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Creating and implementing relevant clinical documentation standards is one of the most critical steps in adopting or optimizing a hospital’s electronic health records system (EHR). An essential part of any new clinical implementation—not overshadowed by the solution itself—documentation and content play integral roles in a hospital’s clinical and operational efficiency.
This article discusses a few things a hospital should consider when setting up clinical content and what they should expect from a knowledgeable healthcare IT implementation team.
Clinical content is a foundational element of an EHR. Notes, treatment plans, patient diagnosis care standards, test results, medication administration—all these and more are guided by uniform documentation. Thus, this entire content library must be given the utmost attention.
From a clinical perspective, nurses and physicians can perform with more efficiency and accuracy when they have a reliable solution for the entry, storage, and retrieval of evidence-based clinical content.
Operationally, setting clear and relevant clinical documentation standards is critical because of its close ties to improving the value of care. A better value often means reduced costs and maximized reimbursements.
Setting up clinical content requires collaboration from the facility and the EHR vendor. By ensuring this process includes critical decision-makers from both parties, vendor and facility can make sure documentation meets each specific need—clinically, operationally, and from a regulatory perspective.
An EHR vendor will support this process with implementation experts who have hands-on clinical experience in a best-case scenario. Putting this expertise at a hospital’s disposal enables a streamlined and informed approach to setting up clinical content.
For example, vendor and hospital users can create standardized naming conventions that don’t stray too far from previous models and make sense for specified workflows. Something as simple as uniform filenames can ease use and support a clinical team.
Also, an EHR vendor must have the expertise on hand to catch potential documentation issues that may not meet local, state, and government guidelines. It can be time-consuming for hospital staff to keep up with regulatory changes. Knowing industry standards and documentation policies is often a significant part of an implementation expert’s job. This degree of foresight will help prepare a facility to meet government guidelines such as Promoting Interoperability.
Even with the help of a skilled vendor, setting up clinical content is an intricate process. Facilities can reduce the stress clinical documentation can create by focusing on three key aspects—timeline, operations, and content governance.
Successful hospitals will work with their EHR vendor to lay out a realistic approach for setting up clinical content before a go-live event. We find the best practice is to identify and agree on any “must-have” documents or templates and use them for the first 120 days after going live.
The development of clinical content as it relates to operations entails various aspects. Every piece of documentation to be considered must address these points to avoid any operational issues in the future. They include:
Once an EHR is “live,” it is not unlikely for clinical teams to request changes to the content. At MEDHOST, we insist hospitals create clinical governance committees tasked with evaluating and prioritizing requests as they relate to your overall vision. A governance committee can also make sure any newly created documentation and roles standards follow the specified guidelines laid out before implementation.
In addition, a clinical governance committee defines the ongoing processes for clinically related content regarding—patient safety, continued education, onboarding of new staff, reviews, and maintenance. A facility can also encourage CMS guidelines like Promoting Interoperability and Appropriate Use Criteria through the governance committee.
MEDHOST takes specific care to introduce governance concepts and promote engagement within the organization.
All of the best practices and components outlined come into play during every implementation of any MEDHOST solution, whether migrating to a cloud-based EHR or adding a new revenue cycle solution. Our team of implementation experts claims decades of combined clinical experience to help hospitals find a clear pathway to standardized documentation that supports continued clinical and operational success.
To learn about how the MEDHOST implementations team can set you up for success now and into the future, reach out to us at inquiries@medhost.com or call 1.800.383.6278.
An estimated 82 percent of hospitals in the Hospital Readmissions Reduction Program (HRRP) received readmissions penalties1 and readmission costs were higher than initial admission costs for about two-thirds of common diagnoses in 2016.2
Generally, HRRP imposes severe financial penalties for unplanned readmission within a 30-day window. To avoid readmission penalties, healthcare facilities must focus on reducing readmission rates, improving patient outcomes, patient satisfaction, and increasing reimbursement. While readmissions are occasionally unavoidable, it is essential for facilities to focus on reducing those that are preventable.
According to a 2015 study, patients discharged from facilities serving semi-rural areas had a 32 percent greater chance of being readmitted and patients discharged from rural areas had a 42 percent greater chance of being readmitted, than those discharged from facilities in urban areas. The researchers discovered that the increase in readmission rates was driven by lower rates of post-discharge follow up care and utilization of the emergency department for primary care.3
Auerbach et al. (2016) found that approximately one quarter of readmissions are preventable by implementing discharge readiness plans, improving communication between team members, and involving the patient and caregiver in discharge planning.4 Medication reconciliation, clear discharge instructions, and patient education are key areas to consider for effective discharge planning to ensure patients can be safely transitioned to the next level of care.
Medication reconciliation ensures that patients are discharged with the correct medications, dose, time, and instructions. Your EHR should have the ability to complete medication reconciliation prior to the patient’s discharge or transition of care. Medication reconciliation can help reduce the risk of the patient experiencing an adverse drug event following discharge which is a leading preventable readmission reason.5
Ensuring that patients receive and understand the correct discharge communication and documents provides a very high return on time invested. Post-discharge follow-up appointments are critical in successfully managing the patient’s treatment outside of the hospital and reducing readmission or return visits to the emergency department. During the discharge process the patient should be provided with the dates for all follow-up appointments and digital appointment reminders should be utilized when possible.
The patient and their caregiver should have a clear understanding of the follow-up care needed, and information related to who to call and when for questions following discharge. MEDHOST provides the ability to complete discharge documents, education, and follow up instructions customized for the patient. Our solution also improves communication to primary care providers by ensuring the discharge summary is available at the time of the patients discharge. The discharge summary provides relevant information related to medication changes, pending tests or results, and follow up care that is needed.
Additionally, MEDHOST provides the ability to complete and document medication reconciliation before patient’s discharge to help reduce the risk of an adverse drug event following discharge. To increase patient engagement and improve outcomes, patients can securely access their personal health records online through YourCare Community® to review medications, instructions, lab results, receive appointment reminders, and more.
Want to learn more how MEDHOST solutions can help reduce readmission risk, contact us at inquiries@medhost.com or call 1.800.383.6278.
1 Advisory Board. (2018, September 27). Map: See the 2,599 hospitals that will face readmissions penalties this year.
2 Statistical Brief #248. Healthcare Cost and Utilization Project (HCUP). February 2019. Agency for Healthcare Research and Quality, Rockville, MD. Retrieved from here.
3 Horwitz, L. I., Wang, Y., Altaf, F. K., Wang, C., Lin, Z., Liu, S., Grady, J., Bernheim, S. M., Desai, N. R., Venkatesh, A. K., & Herrin, J. (2018). Hospital Characteristics Associated With Post discharge Hospital Readmission, Observation, and Emergency Department Utilization. Medical care, 56(4), 281–289. Retrieved from here.
4 Auerbach, A. D., Kripalani, S., Vasilevskis, E. E., Sehgal, N., Lindenauer, P. K., Metlay, J. P., Fletcher, G., Ruhnke, G. W., Flanders, S. A., Kim, C., Williams, M. V., Thomas, L., Giang, V., Herzig, S. J., Patel, K., Boscardin, W. J., Robinson, E. J., & Schnipper, J. L. (2016). Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients. JAMA internal medicine, 176(4), 484–493. Retrieved from here.
5 Jennifer E Prey, Fernanda Polubriaginof, Lisa V Grossman, Ruth Masterson Creber, Demetra Tsapepas, Rimma Perotte, Min Qian, Susan Restaino, Suzanne Bakken, George Hripcsak, Leigh Efird, Joseph Underwood, David K Vawdrey, Engaging hospital patients in the medication reconciliation process using tablet computers, Journal of the American Medical Informatics Association, Volume 25, Issue 11, November 2018, Pages 1460–1469, https://doi.org/10.1093/jamia/ocy115
Human trafficking, believed to be the third-largest criminal activity in the world, is a form of modern-day slavery where people are bought, sold, and smuggled, often beaten, starved, and forced to work as prostitutes with little or no pay.1
It is a human rights violation that severely impacts millions of people worldwide. Emergency nurses have a unique opportunity to recognize victims of human trafficking and intervene. A recent study revealed that of 173 U.S. victims surveyed, 68 percent had presented to a healthcare provider at least once while being trafficked, most frequently to an emergency department provider.2
Determining the magnitude of human trafficking has proved challenging for law enforcement, policy makers, and trafficking advocates due to the covert nature of the crime and the prevalence of hidden populations.3 The United States government estimates approximately 17,500 people are trafficked nationwide.4 Researchers found that 87.8 percent of surveyed trafficking survivors were seen by a healthcare professional during captivity and went undisclosed, resulting in a missed lifesaving opportunity.5 63 percent of those surveyed were specifically examined in an emergency department.5
Healthcare access for these victims is limited and most will only have one opportunity to be examined by healthcare professionals. At present, the research is limited concerning the effectiveness of training for the emergency department staff on identification and treatment of human trafficking victims. 6 Additionally, limited availability of emergency department-specific screening tools and limited established reporting requirements, together with the barriers to patients disclosing their involvement in trafficking, make it difficult to identify these patients and provide the proper care and advocacy.
Unfortunately, these victims rarely identify themselves, and the failure to recognize victims reduces the opportunity to provide resources to such victims. Only 40.7 percent of the emergency departments specifically screened adults for human trafficking, with most ED clinical staff using one or more safety questions as their screening tools.7 Of the 59.3% of the emergency departments that did not screen adults specifically for human trafficking, several screened only children; some focused on domestic violence or abuse/neglect screening; others asked questions about safety in general but clarified that it was not specific to screening for human trafficking; and some offered no information on any actions taken in the emergency department related to human-trafficking screening.8
Typically, these victims report a high incidence of health issues such as physical abuse, sexually transmitted infections, undernourishment, and psychological trauma. When a victim seeks medical attention, this presents healthcare staff a rare opportunity to recognize victims. Hence, healthcare facilities, especially emergency departments, become the venue for identifying victims of human trafficking, providing a prospective safe haven for victims. To combat human trafficking, healthcare workers need to be trained on how to identify and approach such victims and understand what actions to take once a victim is identified.
At the health facility, screening begins at the registration desk, where the staff can look for signs of trafficking. Signs may include the patient has no insurance, guardianship information, and personal identification, the patient offers to pay with cash, or the patient may be with another individual who answers all the questions for the patient.7 If registration personnel are successful in identifying a possible victim, or if the screening for human trafficking indicates abuse, the emergency nurse can take further actions to provide help and resources.
Other red flags that may help identify victims of human trafficking include: The patient is unaware of his/her location, the patient exhibits fear, anxiety, depression, and avoids eye contract, and the patient is reluctant to explain his/her injuries.7 In addition, emergency department nurses need to know the common signs that victims of human trafficking present with to the emergency department. The most common signs of trafficking are bruises, broken bones, scars, pelvic inflammatory disease, urinary tract infections, multiple abortions or pregnancies, sexually transmitted infections, malnutrition, feelings of helplessness, shame, humiliation, and confusion.9 As victims may be fearful of the trafficker accompanying them, sometimes a silent visual notification tool can be implemented to notify staff of abuse or unsafe living situations. After that visual tool has been identified, the team members should be alerted immediately, and the patient can be escorted to a designated safe area until further steps can be taken.
If human trafficking, exploitation, or slavery is suspected, an advocate, such as a social worker or case management, should be contacted to assess the victim’s needs and educate the patient about his/her rights. If the victim is an adult, law enforcement should be contacted only after obtaining patient consent. If consent is not obtained, the patient should be given the number to the National Human Trafficking Hotline to memorize and resources should be provided. If the victim is a minor, law enforcement should be contacted to report suspected abuse.
Increasing the understanding, knowledge, and skills of ED staff and providers is essential for accurate identification of such victims so resources can be provided. MEDHOST Emergency Department Information System (EDIS) allows for screening tools to be built per your needs, as well as charting choices that can be created to help your facility identify victims of human trafficking. To learn more about how MEDHOST EDIS can help run your hospital more efficiently with customizable tools, please reach out to us at inquiries@medhost.com or call 1.800.383.6278.
1 U.S. Department of Justice. (2019). Human trafficking/involuntary servitude. Federal Bureau of Investigation. Retrieved from https://www.fbi.gov/investigate/civil-rights/human-trafficking
2 Breuer, G. J. & Daiber, D. (2019). Human trafficking awareness in the emergency care setting. Journal of Emergency Nursing, 45(1), 67-77. https://doi.org/10.1016/j.jen.2018.11.011
3 Hachey, L.M., & Phillippi, J.C. (2017). Identification and management of human trafficking victims in the emergency department. Advanced Emergency Nursing Journal, 39(1), 31-51. https://doi.org/10.1097/tme.0000000000000138
4 Ahn, R., Alpert, E. J., Purcell, G., Konstantopoulos, W. M., McGahan, A., Cafferty, E., … Burke, T. F. (2013). Human trafficking: Review of educational resources for health professionals. American Journal of Preventive Medicine, 44(3), 283–289. https://doi.org/10.1016/j.amepre.2012.10.025
5 Lederer, L. J., & Wetzel, C. A. (2014). The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Annals of Health Law, 23(1), 61–91.
6 Donahue, S., Schwien, M., & LaVallee, D. (2019). Educating emergency department staff on the identification and treatment of human trafficking victims. Journal of Emergency Nursing, 45(1), 16-23. https://doi.org/10.1016/j.jen.2018.03.021
7 Egyud, A., Stephens, K., Swanson-Bierman, B., DiCuccio, M., & Whiteman, K. (2017). Implementation of human trafficking education and treatment algorithm in the emergency department. Journal of Emergency Nursing, 43(6), 526-531. https://doi.org/10.1016/j.jen.2017.01.008
8 Dols, J. D., Beckmann-Mendez, D., McDow, J., Walker, K., & Moon, M. D. (2019). Human trafficking victim identification, assessment, and intervention strategies in South Texas emergency departments. Journal of Emergency Nursing, 45(6), 622-633. https://doi.org/10.1016/j.jen.2019.07.002
9 Lamb-Susca, L. & Clements, P.T. (2018). Intersection of human trafficking in an urban emergency department. Journal of Emergency Nursing, 44(6), 563-569. https://doi.org/10.1016/j.jen.2018.06.001
The U. S. Department of Health and Human Services (HHS) and numerous national organizations and task forces have established guidelines recommending screening for intimate partner violence (IPV).
Clinical practice and risk management experts indicate that best practice would be to include screening in emergency department protocols. Under the Affordable Care Act, these services are generally covered in new health plans without requiring a co-payment, co-insurance, or deductible.1
In the United States, over 43.6 million women and 37.7 million men have experienced physical violence, sexual violence, stalking, or psychological aggression by an intimate partner.2 About one in four women and one in ten men have experienced and reported some form of intimate partner violence.2 IPV affects all people regardless of gender, age, race, socioeconomic status, religion, or sexual orientation. Survivors of IPV can experience long-lasting effects including mental health issues, depression, and post-traumatic stress disorder (PTSD) symptoms.2
Nurses working in the emergency department (ED) can play a crucial role in the identification and management of IPV. EDs should be fully equipped and ready to identify and triage such cases since they are often the first point of contact for victims. Universal screening for IPV must be conducted consistently to increase identification and management of victims and ensure resources and referrals are provided.3
Most EDs have mandated protocols for IPV screening and intervention, but not all clinicians have received specialized training to respond to victims of various types of violence. Examination and clinical management of these patients are very complex, requiring documentation that is subject to increased scrutiny by the justice system. Clinicians, especially in the emergency room setting, must be ready for such victims while continuing to manage the rest of the department.
Screening for IPV should be conducted in a private place without visitors present. The screening questions should be asked using a respectful and nonjudgmental tone of voice.4 If the screening reveals any signs of abuse, the provider should be promptly notified so a secondary screening can occur, immediate safety concerns are addressed, and treatment protocols are followed. Patients should be offered the opportunity to contact law enforcement and should be given a referral to a domestic violence agency.
Victims cannot be accurately identified consistently without proper IPV screening tools. It is important for your emergency department EHR vendor to provide you with tools to improve IPV screening. MEDHOST Emergency Department Information System (EDIS) has a plug-in builder that allows for screening tools to be built per your needs, as well as charting choices that can be created to help your facility identify victims of IPV.
To learn more about how MEDHOST EDIS can help run your hospital more efficiently with customizable plug-ins and other tools, please reach out to us at inquiries@medhost.com or call 1.800.383.6278.
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