CNO Dr. Jane Englebright is committed to easing clinical documentation burdens. Hear her strategies for separating meaningful data from noise, so clinicians and patients can get the most from their time together.
Title: Healing a Health System with Meaningful Clinical Documentation
Guests: Dr. Jane Englebright, Chief Nurse Executive and Senior Vice-President at HCA Healthcare.
Host: Christine Parent, Associate Vice President, MEDITECH
Dr. Englebright: If we are putting a lot of things into our electronic systems and no one is viewing them, printing them, pulling them forward into a dashboard of some sort then we really do have to ask ourselves, why are we documenting that information?
Christine: Welcome to another episode of MEDITECH Podcast. We're the leader in healthcare technology empowering you to be a more informed healthcare consumer and provider. Hear the latest from our friends and colleagues on topics we think you should know about.
I'm Christine Parent, MEDITECH's Associate Vice President, and today I'm talking with Jane Englebright, PHD, RN. Jane is the CNE and Senior Vice President at HCA Healthcare. She also presented an inspirational keynote at our MEDITECH Nurse Forum. She has been a driving force in the movement to push back on burdensome documentation for our frontline healthcare workers. Welcome, Jane!
So, Jane, when you reflect back on all the challenges of Covid-19, what are some things you feel we can do better for our frontline healthcare heroes so they can spend more time with their patients and put their focus into providing great care?
Dr. Englebright: There's a lot to reflect on from these last two years, but I think, certainly, one of the things that became clear to us is what really is most important. I think a good lesson for us to learn is what things did we put to the side, and what things did we feel we absolutely couldn't let go of? We need to go back and reexamine those things on the side and ask why they can't just stay there. What can we do to reduce burden in all areas, but for this crowd especially, documentation burden and the burden created by our technology systems. How do we make that easier for our clinicians? Because we now know where they need to spend their time. Their time needs to be spent with our patients both giving care and coordinating care.
Christine: I agree; that was highlighted during the past two years, the burden of the documentation and trying to really reduce what you consider non-meaningful documentation that has really become highly reported in a national imperative. What are your recommendations for moving the needle forward into this right direction of reducing this non-meaningful documentation?
Dr. Englebright: The example that we gave, and talked about during the conference, came out of the Nursing Knowledge Big Data system. What I like about that, it builds upon the work of several individual organizations and systems that have undertaken this work. It's amazing that so many of those came to the same conclusions about the components of documentation that are really not that important for any given episode of care. To really move the needle for the country, I think we need to have more of that coming together rather than each individual institution doing their own thing. That's really what's going to change the standard of care.
Christine: To follow up on that, how can we ensure the clinical documentation at a health system is meaningful versus just noise? And how does this speak to the end user's experience?
Dr. Englebright: Well, I think we have some data we can bring to bear on that. What's being used? What's being read? What's being looked at and what isn't? Then we have to ask, why. Is it because it's not meaningful? Is it because it's too hard to find? Is it because it's varied among a bunch of other non-meaningful things? Or is it a competency-level on the part of the individual practitioners? But if we are putting a lot of things into our electronic systems and no one is viewing them, printing them, pulling them forward into a dashboard of some sort then we really do have to ask ourselves, why are we documenting that information?
Christine: Looking at your experience, can you provide an example of a time when HCA increased the mindfulness of a particular area of clinical documentation?
Dr. Englebright: I think one of the areas where we really focused a lot at HCA Healthcare on mindfulness was in the planning of care on the part of the Nursing team. This was a time when we actually turned off some of the great features that we have in our systems of automatically populating a plan of care. Because what we found is that the nurses were overly reliant on the computer. If the computer thought that this should be included in the plan of care, they just included it. They didn't take that time to be mindful and go down and look at all the suggestions and figure out which ones were appropriate for this episode of care. So we turned all of that off.
Now what we have is a display that the nurse can look at to think about the different dimensions of care using the Clinical Care Classification System model to put that in front of the nurse and say, pick the top three to four that are going to be the focus of nursing care during this episode. We turned that into a very mindful exercise, rather than an automated process, and really decreased the number of problems, the number of goals, and the number of interventions that are on our plans of care.
Christine: Using cases from the pandemic, what do you think is the lasting impact of healthcare in the future?
Dr. Englebright: I think a couple of things that we learned from the pandemic, in relation to our documentation, is the need for a timely response to changes in practice. As guidelines change, as treatment protocols change very rapidly with this novel virus, and the learnings that we all experienced early on, the need for our documentation systems to help us by collecting discrete data so we could evaluate the impact of our care and what was making a difference and what wasn't. Then the ability to get those care protocols and techniques directly to the frontline caregivers in the midst of giving care to the patient was such an important way to spread the new knowledge as it was developing. I think that speed of response and the feedback loop that our EHRs can provide to us both in giving information and then collecting information for learning.
Christine:That was great. We talked about some meaningful documentation examples but what are some common, non-meaningful documentation areas that you've observed in the industry? How do you see changing the approach making a real difference in care?
Dr. Englebright: Some of the areas for eliminating non-meaningful documentation include things like health maintenance activities that are maybe outside of this episode of care. My favorite is, you know, what is the date of your last mammogram. Unless that's something we're going to do something about, we can just give every woman over 50, or over 40 whatever the guideline is now, a brochure saying be sure you get your annual mammograms. Rather than asking questions about that. We have gotten in the habit of adding queries to our documentation after every regulatory event where we have to put a plan of correction in place. We start collecting all of this additional data, and we never take it back out once the action plan is completed. So that's a very ripe area.
I think another area is looking at which disciplines are asking which questions. Does everything need to be asked by everybody? For instance, we found in our work that we had a lot of questions about stairs in the home and things that our case managers wanted us to ask just in case the patient was going to need case management; just in case the patient would be going home with limited mobility. We have tried to take advantage of the technology to say, can we only ask questions at the right time, by the right person, for the patients who need it, rather than asking everything of every single patient.
Christine: Jane, for those wanting to get involved in these initiatives, can you share what outside organizations or memberships you are involved in? What are these groups actively doing to improve the quality of clinical documentation?
Dr. Englebright: Basically, I'm involved with two groups. One is the Information Technology Expert panel with the American Academy of Nursing. They don't really have anything, right now, that they're doing in terms of a project; although, they are advocates in the policy arena to continue to suppress the various regulatory agencies to relook at their documentation requirements. Then the other one is the Nursing Knowledge Big Data science group that the University of Minnesota hosts. That group does have a work group, as they call them, on transforming documentation. That's the work that I reference that we have done jointly, as a task force there, on reducing documentation burden. They have a lot of different projects and things that they're pushing forward with.
Christine: That's great information. The quadruple aim has been called the true north to health system performance. Can you expand on how these efforts tie into accomplishing the quadruple aim of enhanced patient experience, improved population health, reduced cost, and improved work life for health care providers?
Dr. Englebright: Well, if we've learned nothing else these two years it is that you can't achieve one of these without achieving all of them. They are all equally important. As our caregivers have been stressed, burned out, traumatized, and leaving the profession it seriously inhibits our ability to give good care, to give a good experience, and to reduce cost. These things are intimately intertwined and to be successful as a country, as an organization, we have to address all four of them equally. To me, that has been the big learning that I think we've all come to as we've looked at what's going on right now. Then how do we move it all forward? To me, this balance that we need to have in documentation between that which is necessary, and meaningful, and is entered in such a way that it can be harvested and used for learning, has to be balanced with how much time are we taking away from patient care in order to collect data. That's a healthy tension that needs to be there.
How we have suggested you approach that, in the Nursing Knowledge Big Data work, is really to create a set of guiding principles about what is most important to you, and to test every single additional data element that people ask for against those guiding principles. Is it moving us forward in the direction we want or not? Rather than, does it seem like a good idea?
Christine: What's something we may not know about Jane Englebright?
Dr. Englebright: I guess my new hobby is serving as a vaccinating nurse in vaccination clinics around the Nashville area. That's been one thing I've been doing. Then, probably my other thing that I've been very thankful for during this time is, we actually have a farm just outside of Nashville. That is where I have been spending a lot of time during the pandemic. The first question I always get about the farm is do you have any animals? And the answer is no. We have recently become beekeepers, though. So we have some things to do. Mainly it's a place to relax, to spend time at the creek in the summertime, and in the woods in the winter time, and have some good family time with the kids and the grandkids.
Christine: Thanks for tuning in. As always, be sure to subscribe to hear our latest episodes, and we'll talk to you next time!