Health CIO Network Webinar: Overcoming the Challenges of Clinical Documentation

© 2014 Nuance Communications, Inc. All rights reserved. 1

Overcoming theChallenge of ClinicalDocumentation

Nuance commissioned research on: Understandingthe patient, process and economic implications

Ignetica Ltd (www.ignetica.com) Client ConfidentialProject Site www.ignetica.clientsection.com

Health CIO Network: 19 June 2015The impact of clinical documentation on clinicians, patients & trust economics.

ClinDocs – Summary Findings

Ignetica Ltd (www.ignetica.com)

Page 3Client Confidential

Project Site www.ignetica.clientsection.com

Introduction

• In response Nuance commissioned IgneticaLtd to undertake alight touch (clinician perceptions) study to provide this insight.

• The study is not intended to test the impact of a newtechnology, nor to audit records to evaluate theiraccuracy/completeness (there are of course other studies inthese areas).

• The focus of this study is to understand the situation andimplications when ClinDocs are not as complete or accurate asclinicians would wish.

• In so doing, to also understand the context of cliniciansinteractions with clinical documentation

It is widely recognised that quality of clinicaldocumentation can be considerable challenge, butthere is very little research which identifies theextent of the impacts on clinicians, patients andultimately trust economics.

Ignetica Ltd has prepared this presentation based on the full research report for the sole use of Nuance Communications in accordance with the terms of engagement for this project. The document should not beused for any other purpose without the express permission, in writing, of Ignetica. Any recommendations, opinions or findings stated in this report are based on circumstances and facts as they existed at the timeIgnetica performed the work. Any changes in such circumstances and facts upon which this report is based may adversely affect any recommendations, opinions or findings. © Ignetica Ltd, 2015





Study approach

Qualitative Research & Hypothesis

The study involved several phases designed to provide a hypotheticalmodel of the potential impacts, to test andrefine this with clinicians and then though wider survey insight across four centres …

Initial Hypothesis

• Literature review and end-to-end Acute CinDocs mapping

• Identification of areas most sensitive to accuracy & completion

• Development of initial hypothesis for review

Engagement with 4 Trusts representing Acute Healthcare

• 2x Large University Trusts, 1x Large DGH + Community and 1xMental Health Trust (& allied network)

• Review with Trust CCIOs to test and refine the hypothesis

Development of hypothesis to be tested & enumerated

• Finalisation of the hypothesis logic and development of survey tofurther test and fully enumerate.

Primary Research

• Web-based clinician survey deployed at the four trusts

• 197 responses received (c40% Drs, 20% Nurses, 27% therapists)

Data Analysis

• Full data analysis per centre and overall

Impacts Analysis and reporting

• Analysis of the impacts for clinicians and patients

• Analysis of the economic implications

• Final reporting

Quantitative Research & Analysis





Survey insight …

Based on the hypothesis, the survey was undertaken to understand on a wider basis how frequently info is notavailable when required, including the reasons, responses, implications and operating context …

ReasonsThe reasons for informationissues

How clinicians cope withthese challenges

Responses ImplicationsFor clinicians, patients andoverall economics

?

How frequently doClinDocs not inc

the info you need …

.. at the time and the detailyou require ?

• How likely are information delays to cause extended LOS/pathway?• How satisfied are you that your notes are as complete as you would wish?• Would your notes be more complete if you had more time available?• What would be the benefit of more complete notes?

ClinicianPerceptions

• Methods used for ClinDocs access (e-health stage)• Methods used for ClinDocs addition (e-health stage)

• Clinical Role (Dr/Nurse etc)• Clinical Area (Medicine, Surgery etc)• Age profile of respondees

Baseline &Demographics

• Time spent reviewing clinical documentation• Time spent adding to clinical documentation• Percentage of adding time that is narrative based

• Analysis of working time by setting• Time is spent searching for info

Core activity &ClinDocs timing





Responses

What the study has told us …

The study has provided insight spanning accuracy and completion, context of how clinicians interact with ClinDocsand the their views on the current situation …

Reasons

• 27% | Not sufficiently complete

• 14% | Not clear in meaning

• 13% | Not clear in legibility

• 14% | Known but hasn’t yetbeen included in notes

• 16% | Diagnostics/ investigationsare still required to ascertain theinformation

• 11% | It is not clear whatinvestigations/ diagnostics havebeen requested

• 6% | Other

• 33% | Search for information

• 12% | Request investigation/diagnostics, may duplicate.

• 12% | Work without becausetoo critical to wait

• 26% | Work without theinformation because notcritical & would take too longto resolve

• 12% | Wait and check againlater to see if it is then present.

• 6% | Other

Implications

Time consumed and delayed

• Time consumed searching forinfo (52 mins pp/day 69.9 Dr)

• Time consumed rechecking(63 mins pp/week overall)

• Delay to delivery of care (frominfo request to being availableto act on)

Activities (leading to cost)

• Most common duplicatedactivities/ diagnostics

Information Gaps

• Views on working without infoDR=36.4%

Nurse=28.4%Therapists =9.5%

How frequently do ClinDocsnot include the info you needat the time and the detail you

need?

AllNotavailable27.4%

Available72.6%

• 41% directly linked to accuracycompletion with 11% influenced byaccuracy and completion

• Searching & working withoutinformation because NOT criticalare most frequent responses

n=141





Clinician view on LOS/Pt journey

Respondees were asked for their views on the potential for info-delays to impact patients journey/LOS, with all(other than therapists) regarding it as more likely than not …

n=85

Mean rating (1-5)Per role or field

Distribution of ratings

• 80% of doctors felt it was possible, likely or very likely to extend patientsstay/journeys and “Likely” was the most popular response





The implications

The impacts have implications for Clinicians, Patients and overall economics as summarised below …

Clinicians

Staff Productivity

• Time consumed searching for info (52mins pp/day overall and 69.9 for Drs)

• Time consumed rechecking for info (63mins pp/week overall)

• Sessions not utilised effectively due toinformation not being available (eg 3.5OP clinic appointments per clinicianweek due to info issues)

Staff Satisfaction

• Level of Frustration (68% indicatefrustration in responses)

Patient Experience

• Delayed and disrupted delivery of care(extended timescales, duplicated OPappointments and potential IP LOS)

• Duplicated diagnostics (eg bloods)

Patient Safety

• Working without full information (thoughnormally because not critical 26%)

Patients Economics

Time Value £7.6k pa (Drs £19.5k pa)

• Time consumed searching for info

• Time consumed rechecking for info

Cost Optimisation (£2.5-6.8k pp/pa)

• Duplicated investigations/diagnostics

• Opportunity cost of under- utilisedcapacity due to information issues

Revenue Enhancement (£12.5k pp/pa)

• Potential opportunity to utilise OP capacitythrough reduced info issues

• Potential opportunity to utilise IP capacitythrough reduced info delays





Wider context – ClinDocs time

• Overall over 50% of time is spent on reviewing or adding toclinical documentation.

• In a sense this isn’t a surprise due to its central role in theclinical process, but it does highlight how even small infoimprovements can have a big impact.

• From an Adding perspective a total of 10.8 hours isconsumed on average per clinician per week, with 68.6%being narrative

• As shown this means 7.4 hours per week is spentgenerating narrative content and 3.4 hours on structureddata on average.

• This is a very significant measure since it is this activitywhich is key to producing accurate and complete clinicaldocuments. And clinician's believe with more time theirnote would be more complete ...

It has also provided further insight, for example on the time spent reviewing and adding to clinical documentationand what proportion of the later was narrative content …

Hours per week n=119

Hours per week spent adding to ClinDocs





More complete notes with more time?

The overwhelming response from clinicians was that with more time (or therefore technology which means the timeis more productive) their notes would be more complete …

n=85

Mean rating (1-5)Per role or field

Distribution of ratings

• “Very likely” was the overall modal response, with 75% of respondeesindicating somewhat likely, likely or very likely.





Queries & Further Information

Queries arising from this document should be forwarded in the first instance to Peter Booth atIgnetica via email: [email protected] direct dial +44 (0)1606 888578

www.ignetica.com

Tel: +44 (0)1606 301100

End of Document


Download a copy of the ClinicalDocumentation Research

http://engage.nuance.co.uk/study-nhs-trust-clinical-documentation-challenge

© 2014 Nuance Communications, Inc. All r ights reserved.

Real LifeElain Scott, Alder Hey Children’s Hospital PICU

An NHS Nurse Technology Fund AwardCase Study and Benefits Realisation at

Alder Hey Children’s HospitalElaine Scott

PICU Lead Nurse for Badger EPR

Peter WhiteSenior Staff Nurse PICU,Clinical Nurse Educator

Synopsis:

A Case Study describing Alder Hey Paediatric Intensive Care Unit’s(PICU) Nurse Technology funded project to roll out a speech-enabledEHR including the rationale, challenges, implementation strategy and

the realised benefits for patients, the team and the hospital.

The grant for our project•Response to the call for applications in December 2013

•Bid for software and noise-cancelling microphones

•Fit with current strategy for EPR

•Badger PICU

•Structured data

•Nursing model

Typing – wpm - 2015 Speech – wpm - 2015

Mean16.53846

Mean98.91667

Standard deviation

6.036215

Standard deviation

8.836158Median

16Median

98Maximum

29Maximum

124Minimum

9Minimum

73IQR

11-20IQR

93-104.25

Freeing up Time to Care

Study of note production speed n=20

Not just structured data.

Importance of “story”

•Determining diagnosis

•Communication with families

•Root cause analyses

•Rationales and interpretations

Interface issues:Problem Our solution

• Meditech v.5 – old system – DOS style interface -soon to be replaced by Meditech v6 and by Badger

• Notes recorded in a ‘Memo box’ and assessment in a‘wrapped text box’.

• Unable to select words or use dropdown menus inMeditech 5.0.

• No integrated spellchecker

• Work around achieved using dialog box.

• Verbal commands work properly

• Special transfer commands

•Difficulty of supporting training.

•Isolation of trainers

•Time to train

•Intrusive environment

•Clinical priorities

• Our attempts to solve these problems.

Training problems:

“It just flows….”

Uptake from the nursing staff:• Very positive response from first users.

• Used exclusively for notes by several staff (except forcertain situations – child protection, etc.)

• Nurses creating own templates which may be sharedwith everyone.

• Some resistance from ‘older’ nurses – upset at thegeneral shift towards everything on a computer.

• Difficulty for Indian nurses.

Problem solving:

•Not optimal specification PCs

•Accepted speed over quality – fullspec PC 5 passes, only 3 on PICU

• Long loading times.

•Connectivity

Where are we now?• Badger Nursing goes live this weekend

• Planning a re-invigoration of staff participation

• Reassessment of the benefits of speech-to-text

• Incorporation of user performance feedback

• Flexibility to capitalize on our Badger implementation

White P. and Scott E. (2015)'Applying speech-to-text systems in documentation'Nursing Times, 111(15), pp. 15-17

The future?

•Standardization for high quality notes

•Nursing and Midwifery Council’s (2010) guidance

•Mobile solutions

•Discrete programming for particular situations

•Empowerment of PICU nurses by giving them the right toolsfor the job.


Read the full Alder Hey story here:

http://engage.nuance.co.uk/speechrecognition-icu-epr


Want to overcome yourclinical documentationchallenges?


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