Definition and Use of Clinical Pathways and Case Definition Templates AHIMA Children’s Health System of Texas Tuesday Nov 15th, 2016

Agenda: Review standards-based clinical guideline-directed patient data capture Tool. Review information from previous calls (15mins) Review draft list of requirements (30mins) Review outstanding questions (10mins) Discuss next steps (5mins)

Why: Benefits of Clinical Pathway Less time-consuming to capture patient information Improved quality through more complete and accurate patient documentation Providers spend more time with patients Improved continuity of patient care Standardizes patient care and limits variations in care Common language facilitates better communication between stakeholders Helps streamline billing processes for hospital revenue Provides method of continued training for Healthcare Providers Helps drive public health reporting

What: Types of Clinical Guidelines Clinical Guidance: Evidence-based, best practice recommendations for disease treatment and or management usually published by guideline organizations (e.g. Journals) Clinical Protocol: Explicit process usually specific to an organization based on clinical guidance. Clinical Pathways: Pre-defined set of activities/procedures and data to be captured about patient care based on clinical guidance and protocols initiated by Provider. Owned by Physicians. Clinical Criteria: A set of uniformly applied indicators for determining whether the identified clinical definitions can be applied to the particular disease, injury, or other health condition. Clinical Definition: A component of a clinical pathway that defines what data/coding should be used to record a specific activity, at the most specific level of specificity. Owned by HIM ElectronicTemplate: An existing electronic representation of patient data in an EHR that can be enhanced to capture clinical definitions. E.g. Progress Note has standard sections – in history of present illness, would capture clinical definitions (may repeat in assessment and care plan to align treatment)

Who: Clinical Pathway Team/Actors Executive Leadership Healthcare Informaticists Physicians EHR Systems Support Nurses Medical Librarian HIM Leadership Pharmacy Staff CDI Specialists Trainers/Educators Coders Patients Allied Health Staff (Respiratory, Social Work, etc.)

Required components/workflow Role Description Input Output Executive Leaders of: Physicians, Nurses, Quality, Ancillary Systems, HIM, Regulatory and Compliance, Information Systems Provide the approval for developing clinical pathway and clinical definitions Approvals Providers (Includes SME’s such as Physicians, Nurses, Ancillary Health Staff (e.g. Respiratory, Social Work, Radiology, Lab, Nutrition, Pharmacy, etc.) Define documentation workflow (identify electronic templates and data element requirements) for clinical pathway and clinical definitions Methodology Required components/workflow HIM Leaders, CDI Specialists, Coders How to make it happen. Definitions driven by HIM Chart Reviews, Case Studies, Reference Material, Policies, Procedures Specific clinical definitions around specific diagnoses Healthcare Informaticist (Incl EHR Systems Support), Nursing Informaticists Helps provide data to organization for more informed decisions. What is current data available for benchmarking/measuring results (e.g. better outcomes) Benchmarking (e.g. peers, regional, national, global) IT Analyst/Specialist Builds the electronic template; includes testing and integration Specific clinical definitions Build within EHR system Trainers/Educators Help design clinical training and walk users through updates relating to clinical pathways and clinical definitions Clinical pathways, clinical definitions EHR Training in EHR Patients Clinical pathways and clinical definitions are designed to provide better health outcomes for individual patients and population health Better health outcomes

How: Steps For Creating Clinical Definitions #1 Step Name Notes Actors Tools 1 Determine the disease processes needing additional clinical criteria? Specialty SME’s provide input Disease drives clinical criteria (may be different for different conditions) Top diagnoses by specialty Specialty Providers Data Repository (most common codesets) 2 Determine most common diagnoses Run report based on codes from DRG CDI Specialists Data Repository 3 Determine how to document diagnoses with more detailed terminology. Identify missing language to drive to acuity levels needed Identify what Providers should say instead Review of chart in EHR 4 Complete research and find clinical definitions Research Clinical Pathways to find out what Providers think definition should be. Determine different perspectives from different groups Use clinical pathways (Nelsons – basic guideline) Discuss with stakeholders SME’s, CDI Specialists, Nutritionists, Gastro, Endocrinologists Word, Browser

How: Steps For Creating Clinical Definitions #2 Step Name Notes Actors Tools 5 Document terminology and definitions Summary of different perspectives CDI Specialist Word 6 Document former vs recommended terminology Former terminologies come from the EHR. Recommended terminologies are from the coding terminologies. ICD 7 Obtain approval for clinical definitions and clinical pathway ?? 8 Publish shortened version of Clinical Definitions Publish pocket book or guide. 9 Consult specialties to determine appropriate templates to build level of specificity Talk to Advanced Practice Nurse/Provider – they have electronic templates they use on regular basis at clinic and hospital. Look at templates and pick most common ones and work on enhancing them with these recommended terminologies Give ability to pick from drop-down template (in prognosis for order, reason for visit, etc.) Or pull from short preference list diagnosis list specific to specialty APN, CDI Specialists, Providers

How: Steps For Creating Clinical Definitions #3 Step Name Notes Actors Tools 10 Publish template updates to Providers ClinDoc team from Epic work with team to build template. Tool in Epic to collect documentation is NoteRider – Collects discrete data, and adds automation. ClinDoc Team NoteRider 11 Perform updates to clinical pathway and clinical definition Review to determine if changes are required - basic definitions and underlying criteria don’t change. For move to ICD10, had to update all definitions which allowed more specificity in procedural coding. If new information becomes available (complication list – CC’s and MCC’s, changed lists (additions/subtractions)), go back and review ??

CDI Specialist Providers IT Analysts CDI Specialist Providers IT Analysts Documet terminology and clinical definitions Complete research and find clinical criteria and clinical definitions Determine how to diagnose with more detailed terminology Determine common diagnoses Document former vs recommended terminology Not Approved Perform updates as needed Publish template updates to EHR for Provider use Determine appropriate templates to build level of specificity Approved Publish clinical criteria and clinical definitions Perform updates as needed Determine common diagnoses Document former vs recommended terminology Documet terminology and clinical definitions Complete research and find clinical criteria and clinical definitions Publish template updates to EHR for Provider use Not Approved Determine appropriate templates to build level of specificity Approved Publish clinical criteria and clinical definitions Determine how to diagnose with more detailed terminology Executive Leadership Executive Leadership

When: Decision to Use Clinical Pathways How long does the process take to have a clinical pathway implemented? >12 weeks Week 1 – 2: Requirements & Assessment Week 3 – 4: Review & Feedback Week 5 – 12: Gather consensus Beyond week 12: Reporting…

What: Clinical guideline hierarchy Clinical Guidance Clinical Pathways Clinical Criteria Clinical Definition Data set Freeform guidance Clinical Protocols Global Guideline Library Local Guideline Library Clinical Criteria Component Library Clinical Definition Component Library Global Terminology Library Out-of-scope In scope

Where: Access to Clinical Pathways/Guidelines Clinical Documentation data capture EHR System Components EHR System Clinical Data Repository Clinical Face Sheet Clinical Notes Care Plan Laboratory Lab Results Clinical Pathways, Clinical Guidelines

How: Clinical Definition Components Long Name Clinical Criteria/Indicator Description/Rationale Indicator types (not coded) Indicator values (not coded) Developer/Approver Clinical Reference Terminology System(s) Definition Provenance data elements Coded values (specific) E.g. date, place Clinical Classification System References (incl others from definition template) Free-text values (for snippets) How to render multi-select smartlist, etc Specialty (e.g. Cardiology) Template type Form of treatment Section of Template Disease Example/Case study Original diagnosis code

Outstanding Questions In what formats would the results from CDI content standardization tool need to be to be imported by EHR system? How do the clinical definitions get implemented in EHR? What are data requirements Clinical criteria Clinical definitions Any other important related components?