Section 6.2 Optimize
Optimization Strategies for Use of EHR and
HIE in Documentation
Use this tool to help ensure that all documentation requirements for your local public health (LPH)
department clients can be met efficiently and effectively. Optimization strategies for documentation
begin with proper configuration (i.e., system build), testing, and training. They extend to ensuring
adoption and optimal utilization.
Time needed: 12 - 18 hours, 4 hours on a periodic basis thereafter
Suggested other tools: 2.11 Exchange of Clinical Summaries and Other Health Information CCR–
CCD–C-CDA, 5.3 Monitoring SMART Goal Achievement to Assure Effective use of EHR and HIE,
6.9 EHR and HIE Security Risk Analysis
How to Use
1. Determine that all necessary data can be documented using your electronic health record
(EHR) system.
2. Use implementation tools to ensure optimal workflow and process design, data management,
system configuration, and training.
3. At a specified period of time after go-live—and on a regular basis thereafter—use the
workflow and process maps that have been redesigned to reflect your goals to verify that the
EHR and HIE are being used as intended.
Documenting Client Identification
Most LPH departments find that client identification and tracking individual, family, and community
services are quite challenging. The following are some key considerations that should be part of your
EHR configuration, and adhered to by policy:
 Ensure that the client is fully identified, using government-issued identification. Record
documentation used. Verify this information at each point of contact.
 When a family will receive LPH services, determine in advance whether a family EHR or
individual EHRs will be created. If separate records are maintained, ensure appropriate
identification of family members in each record and linking capability—especially if it is
necessary to track each family member for specific care modalities, such as infectious disease
testing.
Maintaining Client-Provided Documentation
 Referral portal or transaction. Receiving the referral should be enabled electronically. Ideally,
the LPH department would have a portal where those making the referral would enter all
pertinent data, or it would come across via the Consolidated-Clinical Document Architecture
(C-CDA). At a minimum, the referral functionality should include client identification,
referral status, problem list, and reason for referral.
 Incorporating paper forms. It may be necessary to incorporate paper forms into the EHR via
scanning. Some paper forms come from external sources, such as hospitals, physician offices,
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etc. In addition, some LPH departments may continue to use some paper forms for patients or
their families/caregivers to complete. Paper forms may include consent forms, agreements,
and advance directives. Prior to selecting your EHR and HIE, you should understand how
many paper forms may continue to be received after adoption, and electronic alternatives.
Scanning documents in the home and viewing them on a small screen, such as a personal
digital assistant (PDA), is not ideal; taking paper documents back to the office poses other
challenges. Many mobile devices designed for use with an LPH department’s EHR are able
to capture a client’s digitized signature directly on the device.
 Intake completion guidance. Intake may be as simple as collecting client identification and
referral information, or it may entail a more comprehensive assessment and documentation of
the client’s situation. Ideally, the EHR should support assessment documentation, offering
guidance about what information is required. This is referred to as context-sensitive
information gathering. As you enter data, the template’s logic branching helps validate
entries. This can improve user satisfaction, speed up the intake process, eliminate errors and
omissions, and reduce turnaround time. Based on the initial intake and compilation of the
problem list (see below), the EHR should be able to offer a care plan template unique to the
type of patient being seen. Some systems enable you to customize care plans in accordance
with your own standards of practice and/or payer rules. Care plans should also include or link
directly to goals and interventions.
Documenting Problem List
Most referrals will include a statement of the client’s problem, or a problem list that consists of the
medical diagnoses for which the client has received medical treatment. Most public health nurses
prefer to document nursing problems, consistent with the Omaha System, and it is advisable that
nurses be trained to use this system. Select an EHR that includes support for this documentation.
Professional judgment is required to select the appropriate terminology to document nursing
problems, which are described based on the signs and symptoms for which nursing services are
provided. For example, if a nurse observes inflammation of the skin around the stoma where a client
has a colostomy, the problem to be addressed by the nurse is the inflammation
Some EHR systems have specific requirements for documenting, updating, changing, and deleting
problems and their associated documentation. If this is not true for your EHR, it is advisable to
develop your own policies. For example, if a problem is entered and there is charting for the
problem, the problem should not be able to be deleted. If the problem has been resolved, there should
be the ability to document resolution with an annotation or symbol.
Documenting Medications
Obtaining referral information in the form of the CCD or CDA should supply you with a medication
list that is current at the time the CCD or CDA was generated. It is essential to determine whether the
medication list is current for your client. A list supplied through an HIE organization (HIO) should
be the most up-to-date list. The list will usually include only medications that have been prescribed
for a patient and/or filled by a pharmacy (check which). It may not include over-the-counter
medications, samples supplied by a provider, or those acquired by other means. And of course, no
assumption can be made about whether the person is actually taking the medications. Just as with the
problem list, the medication list must be verified at every point of contact. Medication list
functionality in the EHR should include the source of the medication and its current status of
administration.
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Documenting Care Plans
Electronic care plans can be achieved through most EHR systems. Many of these systems include
care plan templates specific to your patients’ problems (and driven by the problem lists you create
using the Omaha System). Some EHR products enable you to create new templates or customize
their templates to your standards of practice, physician expectations, or payer requirements. The
nurse should continually update the care plan by adding, deleting, or modifying goals and
interventions.
As providers move toward new models of care, such as the patient-centered medical home, the care
plan is increasingly becoming an important tool for patient engagement and self-management. The
care plan should be discussed and even negotiated with the client to increase the likelihood of
compliance. For example, if a nurse believes it is important for a client with diabetes to “exercise,
diet, and stop smoking” the likelihood of the client doing all three is not very good. The nurse should
discuss what steps toward a healthier lifestyle the client believes he or she can undertake now.
Describe specifically what type of exercise (“Can you take a brisk walk for 20 minutes a day?”),
what type of diet, and ways to stop smoking. Ask which one or two things are easiest for the client to
achieve. Make that a goal and monitor it with the client. Once success is achieved, move to the next
goal. A presentation by Jeanie Knox Houtsinger for the Louisiana Public Health Institute on Patient
Engagement and Self-Management provide an excellent briefing:
www.lphi.org/LPHIadmin/uploads/Pt-Engage-Self-Mgt-Knox-24859.pdf
Visit Notes
When public health nurses conduct a client visit, a note template can be pre-populated with patient
demographics and other pertinent information that is received from the referring provider—through
an HIE, such as current medication list and lab results—and from the EHR’s problem list. Special
alerts or reminders specific to the patient should appear in conjunction with the note template. Visit
details, including documenting vital signs, review of systems, treatments, teaching, and medication
management can be documented. Often EHRs will include both “point-and-click” capability to
capture all data points and illustrations on which field personnel can document wounds, pain,
incisions, etc.
This documentation should be able to be converted into a narrative summary, which is then available
by simply clicking on an icon. Variances from care plans as a result of patient findings and changes
in services should generate variance codes and result in adjustments to the care plan. The system
should include checks and balances to ensure that any such changes to the care plan are reviewed and
signed off on as needed.
Medication management can also be documented. EHRs should provide a list of medications, dose,
and route. Other systems add alerts that support monitoring for adverse drug reactions, such as by
providing additional information about the drug or pre-approved links to further information.
Patient Information and Education
Patient information and education can be generated from an EHR. This can be patient specific, even
including the patient’s photograph. Teaching materials can illustrate for the patient how to take
medication, how to care for wounds, how to prepare special diets, and how to perform many other
aspects of their care. Those delivering teaching services can be guided as to whether the teaching is
reasonable and necessary. They can also be reminded of the principles necessary to impart patient
information and education to adults.
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Engaging the patient in providing a trend line or other type of diary or report card about how well he
or she is doing managing blood sugar, blood pressure, etc. can be a powerful motivator for the patient
to continue compliance and improve even more. Such report cards can also be used, in aggregate
form, to measure the quality of care your organization is providing.
Copyright © 2014 Stratis Health.
Section 6 Optimize—Optimization Strategies for Use of EHR and HIE in Documentation - 4
Updated 03-18-14