4 Implentation Strategies for Physician Documentation

Section 4.12 Implement

Section 4 Implement—Implementation Strategies for Physician Documentation - 1

Implementation Strategies for Physician Documentation

Identify the automation support available for physician documentation in a skilled nursing facility.

Time needed: 40 – 80 hours
Suggested prior tools: 2.8 Workflow and Process Redesign for EHR and HIE

Automation support is available for physician documentation, including annotation of information as well as ordering treatments and medications. This tool distinguishes between order entry systems, computerized provider order entry (CPOE) systems, and e-prescribing (e-Rx) systems, and describes various strategies for implementing these similar, yet different, applications.

How to Use

Engage physicians who frequently admit residents to your skilled nursing facility in identifying the functionality your facility should have in (health information technology) HIT and (electronic health records) EHR that will be most helpful to them. Although they may continue to prefer manual documentation, there are increasing mandates and incentives for physicians to adopt at e-Rx and CPOE in an EHR. You can remind them that such tools can not only improve medication safety but can support remote use better than a phone call (which requires them to remember to sign the order the next time they are in the facility). Other forms of documentation for the skilled nursing facility EHR can greatly aid timely completion and accuracy of physician history and physical exams, physician progress notes, consultations, and discharge summaries. Increasingly, transfer records and other transition of care documentation can be exchanged electronically—not only with hospitals but with physicians.
Conduct workflow and process improvement mapping to determine how physician-oriented applications being implemented may change current workflows and processes. Ideally, during planning for HIT and EHR acquisition, you have mapped current workflows and processes and you can now identify processes you want to include in the new applications, including how improvements can be made. Work with physicians to ensure they understand potential changes and have input into their efficiency and efficacy. E-prescribing systems, at a minimum, support drug-drug, drug-allergy, and formulary alerts. Ideally, Beers Criteria for Potentially Inappropriate Medication use in Older Adults should be included in e-Rx for physicians and in your electronic medical administration record (EMAR) system (see: http://consultgerirn.org/topics/medication/want_to_know_more ).
Offer full training opportunities for physicians and others who support their documentation. If your facility also uses a pharmacy information system (PIS), laboratory information system (LIS), nutrition and food services information system (NFSIS), radiology information system (RIS), or any other ancillary system that will have orders directed to it automatically from the order entry system, ensure that the staff members who support these processes work with physicians to ensure coordinated processes. Nurses and physicians should work together to ensure that treatment orders flow from the physician order to the nursing documentation component of the information system. Ideally, the physician documentation systems should prompt for specific documentation requirements. Ensure that these meet your state requirements as well as accreditation requirements if you are Joint Commission accredited. Determine how physicians will access the reminders. If the skilled nursing facility continues to accept verbal orders because remote access is not provided for physicians, consider adopting a portal where physicians can enter orders directly, or at least affix electronic signatures to orders.
Monitor usage after go-live. There are many issues associated with physician documentation and ordering systems. They include the length of time it takes to enter an order, alert fatigue, keeping the drug knowledge base and formulary for e-Rx up to date, training new or infrequent users, and monitoring goals achievement.

Forms of Ordering Systems

· Order communication systems enable nursing staff to transcribe a handwritten physician order (or verbal order documented by nursing staff) into a system that routes components of the order to its destination information systems. For example, if the physician writes an order for a lab test and special diet, the order entry system can transmit the lab test component to a laboratory information system and the diet component to a nutrition and food service information system. This type of order entry saves nursing staff time, ensures accuracy, and improves timeliness in communicating orders. The paper order signed by the physician is the formal documentation; however, the destination systems may retain the information received for internal quality checking purposes for some period of time.

· Computerized provider order entry (CPOE) enables providers to enter orders for lab tests, other diagnostic/imaging studies, therapeutic services, nutrition and food services, and nursing services. They also have clinical decision support (CDS) that has many patient safety and other benefits. For instance, diagnostic studies orders can be checked for duplication of orders and associated orders, such as special dietary or preparation provisions. Reminders can be provided for other skilled nursing facility treatment requirements. With some CPOE systems, the physician can enter an order for a medication that goes through the e-Rx system.

· e-Prescribing (e-Rx) enables a provider to write a prescription to a retail pharmacy or pharmaceutical mail order house. These systems provide CDS for patients, as well as formulary alerts. Some e-Rx applications also support medication renewal and the ability for prescriptions to be put on hold, cancelled, or changed electronically.

In the nursing home, the CPOE system can be used for e-Rx with a special pharmacy interface. CPOE systems are designed to communicate with other internal information systems, such as PIS, LIS, RIS, etc., whereas CPOE and ancillary systems are designed using a common protocol (from the standards development organization, Health Level Seven [HL7]). E-Rx systems, however, have two significant differences. First, they must be designed with a protocol from the National Council for Prescription Drug Programs (NCPDP) that retail pharmacy systems use. Second, the exchange of prescription information must happen through a secure gateway or exchange service. SureScripts is the primary company providing such a gateway. It certifies e-Rx users as well as the recipient retail pharmacy systems for secure transmission of the prescription and connection to formulary information from pharmacy benefits managers (PBMs). The e-prescribing gateway is illustrated and described below:

E-Rx is increasingly being used, although some physicians continue to handwrite prescriptions. By 2009, all pharmacies serving Medicare Part D patients were required to accept e-prescribing transactions. Today, all state boards of pharmacy permit its use for all medications except for controlled substances. There are, however, still some issues that need to be addressed:

· Physicians should ensure that their e-Rx systems are kept up to date with new drug knowledge through a subscription to a drug knowledge database service. This assures access to new drug information, alerts, recalls, etc.

· Local pharmacies that are not members of large chains may not yet have made the conversion and become certified with Surescripts to support receiving electronic prescriptions. Although the e-prescribing gateway can convert prescriptions to a Fax for these pharmacies, part of the benefit of reducing transcription errors at the pharmacy is lost.

· Not all PBMs, especially small ones and some state Medicaid agencies, are fully enabled to support the formulary checking function in e-Rx.

· Use of e-Rx for controlled substances is still being addressed. In 2010 the Drug Enforcement Administration (DEA) changed its rules to permit electronic prescriptions for controlled substances under very specific requirements for authentication and transmission, where consistent with state boards of pharmacy requirements. Subsequently, SureScripts has begun to certify e-Rx systems in states that have approved the functionality. If the physician’s e-Rx is not yet certified or if you operate in a state that does not yet permit e-Rx of controlled substances, physicians can still use their e-Rx system for its reminder and alert functionality and generate a printed prescription to reduce legibility errors. The paper copy must be provided to the pharmacy with a hand- written signature until the e-Rx and/or state boards are aligned with the new requirements. State boards of pharmacy may also have stringent requirements for printing on tamper-proof paper, printer security, generic substitution, and other reporting elements for Schedule II drugs.

Nursing Home Implementation of Automated Documentation Systems

Critical success factors for implementing automated documentation systems for use by physicians in a skilled nursing facility include the following:

□ Engagement of physicians. Despite strong evidence to the contrary, many organizations still wait to engage physicians until training is necessary. Physicians must come to understand and trust these systems, believe they are a part of developing the CDS rules embedded therein, and believe they play a role in selecting the system that is most user-friendly. Following are examples of ways to engage physicians:

· Indicate that the nursing home has specific plans to move to an EHR—including physician documentation, CPOE, and e-Rx—by a certain date and wants the physicians engaged from day one. This puts the physicians on notice that the home is serious, but gives them ample time to participate. Physicians are not likely to find many other places that are not moving toward more automation.

· Ask physicians to participate in measurable goal setting, product assessment, standing order development to build their own order templates, and review of clinical effectiveness and efficiency using decision support rules.

· Institute a regular communication process with the physicians who admit to your facility, illustrating your commitment to gaining their engagement and adoption.

□ Engagement of nursing staff. In some cases, physicians are more interested and knowledgeable about clinical information systems than nurses. There are significant workflow changes for nurses, who must be involved in engaging physicians and the revising complementary workflows. Ways to engage nurses include:

· Provide dedicated time for education about HIT, CPOE, and electronic medication administration record (EMAR), building computer skills and exploring the impact of automation on nursing practice in general. This will pay off in many ways:gaining adoption of their own documentation and EMAR components; getting invaluable input from nursing for overall medication management workflow and point of care documentation support; and ultimately encouraging and supporting nurses in their professional work.

· Have nurses work one-on-one with physicians in preparatory steps and during implementation. Their functions are complementary, so their involvement in HIT should also be complementary.

· Provide dedicated time for workflow and process improvement activities, which will provide immediate benefit where there are non-standard practices, and ultimately in the HIT systems. Nurses are typically process-driven, which can be both an advantage and a disadvantage. However, having nurses work on process mapping themselves, early in the consideration phases of all aspects of HIT, helps them see the areas where change is needed, and will help ensure adoption of new processes.

□ Pharmacy’s role in CPOE. While many skilled nursing facilities have limited or no direct pharmacist support, attention should be paid to pharmacy interactions, e.g., notifying those pharmacies you use regularly of your e-Rx adoption.

□ Determination of source and destination systems needed for CPOE to work for all items being ordered. For each of the following systems, you may need to evaluate whether they are prepared to receive orders, notify staff members of an order, and acknowledge receipt of the order. The presence and capabilities of information systems need to be reviewed for the following departments:

· Laboratory

· Nursing

· Nutrition and food service

· Radiology

· Therapy services

· Social work

If orders are placed for a service that does not have an information system, or will not be linked to the EHR, exception processing will be needed. In evaluating systems, determine how the exceptions are routed within the system, or if they need to be handwritten by physicians.

Workflow and Process Improvement to Set Goals

Chart the flow of information within the facility and with the physician office and retail pharmacy to understand what structures will work best.

As current workflows and processes are mapped, providers and other stakeholders should be able to establish measurable goals. Record these in a manner that illustrates how they can be accomplished with HIT and when you will know you have achieved the goals. Review the goal-setting tool (see 1.X Visioning, Goal Setting and Strategic Planning) for specific examples. The following are examples of high-level objectives. Modify or add to these, and make them specific and measureable for your organization:

¨ Reduce errors of omission and commission in ordering to improve patient safety by using CPOE and e-Rx.

¨ Decrease variation in standards of care to improve quality through use of template-based documentation protocols.

¨ Achieve more effective dosing for improved response time to therapy through more precise ordering and EMAR systems.

¨ Increase turnaround time for ordered services that are electronically transmitted directly to their destinations and do not need to be manually entered to facilitate resident response.

¨ Respond more rapidly to changes in resident health status using monitoring from the EHR and other HIT.

¨ Improve downstream productivity by reducing time to address follow-up issues that are alerted or generated from the EHR or other HIT, such as immediate notification of missing data.

¨ Reduce health care cost by monitoring risk for hospital readmission/emergency department use through alerts in an HIT dashboard.

4 Implentation Strategies for Physician Documentation

How to Use

Forms of Ordering Systems

Nursing Home Implementation of Automated Documentation Systems

Workflow and Process Improvement to Set Goals

Other Physician Documentation Considerations