Denver Health nurses gain big efficiencies redesigning Epic EHR workflow
Denver Health physicians had reported that there were multiple locations in their electronic health record where different types of assessments could be documented, and that it was difficult to locate specific patient data due to inconsistencies.
This was due to the fragmented work done to define documentation early in the Colorado healthcare system’s EHR journey. There was a lack of standardization in the approach to design work within the case and the general practice was to give frontline clinical staff what they needed to provide appropriate care to the patient.
“Nursing had low compliance with real-time documentation,” says Renee J. Starr, RN-BC, nurse informatics specialist. “This can be partly attributed to the feeling that there were multiple venues for mapping, in addition to the belief that documenting certain items was not ‘feasible’ or seemed to be for the sake of documenting rather than caring for influence the patient.
“Nursing also regularly encountered warnings that were informational rather than actionable,” she continued. “Medication administration alerts that were too close together were configured with ranges that did not align with organizational guidelines or best practices for medication administration.”
Alerts with recommendations to notify providers who were not respecting usual workflows often caused interruptions that led to frustration and irritability rather than improving patient care, she added.
The proposal to streamline EHR documentation included focusing on documentation areas commonly used by nursing.
“In intensive care units, head-to-bottom assessments are documented at least once per shift and every four hours,” says Amy Fielding, RN-BC, RN informatics specialist. “The goal to optimize body system assessments included defining the most efficient way to document (mapping by exception) and creating standardized definitions for each body system.
“While each of these efforts was individually valuable in reducing the amount of time nurses spent documenting their work, these initiatives were also useful in facilitating a campaign to encourage timely documentation.”
Renee J. Starr, RN-BC, Denver Health
“In addition to standardizing assessment from head to toe, we also focused on documenting nursing interventions,” she continued. “The nurse performs a wide variety of interventions during the shift that are documented (walking, repositioning, toileting, bathing, etc.). The biggest efficiency gain with this assessment was evaluating duplication and redundancy.”
The hypothesis was that removing flowcharts and redundant values would be possible without compromising the quality of the documentation.
“The third area of documentation addressed was the assessment of nurse admissions for all admitted inpatients,” she noted. “The examination took a long time and the nurse had to scroll to see all the questions that needed to be answered.
“The goal of this optimization was to include only useful questions,” she continued. “Paragraphs of read-only information – for example, vaccine history – while still important, should be moved to other areas in the EHR so the nurse can focus on questions that need to be answered immediately.”
Finally, we looked at optimizing alerts. Although the total amount of documentation time required to resolve a best practice alert is small, the number of alerts focused on nursing is significant.
“The aim was to ensure that warnings are clinically relevant and actionable,” Fielding explains. “Each time an interrupting alert is displayed, the nurse should shift the focus of the current task to address the alert.
“Bedside nursing is already a task-saturated and overstimulated environment,” she said. “The goal is to keep the nurse focused on their patients and only interrupt their workflow when necessary.”
There are a wide variety of electronic health record vendors on the market today, including Allscripts, athenahealth, Cerner, eClinicalWorks, Epic, Greenway Health, Medicomp Systems, Meditech, Medsphere Systems, and NextGen Healthcare.
MEETING THE CHALLENGE
In collaboration with a group of primary care physicians, nursing informatics developed a working group to improve nursing documentation and workflows. The group developed a list of principles to guide the team’s discussions and set priorities.
“The team wanted to record the care the patient received, and requested that the majority of documentation efforts focus on demonstrating individualized care, rather than documenting the ‘normal characteristics’ of each patient,” Starr explained. “The options available for documentation should encourage the nurse, at all levels of experience, to provide safe and quality care.
“Nursing at the bedside is already a task-saturated and overstimulated environment. The goal is to keep the nurse focused on their patients and only interrupt their workflow when necessary.”
Amy Fielding, RN-BC, Denver Health
“We must comply with legal requirements while focusing on the usability and efficiency of the work,” she continued. “Another goal was to look at processes across the organization and standardize documentation practices as much as possible while making the information accessible across the continuum of care.”
By working with the health system’s Epic analysts to review usage data for individual flowchart rows and values within those rows, staff were able to determine whether a particular flowchart row or options within the row were being used consistently to document care. This approach allowed staff to inform the team’s decisions and drive current usage without disrupting workflows.
“For efficiency, Informatics has worked with our Epic partners to add tasks or alerts, including in-line documentation in the Epic Brain activity and best practice alerts,” said Starr. “This reduced disruptions and meant we didn’t have to move to another location for documentation.
“While each of these efforts was individually valuable in reducing the amount of time nurses spent documenting their work, these initiatives were also useful in facilitating a campaign to encourage timely documentation,” she added.
The meticulous analysis of each individual flowchart and its associated values, while tedious, was rewarding for the nurses.
“We have removed 28 flowchart rows and 123 flowchart values from the intervention portion of the EHR,” Fielding reported. “From the admission intake form, 31 flowcharts and 80 flowchart values have been moved or eliminated. By reducing the number of flowcharts and their contents, we have reduced the time nurses have to spend on documentation and have achieved an improvement of almost 10 across the house % seen.
“This is on average more than 10 minutes faster for documentation,” she continued. “In addition to a decrease in time spent in the EHR, we also saw a 9.4% increase in timely documentation (documentation within 60 minutes of the assessment/intervention) from nursing (62.7% in October 2022 to 72.3% in May 2023). “
Reviewing each nurse-focused best practice alert was found to yield efficiency gains for the nurse.
“Over the course of two years, the number of best practice alerts for nursing increased from over 2.1 million (in the second quarter of 2021) to 255,000 (in the second quarter of 2023), a decrease of 86%,” reported she. “Additionally, the percentage of time nurses took a discrete action within the best practice alert increased by 18% (8% in Q4 2022 to 26% in Q2 2023).”
ADVICE FOR OTHERS
“Our advice includes engaging nurses with varying levels of experience and a wide range of specialties,” Fielding said. “It was critical that end users could identify documentation pain points within the EHR. This helped participants gain a sense of ownership in the process and ensured that nurses at the bedside were heard by the IT department.
“This process can then be used to generate a list of areas to be addressed and establish priorities based on feasibility and available resources,” she continued. “Then, work with your super users and leadership to create clear rules about when to keep a flowchart or when to remove it.”
Then the fun begins, she said.
“Determine which flowchart rows and values can be deleted,” she explained. “Make sure you quantify the number of deletions so you can share the final results with nursing. Additionally, consider the reports or tools needed to illustrate the documentation improvements.”
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