# Presentation: 042998

## 
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
801-466-5595 (T)     801-466-6685 (F)
shorn@isisicor.com

**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**
**801-466-5595 (T)     801-466-6685 (F)**
**shorn@isisicor.com**

**Using Clinical Decision Support Systems to Measure Quality of Care for Special Populations**

## Research Based Foundation

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

## Long Term Care CPI ResultsOutcome: Develop Pressure Ulcer

**General**
** ****Assessment**

**Incontinence**
**Interventions**

**  ****Nutrition**
**Interventions**

**Staffing**
**Interventions**

**+ Age ******** 85**
**+ Male**
**+ Severity of Illness**
**+ History of PU**
**+ Dependency in **
**   ****>= 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**
**- Enteral Supplements**
** ****disease-specific**
** ****high calorie/high **
**  ****protein****   **

## CNA Daily Documentation and Workflow
Standardized data in documentation flow sheets;  include best practice elements
Improved communication with clinical team (RN, CNA, MDS, Dietary) 
Wound Nurse PrU Tracking Documentation
Standardized data in PrU documentation (assessments and treatments)
Timely access to compiled information 
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

**Standardized data in documentation flow sheets;  include best practice elements**
**Improved communication with clinical team (RN, CNA, MDS, Dietary)**** **
**Wound Nurse PrU Tracking Documentation**
**Standardized data in PrU documentation (assessments and treatments)**
**Timely access to compiled information **
**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**

## Slide 5

## Slide 6

## HIT Requirements

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

**Notes:**
Minimal training requirements (good for turnover)

## Example technology #1 Digital Pen	

**Digital 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 Station**** **
**Battery charging**
**Uploading data from memory to database via Internet**

**Example technology #1**** Digital Pen****	**

## 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**

## 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**

## Decision Making Reports

**	**
_**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. **
_**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.**

_**Nutrition 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**

## Nutrition Report

**What are uses of the Nutrition Report?**
**Identify which meals are not being eaten**
**Promote use of nutritional supplements**
**Identify need for consistent weights**

**Decreased meal intake **
**Weight loss**
**Increased incontinence episodes**
**Increased behavior problems**
**Existing red areas on skin**
**History of pressure ulcer in last 90 days**

**Example: Priority Report**

**Identifies residents at risk**

## 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**

## Impact On Pressure Ulcer QMs Study Facilities Combined

**Q4 03 – Q3 05% Change =  - 33% **

**Impact On Pressure Ulcer QMs ****Study Facilities Combined**

**Source:  CMS Nursing Home Compare; Facility QM data reports**

## 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.**
**Implement findings in standardized wound assessment documentation**
**Combine tracking outcomes (development and healing of PrUs) and quality improvement (information to improve clinical decision-making)**

## What is different about this approach?

**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. **
**Involves front-line staff****.  **
**Establish multi-disciplinary design and implementation teams, including CNAs, nurses, dieticians, wound nurses, MDS nurses, social services, and restorative care. **

## What is different about this approach?

**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.****  **
**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.**

## Clinical Strategy

**Early identification of high risk residents**
**Monitor changes in PrUs, nutrition, incontinence, and behaviors**
**Integrate with guidelines and evidence- based practices**

## QI Organization Strategy

**Leverage CNA daily  and Wound RN weekly documentation to provide data for reports**
**Improve accuracy of CNA observations **
**Electronic checking of data now possible**
**Integrate timely information into day to day practice**
**Easy access to summarized information**
**View resident trends and multiple risks**
**Multidisciplinary input**