By Marsha Knapik, Director
Brian Keller, Senior IT Applications Developer
Not so long ago, scribbled nurse’s notes and physician orders, along with paper medication requisitions and numerous other handwritten documents dominated the healthcare system. The gradual move to electronic clinical documentation as an initial step, and now (at advanced organizations) a completely electronic health record, has gained rapid momentum in recent years. In fact, such a movement can now be considered the only way to encourage complete and fully-integrated medical records… a desirable goal for hospital administrators, clinicians, physicians, and perhaps even patients who know the benefits that optimized technology in the healthcare setting can bring.
While rapid advances in technology make it possible to ensure documentation is provided electronically, this technology, if used correctly, can also identify gaps or deficiencies in care, serve as a means to guide best practices, and provide a platform for efficient and effective data collection and reporting. Corazon believes that using IT to its fullest potential is a worthwhile effort that can bring both short- and long-term value to a hospital – clinically, operationally, and financially.
For example, Corazon’s CEREBROS® software provides a documentation template for the required neurological assessments and specific evaluations for a known/suspected stroke patient. This template system ensures that the patient receives all components of the appropriate evaluation; if data to that end is not provided within a specific timeframe, a prompt appears to notify the clinician that an important component of care was missed. Just consider the possibilities if numerous care paths were motivated and tracked and by standardized “steps” – the right patient receives the right care at the right time…EVERY TIME.
Using a software solution designed specifically for a particular patient population can likewise reinforce that a program is following best practice care standards. Cerebros allows an organization to identify any gaps or deficiencies in care provided as compared to the accepted standard. As part of the initial installation of Cerebros, a project team extensively reviews the organization’s existing documentation templates to determine whether they align with the templates supported within the application. Since Cerebros was built from the ground up by a team of clinicians to support best practice care for the stroke patient population, any additional hospital-specific clinical quality metrics could be reviewed and incorporated into the existing workflow if appropriate, maximizing the potential for the system to improve care.
Across the nation, data and outcomes reporting has become increasingly important for clinical, operational, and also financial reasons. For some procedures, outcomes data can determine reimbursement thresholds (or penalties) and customer satisfaction scores (which can no doubt rely heavily on the quality of the care received) can impact many facets of an organization, from the specialty program’s reputation in the local area to the hospital bottom line as a whole.
Indeed, the use of software can also allow for standardized and/or customized reporting, which can lead to not only meeting regulatory and certification reporting standards, but also analyzing and identifying opportunities for improvement. Any system that works on a real-time basis (rather than retrospective) can amplify these opportunities; flaws in policies/procedures, care standards, or any number of other program components can be fixed in the near term, vs. addressing a problem three to six months retrospective after waiting for formal data registry reports.
An efficient, logical, and well-thought-out user interface within a system can help to provide and reinforce best practice care as well. An application that is difficult to navigate, has complex documentation processes, is not user-friendly, and/or is missing appropriate checks and balances will be not only prone to errors, but also inefficient.
In terms of Cerebros, Corazon’s clinical development team ensured that the application was built in a methodical fashion to follow a stroke patient through the care continuum. The optimal design of the application not only guides the clinician through the documentation in a clear and concise manner, but also has the option to activate stop-points if appropriate in order to ensure that best practice care is documented prior to advancing to subsequent stages of care. Used in real-time, this function provides for an audit via an exception report specifically designed for the appropriate clinical quality metrics of a stroke patient.
System flexibility is important in a variety of ways, mostly to ensure that a hospital’s unique quality metrics are captured and reported. In order for patient data to be extracted or reported for the clinical indicators of a specialty program, it is important for a system to either have a robust reporting tool or an option to extract the data to a hospital’s existing data warehouse. A complete reporting solution can then be developed, implemented, and maintained to track and measure all appropriate clinical quality metrics. The result is more consistent, higher quality care.
Although technology and IT systems can be a used to guide and/or reinforce best practice care, proper training for the application is a must to decrease the margin for error. Appropriate training programs should be created and in place for system users, and then ongoing or as-needed training will ensure continued success of the technology.
The healthcare landscape of today no doubt proves that the trend of increasing IT use in all facets of care delivery will not be fleeting. Technology has long been a shifting frontier for hospitals, and surely the opinions, requirements, and standards will continue to change… Corazon believes that as we continue to integrate information systems, there will be ever increasing opportunities to enhance practice and ensure best practice care.
Marsha Knapik is a Director and Brian Keller is a Senior IT Systems Developer at Corazon, Inc., a national leader in strategic program development for the heart, vascular, neuro, and orthopedic specialties. Corazon offers a full continuum of consulting, software solution, recruitment, and interim management services for hospitals, health systems and practices of all sizes across the country and in Canada. To learn more, visit www.corazoninc.com or call 412-364-8200. To understand more about CEREBROS, watch our information video at http://www.corazoninc.com/our-services/it-solutions/cerebros.html. To reach the authors, email [email protected] or [email protected].