1. 1 Using HIT to Improve Outcomes for Elderly Nursing Home Residents Wednesday, Sept 26, 2007; 10 – 11:30am Susan D. Horn, PhD Institute for Clinical Outcomes Research 699 E. South Temple, Suite 100 Salt Lake City, Utah 84102-1282 Salt Lake City, Utah 84102-1282 801-466-5595 (T) 801-466-6685 (F) shorn@isisicor.com Using Clinical Decision Support Systems to Measure Quality of Care for Special Populations

2. 2 Research Based Foundation National Pressure Ulcer Long-term Care Study (NPULS), 1996-1997 6 long-term care provider organizations 6 long-term care provider organizations 109 facilities; 2,490 residents 109 facilities; 2,490 residents 1,343 residents with pressure ulcer; 1,147 at risk 1,343 residents with pressure ulcer; 1,147 at risk 70% female; Average age = 79.8 years 70% female; Average age = 79.8 years Funded by Ross Products Division, Abbott Laboratories

3. 3 Long Term Care CPI Results Outcome: Develop Pressure Ulcer General Assessment Assessment IncontinenceInterventions Nutrition NutritionInterventionsStaffingInterventions + Age  85 + Male + Severity of Illness + History of PU + Dependency in >= 7 ADLs >= 7 ADLs + Diabetes + History of tobacco use + Dehydration + Weight loss + Mechanical devices for the containment of urine (catheters) - Disposable briefs - Toileting Program - RN hours per resident day >=0.5 - CNA hours per resident day >= 2.25 Medications - SSRI + Antipsychotic Horn et al, J. Amer Geriatr Soc March 2004; 52(3):359-367 - Fluid Order - Nutritional Supplements standard medical standard medical - Enteral Supplements disease-specific disease-specific high calorie/high high calorie/high protein protein

4. 4 1.CNA Daily Documentation and Workflow » Standardized data in documentation flow sheets; include best practice elements » Improved communication with clinical team (RN, CNA, MDS, Dietary) 2.Wound Nurse PrU Tracking Documentation » Standardized data in PrU documentation (assessments and treatments) » Timely access to compiled information 3.Clinical Reports: Timely Information for Care Planning » Identify residents at risk for pressure ulcer development » Summarize information for clinical decision-making » Shorten response time between identification of resident need and intervention Scope of HIT

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7. 7 HIT Requirements Ease of use: practical for CNA staff (e.g., pen and paper solution or hand-helds)Ease of use: practical for CNA staff (e.g., pen and paper solution or hand-helds) Minimal training (good for turnover)Minimal training (good for turnover) Rapid staff adoption (no need to learn how to use a computer or alter clinical workflow)Rapid staff adoption (no need to learn how to use a computer or alter clinical workflow) Minimal impact to existing clinical workflowMinimal impact to existing clinical workflow CNAs and wound RN up and running in 2-3 monthsCNAs and wound RN up and running in 2-3 months Low costLow cost

8. 8 Digital PenDigital Pen » Thin and light device that writes like an ordinary pen » Includes camera that records pen strokes in pen memory that stores up to 200 pages » Records position and time 75 times a second; camera records pen strokes in pen memory » Used with digitized form, digital pen reads unique pattern of dots to interpret the data Docking StationDocking Station » Battery charging » Uploading data from memory to database via Internet Example technology #1 Digital Pen

9. 9 Example technology #2 Facility-developed Application Profile:  Facility programmers developed application: relational database  Hand-held devices for data input  CNA documentation of daily notes  Wound nurse documentation of PrU  Reports to monitor resident changes Project Requirements:  Incorporate standardized data elements into application  Behaviors  Skin observations  Develop AHRQ reports

10. 10 Example technology #3 Electronic Medical Record Profile:  Add CNA standardized documentation data elements into EMR  Add Wound RN standardized documentation data elements into EMR Project Requirements:  Incorporate standardized data elements into application  Behaviors  Skin observations  Develop AHRQ reports

11. 11 Decision Making Reports Documentation Completeness Report. Summary of CNA documentation completeness rates.Documentation Completeness Report. Summary of CNA documentation completeness rates. Nutrition Report. Displays average meal intake, resident diet, supplements, resident weight status (presence of weight gain/loss), last diet consult date, history of pressure ulcer indicator, and presence of pressure ulcer.Nutrition Report. Displays average meal intake, resident diet, supplements, resident weight status (presence of weight gain/loss), last diet consult date, history of pressure ulcer indicator, and presence of pressure ulcer. Behavior Report. Displays the total number of times a resident exhibits a behavior by shift.Behavior Report. Displays the total number of times a resident exhibits a behavior by shift. Priority Resident Report. Displays residents who are at risk for pressure ulcer development and high priority for staff focus.Priority Resident Report. Displays residents who are at risk for pressure ulcer development and high priority for staff focus.

12. 12 Nutrition SummaryNutrition Summary » Average meal intake for 4 weeks » Fluid intake for 4 weeks » Supplement use » Dietary consult date » Weight change since last week » Existing pressure ulcer » History of resolved ulcer Weight Summary » Weight 180 days prior » Weight 30 days prior » Weight for each of past 4 weeks » Weight change since last week » 5-10% weight loss past 30 days » >10% weight loss past 180 days » Psychiatric medications received Example: Nutrition Report Stratified by Risk Provide ‘BIG picture’ over time, not just snapshot of one shift or one day

13. 13 Nutrition Report What are uses of the Nutrition Report? Identify which meals are not being eatenIdentify which meals are not being eaten Promote use of nutritional supplementsPromote use of nutritional supplements Identify need for consistent weightsIdentify need for consistent weights

14. 14 Decreased meal intakeDecreased meal intake Weight lossWeight loss Increased incontinence episodesIncreased incontinence episodes Increased behavior problemsIncreased behavior problems Existing red areas on skinExisting red areas on skin History of pressure ulcer in last 90 daysHistory of pressure ulcer in last 90 days Example: Priority Report Identifies residents at risk

15. 15 Results  Decrease Pressure Ulcer Development  Increase Adherence to Best Practices  Increase Staff Accountability and Satisfaction –Inclusion of front-line workers in QI efforts –Comprehensive documentation at point of care –Communication among care team improved  Reduce Inefficiencies –# documentation forms for CNAs –CNA time looking for documentation book –Time to compile reports for State Regulators and MDS –Time for Wound RN to summarize and report data  Improve State Survey Process  Establish a foundation for EHR

16. 16 Q4 03 – Q3 05% Change = - 33% Impact On Pressure Ulcer QMs Study Facilities Combined Source: CMS Nursing Home Compare; Facility QM data reports

17. 17 Pressure Ulcer Healing Analyze PrU assessment and treatment data to determine those practices that are associated with faster healing, controlling for resident and initial ulcer characteristics.Analyze PrU assessment and treatment data to determine those practices that are associated with faster healing, controlling for resident and initial ulcer characteristics. Implement findings in standardized wound assessment documentationImplement findings in standardized wound assessment documentation Combine tracking outcomes (development and healing of PrUs) and quality improvement (information to improve clinical decision-making)Combine tracking outcomes (development and healing of PrUs) and quality improvement (information to improve clinical decision-making)

18. 18 What is different about this approach? Integrates sustainable quality improvement into daily operations.Integrates sustainable quality improvement into daily operations. –Project activities are integrated into versus added on to daily work. Streamlines documentation with focus on critical data elements and information flow.Streamlines documentation with focus on critical data elements and information flow. Involves front-line staff.Involves front-line staff. –Establish multi-disciplinary design and implementation teams, including CNAs, nurses, dieticians, wound nurses, MDS nurses, social services, and restorative care.

19. 19 What is different about this approach? Translates documentation into care planning information.Translates documentation into care planning information. –Migrate from a paper/form document environment toward a data culture environment. Translates data into multi-disciplinary clinical reports.Translates data into multi-disciplinary clinical reports. –Migrate from a culture of accessing quarterly reports for retrospective analysis to using weekly clinical reports by multi-disciplinary team for timely resident care planning.

20. 20 Clinical Strategy Early identification of high risk residentsEarly identification of high risk residents Monitor changes in PrUs, nutrition, incontinence, and behaviorsMonitor changes in PrUs, nutrition, incontinence, and behaviors Integrate with guidelines and evidence- based practicesIntegrate with guidelines and evidence- based practices

21. 21 QI Organization Strategy Leverage CNA daily and Wound RN weekly documentation to provide data for reportsLeverage CNA daily and Wound RN weekly documentation to provide data for reports Improve accuracy of CNA observationsImprove accuracy of CNA observations Electronic checking of data now possibleElectronic checking of data now possible Integrate timely information into day to day practiceIntegrate timely information into day to day practice » Easy access to summarized information » View resident trends and multiple risks Multidisciplinary inputMultidisciplinary input