Streamlining/Transforming Documentation Streamlining/Transforming Documentation* & Admission History & Current State Screening Task Force** *David Boyd, DNP, RN, CNS, RN-BC Regional Director, Nursing Informatics * KP NCAL *Shannon Hulett, DNP, RN, CNL Manager, Nursing Technology * Gundersen Health System & **Jane Englebright, PhD, RN, FAAN Senior Vice President, Chief Nurse Executive * HCA Clinical Services Group

Purpose Explore ways to decrease the documentation burden and serve up information in the electronic health record at the right time in the workflow to support evidence-based and personalized care. Elevate purpose-driven, role-based, patient-centric, evidence informed documentation transformation to capture nurse observations and interventions and drive purposeful secondary-use and precision nursing. Transformation supports enhanced data utilization to drive and measure improvement in patient outcomes and illuminate nursing’s value and contribution in healthcare.

Precision Nursing Patient centered, highly reliable, evidence based and personalized nursing practice across the continuum of care that supports: Quality Outcomes Safety Decreased Costs Efficiency Nurse Satisfaction WG 10 – 2015-2016

Purpose The Admission History Cross-WG Task Force is charged with defining a model for Nursing Admission History for the adult patient admitted to an acute care facility for medical/surgical care. Focused on the ‘what’, future work will focus on the ‘how’. The outputs will provide the foundation for continued work in defining Nursing Admission History for other patient populations and care settings.** **The Task Force is composed of volunteers and representatives from five NKBDS Work Groups: Transforming Documentation, Care Coordination, Social Determinants of Health, Clinical Data Analytics and Encoding/Modeling.

Active Workgroup Members David Boyd Shannon Hulett Sarah Michel Jane Englebright Bonnie Adrian Rebecca Kohler Mary Hook Susie Hull Tess Settergren Susan Grossman Tsedey Melaku Maxy Mathew Avaretta Davis Deborah Ariosto Kay Lytle Darinda Sutton Patty Sengstack

Meeting Dates July 26, 2018 September 27, 2018 January 31, 2019 March 28, 2019 May 23, 2019 4th Thursday of the Month - (11-12 P, 1-2 C, 2-3 E)

Accomplishments Transforming Documentation WG • Continued WG meetings • Ongoing participation in ANA/ONC Documentation Burden Task Force • Developed draft Documentation Burden Domain Framework publication under the leadership of Dr. Patty Sengstack • Supported HIMSS Nursing Informatics Committee discussion of documentation burden

Accomplishments Admission Taskforce • Organized team, developed a draft Charter and Guiding Principles (Charter reviewed and approved by NKBDS Steering Committee) • Initiated document aligning Admission History elements with ANA Scope and Standards of Practice • Agreed to meeting cadence required for June 2019 presentation of conference outputs • Established pre-conference breakout track for Big Data 2019

Presentations 2018 Epic User Group Meeting: David Boyd & Kay Lytle * NKDBS Update 2019 Epic Expert Group Meeting: Shannon Hulett, Bonnie Adrian (presenters) – Nursing Documentation Collaborative June 2019 Big Data Pre-conference – Standardizing the Nursing Admission History and Screening to Reduce Documentation Burden 2019 Summer Institute in Nursing Informatics, Shannon Hulett - EHR Remodeling:  Gundersen Health System’s Nursing Journey - Work Group Facilitation: What is needed in a burden reduction toolkit to move forward?

Next Steps Continue WG meetings - update participant roster Explore lateral integration across functional expert domains/teams – ANA/ONC, HIMSS NI, Vendors, etc. Implement spread plan developed in Pre-Conference Track – publish, present, repeat Determine cross-WG team linkages

Questions? David Boyd, DNP, RN, CNS, RN-BC Regional Director, Nursing Informatics Kaiser Permanente, Northern California david.l.boyd@kp.org Shannon Hulett, DNP, RN, CNL Manager, Nursing Technology Gundersen Health System slhulett@gundersenhealth.org