As electronic health record (EHR) use, technologies, regulatory requirements and clinical practice have evolved in the health care industry, there has been limited standardized guidance around what clinical content should be documented within the EHR. The modern health care organization often has a highly customized and overdesigned EHR with a plethora of information – not all of which is used or documented on a regular basis.
Today, across the health care industry, hospitals and health care systems are seeking ways to optimize their EHRs. For many organizations, this means looking at the roles who use the EHR most often – particularly nurses, who are the largest user group.
Regardless of what EHR an organization is using, documentation optimization is an issue that all health systems across the country are struggling with. Often, nurses feel like they spend most of their time documenting in the EHR rather than caring for patients. Health care organizations aiming to increase nursing satisfaction and workflow efficiencies should naturally seek to decrease the documentation burden on these front-line caregivers.
The greatest reason for introducing an optimization project is to give care teams a better experience and improve patient outcomes, but often this means starting at square one again. Here’s where the essential clinical dataset (ECD) comes in.
What is the essential clinical dataset?In a nutshell, the ECD defines the data elements that are essential to be documented for a patient within the EHR so the care team may provide quality care.
We realized that the industry needed a standardized dataset that provides essential elements for EHR documentation. Across the 12 organizations in our ECD Collaborative, we found that anywhere from 194 to 986 data elements were being collected as part of the adult admission and intake. This was an eye-raising variance – one we knew deserved a better solution.
Using practice-based evidence to define the ECDFinding a lack of evidence in industry literature, Cerner extracted the admission and intake data elements from all 12 collaborative clients as the first step of our practice-based evidence approach. We did a cross-analysis of the data elements across the collaborative and reviewed the frequency of the data element across the 12 organizations and the frequency upon which it was being documented. If a data element was present in eight or more clients from the collaborative, and was documented at least 60 percent of the time, we strongly considered this for the ECD. We also accounted for Centers for Medicare and Medicaid Services (CMS), The Joint Commission and Det Norske Veritas Healthcare, Inc. (DNV) regulations as well as Meaningful Use Stages 1, 2 and 3. At the end of this process, we narrowed the ECD for admission and intake history to 87 elements. Each organization that adopts the ECD must additionally apply their state and local regulations, adjusting for any nuances. The organization may continue to localize the ECD based on its needs.
ECD adoption benefitsOne of the benefits of the ECD is it decreases the amount of time that nurses spend on documentation, one of their many responsibilities. Additionally, by decreasing the number of intake questions to only what is essential and relevant, the compliance rate increased.
When a time-pressed nurse is doing an admission and facing the daunting task of completing an assessment that is 200-900 questions long, they are likely to skip questions that they think to be irrelevant to their patient. With the ECD, the nurse is only being asked to document on essential questions for each patient. The nurse will see the value in the content, leading them to have a better quality of documentation and higher utilization of all fields.
Another benefit to the ECD: With fewer questions to answer, there’s less low and non-value data entered into the patient’s EHR, which limits extra noise and makes all the information entered relevant. With the ECD, the questions that are documented are of value across the board – not just for nurses and physicians, but to dieticians, social workers and other extended members of the care team. Additionally, this leads to higher levels of satisfaction for the whole care team.
Across the industry, there is recognition of this need. Recently, the American Nurses Association (ANA) and the federal government, through the Office of the National Coordinator (ONC) and CMS, emphasized the need to decrease the burden of documentation across all our clinicians. A national task force being led by the ANA and the ONC, has been established to specifically look at the issue and the problem of documentation burden for nurses.
The work we have initiated with our client collaborative team was always intended to be EHR-agnostic, with a goal that once we validated the methodology, we could replicate it across the industry. We believe that the ECD will benefit the entire clinician community.
We support nurses and the entire care team by connecting workflows across the continuum of care. Learn more about how Cerner is innovating care delivery.