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February 22, 2013 Readers Write 9 Comments

Now That We Have Data, How Do We Improve Patient Care?
By Cynthia Davis

2-22-2013 6-55-59 PM

I’m a former ICU/ER nurse with three decades in and around healthcare delivery. I understand first hand why we need technology in operating rooms, in the ER, at the patient’s bedside and during clinic visits. It is because technology can have a significant impact on improving care and outcomes. Patients are safer. Doctors have access to data on medical history and allergies when they are making decisions that can save the life of someone’s mother or sister or aunt.

Today we are at a critical juncture. Institutions finally have the right technology tools in place. The question is, how do we make that collective leap from data collection to better care? I think it starts with validating and analyzing the data that we are all so busy collecting.

This should be easy. Isn’t that the promise of technology? In my experience, the answer is both yes and no.

Technology is not magic. It does not fix processes. If you have a patient with impending sepsis and the EHR alerts for potential sepsis through vital sign documentation, assessment data, and labs, it doesn’t tell you the process once the alert triggers. It’s a shift in perspective, but for technology to actually improve care, we need to listen and think as clinicians and reexamine workflows and data points as a basis for care decisions.

The first step is going back and reviewing whether we are capturing data at the right time and point of care. The data that is collected needs to be reliable and clean. This sounds simple and straightforward, but in a clinical setting, the challenges can be enormous.

Recently I asked various departments heads what they considered the source of truth for their clinical information for decision making. Six department heads gave me six different answers. They were all using their department reporting tool as the best source of data. As they went along and identified data discrepancies, they fixed these in their own departmental systems, but problems in the original source data were neither corrected nor investigated. Each thought the problem was that the nursing teams had entered the data incorrectly. No one had focused on the data integrity in the primary system.

This breakdown in the data management process highlights the fundamental importance of adopting an overall data governance structure to support data decisions. It reminds me that we all need to examine data design and data management processes to make sure we are capturing the right information at the right time. This critical analysis can point out workflow problems like the one my client encountered, where well-intended workarounds had compromised the integrity of their whole system

Talking to and observing frontline staff is a great way to discover workflow problems that may be undermining the success of your EHR. For example, I once watched a nurse scan a page full of labels before administering a new medication. He did not scan the wristband where the patient identification data was stored until after he had administered the medication. Therefore, he was using the system and accessing stored data, but the order was out of sequence.

This kind of problem will not turn up in a status report from your CIO, which may be more focused on the number of support tickets generated or the ratio of downtime. Clinical leaders have to get to the front line – to the hospitalists or nursing managers – to find out how well the system is working and where there are difficulties.

Finally, fixing workflow issues that compromise data integrity requires a continual emphasis on training. People can only learn so much when you first bring your system live. On an ongoing basis, organizations must invest in management skills training to help clinicians more effectively use these new tools.

Whether it is helping a nurse manager better monitor the nurses who are capturing electronic data or working with a chief medical officer so that they can look at reports and understand what’s happening with their medical staff, training is essential and goes far beyond your go-live.

Cynthia Davis is a principal with CIC Advisory of Clearwater, FL.

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Currently there are "9 comments" on this Article:

  1. Sorry, but we do not have any more data than we had before the hospitals, ERs and ORs were wired. It is just that the data is stored in different places, silos if you will. The data is gathered either by machine that automatically sends it to the repository without notice, or by marginally trained aids who know meaningfully little about the blood pressures they obtain and enter into the elctronic silos, oft without informing the nurses who are busy scanning barcodes and rrouble shooting the bar code scanners when they out a halt on administering the medication.

    What we need is more attention to the old data by those who are in the know and have the data handed to them instead of having to search the silos for it.

    Your blog is getting better with age and thank you.

  2. I don’t understand your comment. Do we not have more data on time stamps, patient location, administering clinician, likely interactions of drugs through clinical content, etc? And isn’t the data more accessible because more than one clinician can access the clinical chart at the same time and physicians can access it remotely (in a “wired” environment)?

  3. Very insightful article Cynthia. As a long time participant in the rural healthcare technology landscape, we need to move past finding reasons NOT to adopt and successfully implement HIT to finding ways to work through the issues. The vendors need to do their part by listening to healthcare providers and improving their products accordingly. However, my personal belief is that the technology is workable IF we put a positive spin on why we should use it and then dig deeper in terms of working through the issues (some of which you pointed out).

  4. Excellent selection of writers, Mr. H.

    About the above, interesting comments but more data or more gibberish? That is the $ multibillion dollar question.

    Workflow of patient care has evolved over decades and has been efficient. Adjusting workflow to the whims of the computerized direction of medical care that was coded for by non clinical programmers, is counter-productive.

    I and my team of doctors will buy into this capricious alteration of medical care when it is less capricious, ie when the data shows improved outcomes and reduced costs.

    The error rates, delays, system unavailabilities, and near misses overall the same if not higher than they were prior to the wiring of hospital care.

    The problem is that the proponents of sauch care have blocked the accurate assessment of its adversities. It is like the heads are in the sand, or some place else.

  5. “Technology is not magic. It does not fix processes. If you have a patient with impending sepsis and the EHR alerts for potential sepsis through vital sign documentation, assessment data, and labs, IT DOESN’T TELL YOU THE PROCESS ( once the alert triggers”

    uh, actually the EMR could/should suggest the sepsis bundle order set when sepsis criteria met….isn’t that part of the point of a “useful” EMR?

  6. Regulations change, but it will always be the right thing to look your patients in the eye, listen carefully, and tell the patient’s story. It is sad that health IT has stolen that from us and our patients. Don’t they see that as soon as they build in all the hardstops, the Gov will just move the goalposts?

  7. “Workflow of patient care has evolved over decades and has been efficient” – Interesting, is there evidence to support this bold statement? The following articles seem to suggest otherwise:

    http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande
    http://healthland.time.com/2013/02/20/bitter-pill-why-medical-bills-are-killing-us/print/

    These articles highlight the economic inefficiencies of the US heath care system. It is highly unlikely that within these inefficiencies, the workflow of patient care has miraculously evolved to be “efficient”. Indeed, “It is like the heads are in the sand, or some place else”.

  8. Dear Ed Head:

    Bold because it is the truth. Ask any doctor who is forced to use these devices that are poorly usable, contain flawed interface software, and promote new errors.

    I am referring to medical workflows, ie the care of patients. Economic inefficiencies are caused by the flawed policies from HHS, CMS and the Congress.

    ntsr

  9. How about if we enlist the assistance of patients through focus groups and forums for feedback and suggestions on improving their care. For instance, when I go for a mammogram or other procedures, I have to wear a wristband that contains my name, medical record number and birth date. I have often found discarded bracelets lying around in changing stalls or on the floor of mammogram centers, for instance. A clear infringement of HIPAA. Maybe if there was a clearly marked bin for patients to dispose of these wrist bands and ensuring they are shredded?

    I am thrilled to have my medical records available electronically especially when I have to see specialists outside of my doctor’s practice, saving me having to tote heavy files to their office.

    However, there are f instances where as a patient I find I still have to complete medical history questions on paper, for instance before a mammogram or patient registration. Why can’t these questions be completed by the patient electronically and at home?

    I am sure engaging patients in the EMR conversion process would be a win-win situation for everyone.







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