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Essential clinical dataset reduces documentation by narrowing scope of intake questions

Published on 5/6/2019

Nurses look forward to helping patients, although the mountain of required documentation can take a toll on workforce satisfaction. In late 2017 and early 2018, BayCare Health System became one of the first organizations to reduce documentation time by working with Cerner to launch the essential clinical dataset (ECD), aimed at reducing the number of questions nurses ask patients during intake.

“When a nurse charted in the admission database, almost 200 questions were available to document,” said Nicole Gitney, MS, RN, director of nursing informatics. “By implementing the ECD project, we significantly reduced the number of questions.”

After implementing the changes, BayCare reduced front-facing documentation, where questions not pertinent to the patient do not appear for the nurse to ask. The face-up documentation fell by 48%,1 leading to an 11% reduction2 in overall clicks.

“This ended up giving us back 1,991 hours per year,3” Gitney said. “That is time the nurses are able to spend interacting with the patient improving their health or doing additional education, instead of sitting in front of a computer doing documentation.”

Time in the Admission PowerForm, one of Cerner’s documentation tools, dropped 10%.4

“We saw a huge increase in nursing satisfaction, and they felt the information collected was more essential to patients,” said Gitney. “They really felt like it streamlined what they needed to document and showed them exactly what was pertinent to patients.”

The ECD didn’t just help nurses who were frustrated with documentation but also helped improve the patient experience.

“I think it decreased frustration for patients because we weren’t asking the same question in a different fashion, and different questions in the ER, and then the inpatient side,” said Gitney.

She says figuring out which questions should stay and which ones to eliminate proved worthwhile but challenging.

“Once we started diving into it, it really frustrated me that we were having nurses do a lot of unnecessary documentation,” Gitney said. “We did look at different items and assess, ‘Is this in the scope of a nurse to ask that information from the patient?’ We really looked at scope, as well as the evidence and regulatory pieces.”

In the future, ECDs may provide more benefits besides reduced documentation time.

“I love that Cerner reached out and started this project,” said Gitney. “For BayCare, it’s going to be very helpful for us to share information across the continuum of care for our patients in and outside of the organization. Using essential clinical datasets are going to help us mine data and benchmark against other organizations and really develop predictive models.”

For more information, visit our essential clinical dataset Model Experience page.

1 Calculated with 178 DTAs before implementation, and 92 left after implementation. (Baseline is from August 1 - October 31, 2017, while post-implementation is from November 23, 2017 – April 23, 2018.)

2 Calculated using a baseline of 119 clicks before implementation and 106 clicks after implementation. (Baseline is from August 1 - October 31, 2017, while post-implementation is from November 23, 2017 – April 23, 2018.)

3 Calculated utilizing a drop of 48 seconds (from 7:51 to 7:03) over 149,307 adult admission databases completed in 2017.

4 Drop of 7:51 from August 1 - October 31, 2017 to 7:03 from November 23, 2017 – April 23, 2018.

Client outcomes were achieved in respective settings and are not representative of benefits realized by all clients due to many variables, including solution scope, client capabilities and business and implementation models.