercial products discussed/displayed in conjunction with this activity. 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. AONE is authorized to award one hour of pre-approved ACHE Qualified Education credit (non- ACHE) for this program toward advancement, or recertification in the American College of Healthcare Executives.

Objectives Discuss three different approaches to measuring nurse documentation time Describe the improvement process developed to increase the efficiency and effectiveness of admission and intake documentation

Partnership History Cerner and Methodist LeBonheur Healthcare Partners since 1996 Strong relationships span across many levels of organizations EMR Implementation Timeline 1996: Pharmacy 2004: Registration, Scheduling, Results Review, Clerk Order Entry, Documentation, HIM, ED, Radiology, Surgery, Lab 2007: ED, CPOE, emar, Data Warehouse 2014: Ambulatory, Bar Code Medication Administration 2015: Maternity, Fetal Monitoring

Problem Nursing documentation for acute care hospitals appears to be time consuming and laborious, much of which provides questionable value for patient outcomes and quality care.

Project Background RNs, patients/families, and physicians dissatisfied with time RN spent documenting Duplicate documentation viewed as rampant and time waster Patient story not clear in EMR Financial ramifications of documentation CEO commitment

Project Goals Reduce amount of nursing time spend documenting Goal: 70/30 based on the TCAB target Reduce redundancies and eliminate non-value added work Are there economies of scale that can be achieved by a one medical record perspective? Increase the clarity of the patient story within the EMR

Historical Approaches to Measurement Nurse Perception of Time in EMR Interviews Surveys Time and Motion Studies (Observation) Identify time spent documenting Identify activities that take RNs away from patients Combination of Nurse Perception and Time & Motion

Time & Motion Studies Nurses spend about 1/3 of time with patients Variation in documentation time reported from 10% to 35% Pros Provide an outsider s view Allow look at process and content Identify redundancies, accuracy, efficiencies Cons Labor intensive Expensive Inter-rater reliability of observers Point or points in time

Perceptions Attitudes Results equivocal related to demographics and pre/post implementation Preference for EMR vs. paper Increases information access and improved efficiency Hinders interdisciplinary communication Too many boxes, not enough space to tell story Legibility and clarity of patient orders Time grabber Time Estimates Range from 50 to 70+% in the EMR Increases overtime

Perceptions (cont) Pros Efficient timely, large numbers of users, wide span of content Reality is perception Cons Reality is perception Return rate Point or points in time

Combination Findings Inconsistency between perceptions and actual recording of time spent documenting Pros Allows triangulation Pros of individual approaches Cons Labor intensive Can be expensive Cons of individual approaches

New Frontier Automatic timers embedded in the EMR Video review of RN s computer session Data at discrete levels Individual clinician Type of documentation tool

Multi-Pronged Approach at MLH Survey (25 questions for RNs, +6 for all users) Direct observations of RN workflow Timers embedded into the EMR Video recording of RN interactions with EMR

MLH FINDINGS Methodist LeBonheur Healthcare

Perceptions/Surveys

Overall Satisfaction with EMR - Nursing

Survey Feedback Which part of the admission process do you feel has the greatest opportunity for improvement? N=377 Could select up to 3 answers

Observations No consistent real time documentation of admission Throughput in ED influence Handoff opportunities Orders overdue Multiple distractions during intake process Clarifying physician orders adds to time Limited technology support to streamline data input Admission process for novice RNs different than expert RNs

Nursing Time Categories & Definitions 18 Categories of EMR Work Main Categories in MLH Data Alerts Nursing Organizer/Activity lists Charging Chart Review Discharge Documentation Histories Medical Record Publishing Medication Administration Meds Rec Messaging Orders Patient Discovery Patient Education Problems and Diagnosis Registration & Scheduling Sign Review Other Documentation Chart Review Medication Administration Orders Patient Discovery Patient Education Other

Video Validation

How Nurses Spent Time in EMR Patient Discovery 2% Patient Education 1% Orders 5% Other 7% Med Admin 8% Chart Review 28% Documentation 49% Flowsheet Charting 36% Electronic Forms 11% N = 2,107 Time: 7/6/14 8/2/14 Applications: Core EMR, ED and Surgery Other 1% Clinical Notes 1%

Nursing Time in EMR: 7/6/14 8/2/14 Critical Care (N=792) 24:58 Med/Surg (N= 910) 15:59 Emergency (N=405) 10:01 00:00:00 00:05:00 00:10:00 00:15:00 00:20:00 00:25:00 Total N= 2107 Documentation Orders Chart Review Med Admin Other Dates: 7.6.2014 8.2.2014 Applications: Core EMR, ED and Surgery

Critical Care Nursing Unit 4ICU 47:55 44:26 Time per Patient 30:27 27:42 25:19 21:23 19:27 16:4 0 12:49 Nurse 1 Nurse 2 Nurse 3 Nurse 4 Nurse 5 Nurse 6 Nurse 7 Nurse 8 Nurse 9 Documentation Chart Review Med Admin Orders Other 9 Nursing Users Dates: 7.6.2014 8.2.2014 Applications: Core EMR, ED and Surgery

Active Time (Min) Nurse 1 Time Card 60 50 Patients Seen: 2 Active Time: 3 Hours 25 Min % Shift Active in EMR: 28.5% % Time Outside Shift Hours: 6.3% 40 30 20 10 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Hours of Day 1 Nursing User Date: 7/17/2014 Applications: Core EMR, ED and Surgery Documentation Chart Review Med Admin Orders Other

Nurse 5 Time Card Patients Seen: 3 Active Time: 2 Hours 37 Min % Shift Active in EMR: 21.8% %Time Outside Shift Hours: 0.1% 1 Nursing User Date: 7/17/2014 Applications: Core EMR, ED and Surgery

Active Time (Min) Nurse 9 Time Card 60 50 Patients Seen: 8 Active Time: 1 Hour 2 Min % Shift Active: 8.9% % Time Outside Shift Hours: 30.0% 40 30 20 10 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Hours of Day 1 Nursing User Date: 7/17/2014 Documentation Chart Review Med Admin Orders Other Applications: Core EMR, ED and Surgery

Total Time in EMR per Patient AVG (hh:mm:ss) MINIMUM (hh:mm:ss) MAXIMUM (hh:mm:ss) ICU N=135 00:39:14 00:01:54 02:29:53 ED N= 270 00:13:15 00:01:18 01:09:45 MS N=251 00:24:04 00:01:48 01:09:09 Day shift RNs only 10/19/14 11/22/14

ADMISSION PROCESS Our Findings

Admission Assessment - Perception N=395 RNs

Admission History - Perception N=395 RNs

Admission Assessment & Hx: Total Elapsed Time Adult Admission Documentation Elapsed Time Key Strokes Clicks Transactions Users Adult Admission History Form 05:17 75.11 75.57 624 325 Adult Admission Nutrition Screening Form 01:01 5.74 13.65 689 332 Allergy Form 00:26 7.12 8.65 543 282 Multidisciplinary Discharge Planning Form 00:09 1.02 3.76 255 126 Pneumococcal Screening Form 00:21 1.50 4.86 850 451 Influenza Screening Form 00:16 1.51 3.66 932 486 VTE Risk Assessment Form 00:08 0.77 2.63 1395 483 Adult Fall Risk Scale 00:24 2.51 10.61 4073 534 Safety/ ADL Form 00:27 8.47 13.53 392 17 Patient Education 00:57 97.79 12.67 631 80 09:26 201.5 149.6 Pediatric Admission Documentation Elapsed Time Key Strokes Clicks Transactions Users PEDS Admission History Form 05:21 63.86 86.86 207 121 Peds VTE Risk Assessment Form 00:23 0.99 7.32 467 165 Fall Risk Pediatric 00:14 1.69 8.02 1171 179 Patient Education 00:57 97.79 12.67 631 80 Safety/ ADL Form 00:27 8.47 13.53 392 17 Allergy Form 00:26 7.12 8.65 543 282 Multidisciplinary Discharge Planning Form 00:09 1.02 3.76 255 126 07:57 180.9 140.8 10/11/2014 10/17/2014

# of Keystrokes Admission Process Time and Effort = Adult = Peds Dates : 10/11/2014 10/17/2014 # of Clicks

Comparison of Findings Admission Hx Ackman & colleagues, 2012 MLH Perception (Survey) MLH Reality (Timers) Adult MLH Reality (Timers) Peds Total time 7 Minutes 5-15 minutes 9 min 26 sec 7 min 57 sec # Clicks 200 129 150 141 # Keystrokes n/a n/a 202 181

Lessons Learned Clear definitions of processes critical to understanding data Admission process cleaner/easier to define than discharge Cannot translate learning from physician timers Trust your gut in evaluating data and new technology Triangulation is useful Be realistic about time takes to perfect new technology

Lessons Learned (cont) Duplicate documentation within nursing and between other professions is time waster and frustration Majority of RNs satisfied with EMR Disconnect between nurse perception and patient/family perception of info being easily accessible

ahas! & Action Items Achieving 70% time spent with patients takes more than documentation optimization Time grabbers and wasters (Adamopoulos, 2014; Hendrich & colleagues, 2008) Redirecting work to other team members (Adamopoulos, 2014) Work on culture change as part of the optimization integrated patient record vs. profession focused Timer output can assist in identifying care team time and cost per patient

Future Consideration Care Team Time *Core EMR, ED and Surgery Users Only (Single Patient - Hip Fracture) Other includes: Clinical View Only, ED Paramedic, ED Tech, Health Unit Coordinator, HIM, Nutritionist, Pharmacist, Quality Manager, Radiology Tech, Rehab Secretary, Room Service Clerk, Surgery Manager, Surgery Secretary

Future Consideration - Care Team Cost Otherincludes:ClinicalViewOnly,EDParamedic,EDTech,HealthUnitCoordinator,HIM,Nutritionist,Pharmacist,QualityManager, RadiologyTech,RehabSecretary,RoomServiceClerk,SurgeryManager,SurgerySecretary

ahas! & Action Items (cont) Attend to people, process and technology in optimization plan Governance structure Communication and education Change management Policies to support

Summary Validation of the timers took longer than planned Nuances of nursing work patterns were different than physician workflows Confident that timer data are reliable and valid for nursing time in the EMR Interviews, surveys and observations augment timer data Optimizing documentation is necessary but not sufficient for achieving the goal of 70/30

Selected References Ackman, M., Perry, L. A., Wolfard, E., Steckel, C., & Hill, C. (2012). Changing nursing practice: Letting go of the nursing history on admission. Journal of Nursing Administration, 42(9), 435-441. Adamopoulos, H. (2014, June 6). Bringing nurses back to the bedside: How Novant Health tripled direct patient care time. Becker's Hospital Review e-weekly. Hendrich, A., Chow, M. P., Skierczynski, B. A., & Lu, Z. (2008). A 36- hospital time and motion study: How do medical-surgical nurses spend their time? The Permanente Journal, 12(3), 25. Kossman, S. P., & Scheidenhelm, S. L.. (2008). Nurses perceptions of the impact of electronic health records on work and patient outcomes. CIN: Computers, Informatics, Nursing, 26(2), 69-77.

QUESTIONS, DISCUSSION Nikki.Polis@mlh.org Darinda.Sutton@cerner.com