Journal of Interprofessional Care
ISSN: 1356-1820 (Print) 1469-9567 (Online) Journal homepage: http://www.tandfonline.com/loi/ijic20
Implementation of an electronic health records system within an interprofessional model of care Beth Elias, Marlena Barginere, Phillip A. Berry & Cynthia S. Selleck To cite this article: Beth Elias, Marlena Barginere, Phillip A. Berry & Cynthia S. Selleck (2015): Implementation of an electronic health records system within an interprofessional model of care, Journal of Interprofessional Care, DOI: 10.3109/13561820.2015.1021001 To link to this article: http://dx.doi.org/10.3109/13561820.2015.1021001
Published online: 08 May 2015.
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Date: 05 November 2015, At: 20:08
http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, Early Online: 1–4 ! 2015 Informa UK Ltd. DOI: 10.3109/13561820.2015.1021001
ORIGINAL ARTICLE
Implementation of an electronic health records system within an interprofessional model of care Beth Elias1, Marlena Barginere2, Phillip A. Berry3 and Cynthia S. Selleck4
Downloaded by [University of California, San Diego] at 20:08 05 November 2015
1
School of Nursing, Community Health, Outcomes and Systems, University of Alabama at Birmingham, Birmingham, AL, USA, 2Department of Medical Nursing, University of Alabama at Birmingham, Birmingham, AL, USA, 3Graduate Medical Education Hospital, University of Alabama at Birmingham, Birmingham, AL, USA, and 4Department of Family/Child Health and Caregiving, School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA Abstract
Keywords
Implementation of electronic health records (EHR) systems is challenging even in traditional healthcare settings, where administrative and clinical roles and responsibilities are clearly defined. However, even in these traditional settings the conflicting needs of stakeholders can trigger hierarchical decision-making processes that reflect the traditional power structures in healthcare today. These traditional processes are not structured to allow for incorporation of new patient-care models such as patient-centered care and interprofessional teams. New processes for EHR implementation and evaluation will be required as healthcare shifts to a patient-centered model that includes patients, families, multiple agencies, and interprofessional teams in short- and long-term clinical decision-making. This new model will be enabled by healthcare information technology and defined by information flow, workflow, and communication needs. We describe a model in development for the configuration and implementation of an EHR system in an interprofessional, interagency, free-clinic setting. The model uses a formative evaluation process that is rooted in usability to configure the EHR to fully support the needs of the variety of providers working as an interprofessional team. For this model to succeed, it must include informaticists as equal and essential members of the healthcare team.
Electronic health record, healthcare informatics, healthcare team, interprofessional care, interprofessional healthcare team, interprofessional practice
Introduction Implementation, including configuration, of an electronic health record (EHR) system in an interprofessional team setting where the model of patient care is evolving is especially challenging (Cresswell, Bates, & Sheikh, 2013). Many vendor-provided EHR systems have limited ability to be customized to provide a better fit between clinic workflow and EHR functionality though most do have configuration that must be completed before use. Typically configuration options include population of dropdown menus to capture patient history, the addition of clinic appropriate International Classification of Diseases (ICD) and current procedural terminology (CPT) codes to document orders and care, the definition of scheduling resources, and population of a drug formulary. As noted by Collins, Bavuso, Zuccotti, and Rocha (2013), ‘‘Site-specific content configuration of vendorbased’’ EHR is critical to effective use of EHR to manage patient care and share information among the patient care team (Collins, Bavuso, Zuccotti & Rocha, 2013). The authors also note the importance of thinking of EHR configuration in terms of knowledge management models, which allow for consideration of all those involved in patient care. Correspondence: Beth Elias, School of Nursing, Community Health, Outcomes and Systems, University of Alabama at Birmingham, 1720 2nd Ave. S., Birmingham, AL 35294, USA. E-mail: [email protected]
History Received 18 April 2014 Revised 4 November 2014 Accepted 16 February 2015 Published online 8 May 2015
In the interprofessional team model the patient moves through a trajectory of care, seeing different team members at each visit, depending on his or her current needs. For example, a patient with hypertension may return to the clinic a week after initiation of an anti-hypertensive medication. At the return visit, the patient is seen by a provider (physician or nurse practitioner) for chronic disease management, a dietitian for a nutrition consultation, and the dispensary personnel for instructions regarding medication adjustments. Data gathered from each provider must flow seamlessly to the next provider, and at the completion of the visit a summary must be compiled in a manner that can be efficiently referenced in a subsequent patient encounter. With this linear patient-care path, from one member of the interprofessonal team to the another, timely communication among the team members is crucial for effective and efficient functioning of the clinic and to patient outcomes (Macnaughton, 2013). Morning huddles, during which providers gather to review the previous care of the patients who will be having appointments that day, can set the foundation for the information sharing that will occur during the visit. Huddles can be described as interprofessional briefing sessions, where all providers gather to review and plan care for the patients they will see during the course of the day. Huddles provide not only an opportunity for more coordinated and collaborative patient centered care, they also build relationships among members of the interprofessional team as views and insights are shared.
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After the huddle, the flow of information throughout a patient visit must be reflected in configuration options for the EHR, which will include not only primary ICD codes but also V codes, which arguably, capture more nursing-related patient care and patient status information than disease diagnoses. In a patient-care model that includes nursing, psychiatric care and registered dietitians, configuration options must be designed, for example, for Exam Notes templates that allow capture of the information needed by these professionals, as well as information they need to share with the rest of the care team. Social cognitive theory (Bandura, 2001) and diffusion of innovation theory (Rogers, 2003), as guides for implementation, allow the development of processes and evaluation models that can evolve as the interprofessional team model and culture of care emerges. Social cognitive theory provides an understanding of the independent and interdependent nature of the effort that we feel is a significant contributor to the development of the interprofessional model. Diffusion theory provides a framework for the successful adoption of change, for both the interprofessional model and EHR implementation, by the care team. Implementation and configuration therefore must be based on information flow and workflow rather than the traditional hierarchal physician-led model to support timely access to patient information, improved clinic efficiency, and optimal patient outcomes. Following recommendations by Weir (2013), evaluation is initially formative with respect to integrate continual feedback into implementation and configuration decisions (Weir, 2013). After the initial implementation is complete, the evaluation moves to a summative model to allow for outcome and impact assessment. However, a formative component will be retained long term to allow the EHR to evolve as the interprofessional patient care model evolves and as information flow and workflow change. Change management models are then defined, which help to structure the evolution of the EHR and support optimal patient outcomes with efficient information flow and workflow. This study examines the challenges of implementing and evaluating an EHR for one particular case of an interprofessional collaborative practice model (ICPM) of care in an urban south–central region of the United States. Challenges include: decision-making regarding configuration with interprofessional stakeholders, including advanced practice nurses, educators, physicians, a dietitian, mental health providers, clerical staff, and dispensary personnel; and ensuring timely information flow as a patient moves through scheduled appointments with multiple team members in 1 d. Innovations include the collaboration of an academic medical center and multiple schools of health professions along with a local ministry, implementation of an EHR in a community-based free clinic, and an ICPM, which includes informaticists as equal members of the healthcare team.
Background The typical decision-making model in healthcare organizations is hierarchical, executive-led, and often focused on the physician as the leader of patient care (Healthcare Information Systems Society, 2013). This model extends to decisions about healthcare information technology (HIT) including EHRs systems. These decisions include not only what systems are purchased, but also the purposes the systems will serve. In a 2013 survey of healthcare executives, respondents reported that two primary foci for clinical information technology in the coming year would be physician tools and integrating systems for quality measures analysis. Less than 1% of respondents reported that systems whose purpose was ‘‘creating clinical documentation flow sheets was a primary clinical focus’’ (p. 8). Clinical documentation
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flowsheets capture patient data that repeats over time, such as vital signs, pain assessments, and intake and output. Flowsheets are commonly used by nurses to document care, assess patient status and determine patient care plans. Interestingly, 36% of survey respondents reported having a Chief Medical Information Officer as a member of their executive team while only 7% reported having a Chief Nursing Information Officer. From this report we can infer that nurses, the largest group of HIT users, are not well represented in the decisionmaking process about HIT tools reducing the chance of successful implementation (Spetz, Burgess, & Phibbs, 2012). Although little is currently known about nurses’ attitudes towards HIT, it has been shown that including different stakeholders in decisionmaking increases the chance for successful implementations (Cresswell et al., 2013). Changes are developing in healthcare as we move to a patientcentered model of care. In its 2010 report The Future of Nursing, the Institute of Medicine emphasized the importance of a multidisciplinary healthcare team as part of this change, with HIT as a means to support the resulting complex team and patient interactions (Institute of Medicine, 2011). Leventhal, Taliaferro, Wong, Hughes, and Mun (2012) have also suggested that the patient-centered care model should be a driver of HIT redesign and implementation, so that the tools can more effectively support providers and patients. The authors note that moving to the patient-centered care model must be done in tandem with HIT changes for the benefit of both to be fully realized. Who’s in charge when everyone is in charge? With the evolving interprofessional team model, it can seem that no individual or centralized group is authorized to make decisions, resolve issues, and guide work. This sense of fluid leadership impacts EHR configuration and implementation processes, which have been based on the traditional hierarchical model. Under this new model, identifying and prioritizing the needs of primary stakeholders become more complex. Managing conflicting opinions on issues, such as the population of dropdown lists, component configuration, and implementation, also becomes more complex as roles are not as clearly defined and power structures are fluid (Macnaughton, Chreim, & Bourgeault, 2013). Workflow and information flow as guides The importance of including informaticians as members of the healthcare team is demonstrated by several recent studies. Waldman and Terzic (2013), for example, argue that advances in technology are creating large amounts of patient data from different areas (genomics, clinical care) and are triggering change in healthcare, among other fields. The authors note that it is now the information itself that needs to set the hierarchical structure that guides us and that the time to define the hierarchal structure is now. The authors further suggest that by using information technology, we can completely realize the potential of these large datasets. Koenig, Maguen, Daley, Cohen, and Seal (2013) discuss the importance of information flow in a multidisciplinary clinic. In this study, the authors describe communication processes between providers as a means for balancing efficiency and collaborative patient-centered care. Information continuity is cited as a particularly important collaborative feature and information technology as a particularly efficient means for achieving it. Others who have examined continuity of care, as a contributor to quality care, have also suggested that both information and provider relationships can support continuity and improve quality, particularly for complex patients (Patterson et al., 2013).
DOI: 10.3109/13561820.2015.1021001
The work of these authors highlights the need to include informaticians as members of the healthcare team rather than viewing them as infrastructure only. To away move from the usual practice keeping of informatics professionals separate from the patient-care setting, we must begin to integrate them more directly and allow them to provide a unifying framework among providers. Information technology tools such as EHRs can become communication channels as well as information channels in support of workflow. As equal and present members in interprofessional patient care, informatics specialists and healthcare practitioners can work together to develop this new model of patient care.
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The interprofessional interagency free clinic This study examines one particular case of an interprofessional model of care in a south–central U.S. city and its surrounding rural areas. The region suffers from a lack of healthcare services for those who are indigent and economically disadvantaged (http://hpsafind.hrsa.gov/HPSASearch.aspx). In 2012 with the support of the health resources services administration (HRSA), a school of nursing nurse-led free clinic that had operated in partnership with a local urban ministry one morning a week, was expanded to two 6-h days per week with care provided by physicians, advanced practice nurses, a dietitian, a social worker, an optometrist, dispensary personnel, and registered nurses. The purpose of the clinic was to provide care for underserved and indigent patients with no insurance or other means of accessing healthcare. More recently, a third day of patient care each week was added with the financial support of a large academic medical center in the nearby urban area. This third day has been primarily scheduled with visits for indigent patients recently discharged from the collaborating medical center following admissions caused or complicated by uncontrolled diabetes. The medical center justified its investment in the clinic with the expectation that providing diabetes management to this patient population would reduce readmissions and thus costs. The result is a clinic that operates not only within an interprofessional model of patient care, but also within a complex three-agency relationship. As part of this effort, the decision was made to implement an EHR system to take the place of the paper charts previously used at the free clinic. Decision-making around the EHR configuration and implementation was been made even more complex by the interagency nature of the clinic, which had no clearly defined hierarchy or administrative processes in place. Moving forward with the EHR thus required the development of a novel process. It was agreed that a process that was evaluative, formative, and rooted in usability to support the needs of the providers would be the most successful. It was also believed that the process needed to be moved forward by informatics professionals, including informatics nurse specialists (INS). Using evaluation frameworks such as usability in a formative manner has been suggested as an effective way to incorporate providers’ workflow into implementation of information technology (Yuan, Finley, Long, Mills, & Johnson, 2013). With a usability framework, the focus can be on provider workflow and their information needs at different points in the workflow. Additionally, the focus can be on the flow of information itself as a patient moves through sequential episodes of care and chronic condition management over time. Within this framework, the EHR must enable the provider to accomplish the task at hand. As noted by Staggers, Xiao, and Chapman (2013), usability is about more than features on an interface, it is a contributor to productivity and efficiency as well as patient safety).
Interprofessional EHR implementation
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Informatics practitioners as interprofessional team members INSs are well positioned to serve as members of the interprofessional healthcare team because they are hybrids by design. Through their understanding of the clinical environment, patient care, and HIT INSs understand both the workflow and information flow as well as evaluation frameworks. Therefore, the first phase in the configuration and implementation of the clinic EHR included INSs using the guide of a formative usability evaluation framework. They followed the procedure below: Attended morning interprofessional huddles during which providers discussed patient care for the coming day’s visits, Interviewed providers about their information needs before, during, and after a patient visit, Shadowed providers to gain an understanding of workflow and to confirm information needs, Shadowed patients to gain an understanding of information flow and interactions among providers, Solicited the academic medical center and ministry for information about existing configurations for EHRs, and Identified providers who were willing to serve as early adopters and usability evaluators. Once workflow and information flow were clearly defined, as illustrated in Figure 1, the INSs iteratively moved through the first phase of the formative usability evaluation to develop initial configurations for EHR form drop-down menus and coding options. The INSs then shadowed patients and providers to determine how well these configurations supported the providers in accomplishing the tasks at hand. Providers were engaged in this evaluation so that decision-making around configuration would be grassroots in nature and reflect provider experiences and observations of what worked and what did not. The configuration decisions were then brought to a team of representatives from each agency for review before implementation. Decision-making about the rollout of the EHR was also grassroots in nature. It used the providers’ information needs and information flow as a guide, starting with the scheduling module for patient appointments in support of the morning huddle, as shown in Figure 2. Simultaneously, ministry volunteers identified current patient paper charts and began a process of entering patient data into the EHR from current time back through previous visits. The INS regularly worked with front-desk staff, volunteers and early adopter providers on usability issues in a spiral development model. The second step for roll-out involved engaging the triage nurses, who initially see patients ahead of the provider visit, and having them document vital signs and patient history data in the EHR. The providers’ workflow indicated that this step is essential before engaging all providers in use of the EHR because of their need for this information prior to each visit. An INS who is present in clinic as part of the interprofessional team, engaged with the triage nurses to move the rollout forward. Attention to
Figure 1. Information flow and work flow.
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Declaration of interest Dr. Frank, University of Alabama at Birmingham School of Nursing, is the Program Director for the HRSA grant that funded this work. The authors report no conflicts of interest. The authors were responsible for the writing and content of this article. This work is funded by a Health Resources and Services Administration Nurse Education, Practice, Quality and Retention (NEPQR) award (UD7HP25047).
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Figure 2. EMR and visit task support.
usability issues at this step was critical to ensure accurate and timely EHR documentation of the triage process. The third step, again indicated by the information and workflow, was to engage providers in the development of Notes Templates. In this area, all types of providers were interviewed about their needs, given mock templates to review, and provided the opportunity to use draft templates in the EHR both with the INS present and on their own. Currently notes templates are used by the dietitian, psychiatric and mental health nurse practitioner, and an endocrinologist. Additional notes templates are being developed for other specialty physicians and advanced practice nurses. Next steps include bringing providers into EHR use during patient visits, configuring a dispensary module to allow for electronic prescribing and dispensing in house, and designing and transitioning to a blended usability evaluation framework, which will include a change management plan. Summative and formative components will be included in the longer-term evaluation model to ensure effective and efficient use of the EHR and to implement changes that may be necessary to the EHR as the interprofessional patient care model evolves.
Concluding comments Lessons learned to date include the importance of developing new models of decision-making around the use of HIT in a patientcentered, interprofessional care model. Putting aside traditional models can result in confusion and some anxiety. However, by focusing on being patient-centered, we can develop models for HIT implementation and evaluation that are rooted in information flow in continual support of provider workflow. We can also use informatics applications, such as EHRs, as another communication channel for the interprofessional team. In addition, by including informatics professionals such as INS as full members of the interprofessional team, we can work to ensure that the decision-making remains grassroots, patient-focused and truly interprofessional.
Acknowledgements Editorial assistance was provided by Jennifer S. Frank, PhD.
References Bandura, A. (2001). Social cognitive theory: An agentic perspective. Annual Review of Psychology, 52, 1. Collins, S.A., Bavuso, K., Zuccotti, G., & Rocha, R.A. (2013). Lessons learned for collaborative clinical content development. Appled Clinical Informatics, 4, 304–316. Cresswell, K.M., Bates, D.W., & Sheikh, A. (2013). Ten key considerations for the successful implementation and adoption of large-scale health information technology. Journal of the American Medical Informatics Association, 20, e9–e13. Healthcare Information Management Systems Society. (2013). 2013 HIMSS leadership survey senior IT executive results. Chicago, IL: Author. Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academy of Sciences Institute of Medicine. Koenig, C.J., Maguen, S., Daley, A., Cohen, G., & Seal, K.H. (2013). Passing the baton: A grounded practical theory of handoff communication between multidisciplinary providers in two Department of Veterans Affairs outpatient settings. Journal General Internal Medicine, 28, 41–50. Leventhal, T., Taliaferro, J.P., Wong, K., Hughes, C., & Mun, S. (2012). The patient-centered medical home and health information technology. Telemedicine Journal and e-Health, 18, 145–149. Macnaughton, K., Chreim, S., & Bourgeault, I.L. (2013). Role construction and boundaries in interprofessional primary health care teams: A qualitative study. BMC Health Services Research, 13, 486. Macnaughton, S.M. (2013). Implementing an interprofessional first-year teamwork project: Some key reflections. Journal of Interprofessional Care, 27, 420–421. Patterson, C., Arthur, H., Peachey, G., Vohra, J., Price, D., Pearson, D., & Mariani, R. (2013). Planning for interprofessional change in primary health care: Exploring the use of the Interprofessional Resource Centre. Advances in Medical Education Practice, 4, 117–125. Rogers, E.M. (2003). Diffusion of innovations (5th ed.). New York, NY: The Free Press. Spetz, J., Burgess, J.F., & Phibbs, C.S. (2012). What determines successful implementation of inpatient information technology systems? American Journal of Managed Care, 18, 157–162. Staggers, N., Xiao, Y., & Chapman, L. (2013). Debunking health IT usability myths. Applied Clinical Informatics, 4, 241–250. Waldman, S.A., & Terzic, A. (2013). Information hierarchies optimize patient-centered solutions. Clinical Pharmacology and Therapeutics, 93, 3–7. doi: 10.1038/clpt.2012.208. Weir, C. (2013). Program evaluation and research techniques. In R. Nelson & N. Staggers (Eds.), Health informatics an interprofessional approach (pp. 72–86). St. Louis, MO: Elsevier. Yuan, M.J., Finley, G.M., Long, J., Mills, C., & Johnson, R.K. (2013). Evaluation of user interface and workflow design of a bedside nursing clinical decision support system. Interactive Journal of Medical Research, 2, e4.
ISSN: 1356-1820 (Print) 1469-9567 (Online) Journal homepage: http://www.tandfonline.com/loi/ijic20
Implementation of an electronic health records system within an interprofessional model of care Beth Elias, Marlena Barginere, Phillip A. Berry & Cynthia S. Selleck To cite this article: Beth Elias, Marlena Barginere, Phillip A. Berry & Cynthia S. Selleck (2015): Implementation of an electronic health records system within an interprofessional model of care, Journal of Interprofessional Care, DOI: 10.3109/13561820.2015.1021001 To link to this article: http://dx.doi.org/10.3109/13561820.2015.1021001
Published online: 08 May 2015.
Submit your article to this journal
Article views: 97
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijic20 Download by: [University of California, San Diego]
Date: 05 November 2015, At: 20:08
http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, Early Online: 1–4 ! 2015 Informa UK Ltd. DOI: 10.3109/13561820.2015.1021001
ORIGINAL ARTICLE
Implementation of an electronic health records system within an interprofessional model of care Beth Elias1, Marlena Barginere2, Phillip A. Berry3 and Cynthia S. Selleck4
Downloaded by [University of California, San Diego] at 20:08 05 November 2015
1
School of Nursing, Community Health, Outcomes and Systems, University of Alabama at Birmingham, Birmingham, AL, USA, 2Department of Medical Nursing, University of Alabama at Birmingham, Birmingham, AL, USA, 3Graduate Medical Education Hospital, University of Alabama at Birmingham, Birmingham, AL, USA, and 4Department of Family/Child Health and Caregiving, School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA Abstract
Keywords
Implementation of electronic health records (EHR) systems is challenging even in traditional healthcare settings, where administrative and clinical roles and responsibilities are clearly defined. However, even in these traditional settings the conflicting needs of stakeholders can trigger hierarchical decision-making processes that reflect the traditional power structures in healthcare today. These traditional processes are not structured to allow for incorporation of new patient-care models such as patient-centered care and interprofessional teams. New processes for EHR implementation and evaluation will be required as healthcare shifts to a patient-centered model that includes patients, families, multiple agencies, and interprofessional teams in short- and long-term clinical decision-making. This new model will be enabled by healthcare information technology and defined by information flow, workflow, and communication needs. We describe a model in development for the configuration and implementation of an EHR system in an interprofessional, interagency, free-clinic setting. The model uses a formative evaluation process that is rooted in usability to configure the EHR to fully support the needs of the variety of providers working as an interprofessional team. For this model to succeed, it must include informaticists as equal and essential members of the healthcare team.
Electronic health record, healthcare informatics, healthcare team, interprofessional care, interprofessional healthcare team, interprofessional practice
Introduction Implementation, including configuration, of an electronic health record (EHR) system in an interprofessional team setting where the model of patient care is evolving is especially challenging (Cresswell, Bates, & Sheikh, 2013). Many vendor-provided EHR systems have limited ability to be customized to provide a better fit between clinic workflow and EHR functionality though most do have configuration that must be completed before use. Typically configuration options include population of dropdown menus to capture patient history, the addition of clinic appropriate International Classification of Diseases (ICD) and current procedural terminology (CPT) codes to document orders and care, the definition of scheduling resources, and population of a drug formulary. As noted by Collins, Bavuso, Zuccotti, and Rocha (2013), ‘‘Site-specific content configuration of vendorbased’’ EHR is critical to effective use of EHR to manage patient care and share information among the patient care team (Collins, Bavuso, Zuccotti & Rocha, 2013). The authors also note the importance of thinking of EHR configuration in terms of knowledge management models, which allow for consideration of all those involved in patient care. Correspondence: Beth Elias, School of Nursing, Community Health, Outcomes and Systems, University of Alabama at Birmingham, 1720 2nd Ave. S., Birmingham, AL 35294, USA. E-mail: [email protected]
History Received 18 April 2014 Revised 4 November 2014 Accepted 16 February 2015 Published online 8 May 2015
In the interprofessional team model the patient moves through a trajectory of care, seeing different team members at each visit, depending on his or her current needs. For example, a patient with hypertension may return to the clinic a week after initiation of an anti-hypertensive medication. At the return visit, the patient is seen by a provider (physician or nurse practitioner) for chronic disease management, a dietitian for a nutrition consultation, and the dispensary personnel for instructions regarding medication adjustments. Data gathered from each provider must flow seamlessly to the next provider, and at the completion of the visit a summary must be compiled in a manner that can be efficiently referenced in a subsequent patient encounter. With this linear patient-care path, from one member of the interprofessonal team to the another, timely communication among the team members is crucial for effective and efficient functioning of the clinic and to patient outcomes (Macnaughton, 2013). Morning huddles, during which providers gather to review the previous care of the patients who will be having appointments that day, can set the foundation for the information sharing that will occur during the visit. Huddles can be described as interprofessional briefing sessions, where all providers gather to review and plan care for the patients they will see during the course of the day. Huddles provide not only an opportunity for more coordinated and collaborative patient centered care, they also build relationships among members of the interprofessional team as views and insights are shared.
Downloaded by [University of California, San Diego] at 20:08 05 November 2015
2
B. Elias et al.
After the huddle, the flow of information throughout a patient visit must be reflected in configuration options for the EHR, which will include not only primary ICD codes but also V codes, which arguably, capture more nursing-related patient care and patient status information than disease diagnoses. In a patient-care model that includes nursing, psychiatric care and registered dietitians, configuration options must be designed, for example, for Exam Notes templates that allow capture of the information needed by these professionals, as well as information they need to share with the rest of the care team. Social cognitive theory (Bandura, 2001) and diffusion of innovation theory (Rogers, 2003), as guides for implementation, allow the development of processes and evaluation models that can evolve as the interprofessional team model and culture of care emerges. Social cognitive theory provides an understanding of the independent and interdependent nature of the effort that we feel is a significant contributor to the development of the interprofessional model. Diffusion theory provides a framework for the successful adoption of change, for both the interprofessional model and EHR implementation, by the care team. Implementation and configuration therefore must be based on information flow and workflow rather than the traditional hierarchal physician-led model to support timely access to patient information, improved clinic efficiency, and optimal patient outcomes. Following recommendations by Weir (2013), evaluation is initially formative with respect to integrate continual feedback into implementation and configuration decisions (Weir, 2013). After the initial implementation is complete, the evaluation moves to a summative model to allow for outcome and impact assessment. However, a formative component will be retained long term to allow the EHR to evolve as the interprofessional patient care model evolves and as information flow and workflow change. Change management models are then defined, which help to structure the evolution of the EHR and support optimal patient outcomes with efficient information flow and workflow. This study examines the challenges of implementing and evaluating an EHR for one particular case of an interprofessional collaborative practice model (ICPM) of care in an urban south–central region of the United States. Challenges include: decision-making regarding configuration with interprofessional stakeholders, including advanced practice nurses, educators, physicians, a dietitian, mental health providers, clerical staff, and dispensary personnel; and ensuring timely information flow as a patient moves through scheduled appointments with multiple team members in 1 d. Innovations include the collaboration of an academic medical center and multiple schools of health professions along with a local ministry, implementation of an EHR in a community-based free clinic, and an ICPM, which includes informaticists as equal members of the healthcare team.
Background The typical decision-making model in healthcare organizations is hierarchical, executive-led, and often focused on the physician as the leader of patient care (Healthcare Information Systems Society, 2013). This model extends to decisions about healthcare information technology (HIT) including EHRs systems. These decisions include not only what systems are purchased, but also the purposes the systems will serve. In a 2013 survey of healthcare executives, respondents reported that two primary foci for clinical information technology in the coming year would be physician tools and integrating systems for quality measures analysis. Less than 1% of respondents reported that systems whose purpose was ‘‘creating clinical documentation flow sheets was a primary clinical focus’’ (p. 8). Clinical documentation
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flowsheets capture patient data that repeats over time, such as vital signs, pain assessments, and intake and output. Flowsheets are commonly used by nurses to document care, assess patient status and determine patient care plans. Interestingly, 36% of survey respondents reported having a Chief Medical Information Officer as a member of their executive team while only 7% reported having a Chief Nursing Information Officer. From this report we can infer that nurses, the largest group of HIT users, are not well represented in the decisionmaking process about HIT tools reducing the chance of successful implementation (Spetz, Burgess, & Phibbs, 2012). Although little is currently known about nurses’ attitudes towards HIT, it has been shown that including different stakeholders in decisionmaking increases the chance for successful implementations (Cresswell et al., 2013). Changes are developing in healthcare as we move to a patientcentered model of care. In its 2010 report The Future of Nursing, the Institute of Medicine emphasized the importance of a multidisciplinary healthcare team as part of this change, with HIT as a means to support the resulting complex team and patient interactions (Institute of Medicine, 2011). Leventhal, Taliaferro, Wong, Hughes, and Mun (2012) have also suggested that the patient-centered care model should be a driver of HIT redesign and implementation, so that the tools can more effectively support providers and patients. The authors note that moving to the patient-centered care model must be done in tandem with HIT changes for the benefit of both to be fully realized. Who’s in charge when everyone is in charge? With the evolving interprofessional team model, it can seem that no individual or centralized group is authorized to make decisions, resolve issues, and guide work. This sense of fluid leadership impacts EHR configuration and implementation processes, which have been based on the traditional hierarchical model. Under this new model, identifying and prioritizing the needs of primary stakeholders become more complex. Managing conflicting opinions on issues, such as the population of dropdown lists, component configuration, and implementation, also becomes more complex as roles are not as clearly defined and power structures are fluid (Macnaughton, Chreim, & Bourgeault, 2013). Workflow and information flow as guides The importance of including informaticians as members of the healthcare team is demonstrated by several recent studies. Waldman and Terzic (2013), for example, argue that advances in technology are creating large amounts of patient data from different areas (genomics, clinical care) and are triggering change in healthcare, among other fields. The authors note that it is now the information itself that needs to set the hierarchical structure that guides us and that the time to define the hierarchal structure is now. The authors further suggest that by using information technology, we can completely realize the potential of these large datasets. Koenig, Maguen, Daley, Cohen, and Seal (2013) discuss the importance of information flow in a multidisciplinary clinic. In this study, the authors describe communication processes between providers as a means for balancing efficiency and collaborative patient-centered care. Information continuity is cited as a particularly important collaborative feature and information technology as a particularly efficient means for achieving it. Others who have examined continuity of care, as a contributor to quality care, have also suggested that both information and provider relationships can support continuity and improve quality, particularly for complex patients (Patterson et al., 2013).
DOI: 10.3109/13561820.2015.1021001
The work of these authors highlights the need to include informaticians as members of the healthcare team rather than viewing them as infrastructure only. To away move from the usual practice keeping of informatics professionals separate from the patient-care setting, we must begin to integrate them more directly and allow them to provide a unifying framework among providers. Information technology tools such as EHRs can become communication channels as well as information channels in support of workflow. As equal and present members in interprofessional patient care, informatics specialists and healthcare practitioners can work together to develop this new model of patient care.
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The interprofessional interagency free clinic This study examines one particular case of an interprofessional model of care in a south–central U.S. city and its surrounding rural areas. The region suffers from a lack of healthcare services for those who are indigent and economically disadvantaged (http://hpsafind.hrsa.gov/HPSASearch.aspx). In 2012 with the support of the health resources services administration (HRSA), a school of nursing nurse-led free clinic that had operated in partnership with a local urban ministry one morning a week, was expanded to two 6-h days per week with care provided by physicians, advanced practice nurses, a dietitian, a social worker, an optometrist, dispensary personnel, and registered nurses. The purpose of the clinic was to provide care for underserved and indigent patients with no insurance or other means of accessing healthcare. More recently, a third day of patient care each week was added with the financial support of a large academic medical center in the nearby urban area. This third day has been primarily scheduled with visits for indigent patients recently discharged from the collaborating medical center following admissions caused or complicated by uncontrolled diabetes. The medical center justified its investment in the clinic with the expectation that providing diabetes management to this patient population would reduce readmissions and thus costs. The result is a clinic that operates not only within an interprofessional model of patient care, but also within a complex three-agency relationship. As part of this effort, the decision was made to implement an EHR system to take the place of the paper charts previously used at the free clinic. Decision-making around the EHR configuration and implementation was been made even more complex by the interagency nature of the clinic, which had no clearly defined hierarchy or administrative processes in place. Moving forward with the EHR thus required the development of a novel process. It was agreed that a process that was evaluative, formative, and rooted in usability to support the needs of the providers would be the most successful. It was also believed that the process needed to be moved forward by informatics professionals, including informatics nurse specialists (INS). Using evaluation frameworks such as usability in a formative manner has been suggested as an effective way to incorporate providers’ workflow into implementation of information technology (Yuan, Finley, Long, Mills, & Johnson, 2013). With a usability framework, the focus can be on provider workflow and their information needs at different points in the workflow. Additionally, the focus can be on the flow of information itself as a patient moves through sequential episodes of care and chronic condition management over time. Within this framework, the EHR must enable the provider to accomplish the task at hand. As noted by Staggers, Xiao, and Chapman (2013), usability is about more than features on an interface, it is a contributor to productivity and efficiency as well as patient safety).
Interprofessional EHR implementation
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Informatics practitioners as interprofessional team members INSs are well positioned to serve as members of the interprofessional healthcare team because they are hybrids by design. Through their understanding of the clinical environment, patient care, and HIT INSs understand both the workflow and information flow as well as evaluation frameworks. Therefore, the first phase in the configuration and implementation of the clinic EHR included INSs using the guide of a formative usability evaluation framework. They followed the procedure below: Attended morning interprofessional huddles during which providers discussed patient care for the coming day’s visits, Interviewed providers about their information needs before, during, and after a patient visit, Shadowed providers to gain an understanding of workflow and to confirm information needs, Shadowed patients to gain an understanding of information flow and interactions among providers, Solicited the academic medical center and ministry for information about existing configurations for EHRs, and Identified providers who were willing to serve as early adopters and usability evaluators. Once workflow and information flow were clearly defined, as illustrated in Figure 1, the INSs iteratively moved through the first phase of the formative usability evaluation to develop initial configurations for EHR form drop-down menus and coding options. The INSs then shadowed patients and providers to determine how well these configurations supported the providers in accomplishing the tasks at hand. Providers were engaged in this evaluation so that decision-making around configuration would be grassroots in nature and reflect provider experiences and observations of what worked and what did not. The configuration decisions were then brought to a team of representatives from each agency for review before implementation. Decision-making about the rollout of the EHR was also grassroots in nature. It used the providers’ information needs and information flow as a guide, starting with the scheduling module for patient appointments in support of the morning huddle, as shown in Figure 2. Simultaneously, ministry volunteers identified current patient paper charts and began a process of entering patient data into the EHR from current time back through previous visits. The INS regularly worked with front-desk staff, volunteers and early adopter providers on usability issues in a spiral development model. The second step for roll-out involved engaging the triage nurses, who initially see patients ahead of the provider visit, and having them document vital signs and patient history data in the EHR. The providers’ workflow indicated that this step is essential before engaging all providers in use of the EHR because of their need for this information prior to each visit. An INS who is present in clinic as part of the interprofessional team, engaged with the triage nurses to move the rollout forward. Attention to
Figure 1. Information flow and work flow.
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Declaration of interest Dr. Frank, University of Alabama at Birmingham School of Nursing, is the Program Director for the HRSA grant that funded this work. The authors report no conflicts of interest. The authors were responsible for the writing and content of this article. This work is funded by a Health Resources and Services Administration Nurse Education, Practice, Quality and Retention (NEPQR) award (UD7HP25047).
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Figure 2. EMR and visit task support.
usability issues at this step was critical to ensure accurate and timely EHR documentation of the triage process. The third step, again indicated by the information and workflow, was to engage providers in the development of Notes Templates. In this area, all types of providers were interviewed about their needs, given mock templates to review, and provided the opportunity to use draft templates in the EHR both with the INS present and on their own. Currently notes templates are used by the dietitian, psychiatric and mental health nurse practitioner, and an endocrinologist. Additional notes templates are being developed for other specialty physicians and advanced practice nurses. Next steps include bringing providers into EHR use during patient visits, configuring a dispensary module to allow for electronic prescribing and dispensing in house, and designing and transitioning to a blended usability evaluation framework, which will include a change management plan. Summative and formative components will be included in the longer-term evaluation model to ensure effective and efficient use of the EHR and to implement changes that may be necessary to the EHR as the interprofessional patient care model evolves.
Concluding comments Lessons learned to date include the importance of developing new models of decision-making around the use of HIT in a patientcentered, interprofessional care model. Putting aside traditional models can result in confusion and some anxiety. However, by focusing on being patient-centered, we can develop models for HIT implementation and evaluation that are rooted in information flow in continual support of provider workflow. We can also use informatics applications, such as EHRs, as another communication channel for the interprofessional team. In addition, by including informatics professionals such as INS as full members of the interprofessional team, we can work to ensure that the decision-making remains grassroots, patient-focused and truly interprofessional.
Acknowledgements Editorial assistance was provided by Jennifer S. Frank, PhD.
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