Section 6.3 Optimize
Optimization Strategies for Use of EHR and
HIE in Assessment, OASIS, Care Plan, Visit,
and Teaching Documentation
Use this tool to help ensure that all assessment requirements, care plans, and clinician visits for your
clients can be efficiently and effectively documented. 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: 4 hours
Suggested other tools: Section 4.5 Workflow and Process Improvement with EHR and HIE, Section
4.6 Data Management, Section 4.7 System Build, Section 4.14 Training Plan
How to Use
1. Determine that required assessments, care plans, and visits can be documented using your
electronic health record (EHR) system.
2. Use implementation tools in Section 4 to ensure optimal workflow and process design, data
management, system configuration, and training.
3. Use the workflow and process maps that have been redesigned to reflect your goals to verify that
users are using the EHR and HIE as intended by a specified time after go-live and on a regular
basis thereafter (see Section 5.3 Monitoring SMART Goal Achievement to Assure Value from
EHR and HIE).
Documenting the Patient Assessment
Most home health agencies find that documenting the patient assessment requires variable
workflows, depending on patient status, resource availability, and other factors. The EHR and HIE
capability you use should be able to accommodate a variety of functions:
□ Referral portal or transaction. Receiving the referral should be enabled electronically.
Ideally, the agency uses a portal where those making the referral enter all pertinent data,
or it would come across via the Consolidated-Clinical Document Architecture (C-CDA)
(see Section 2.10 Exchange of Clinical Summaries via CCR, CCD, C-CDA). At a
minimum, the referral functionality should include patient demographic and payment
information, referral status (e.g., under evaluation, admitted, on hold, ready), diagnosis,
evidence of meeting reimbursement requirements, and services required. Many home
health agency EHRs now are able to provide auto-population of the CMS-485.
□ Incorporating paper forms. It may be necessary to scan paper forms into the EHR. Some
paper forms come from external sources, such as hospitals, physician offices, etc. In
addition, some home health agencies may continue to provide some paper forms to
patients or their families/caregivers. These 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 what electronic
alternatives exist. Scanning documents in the home and viewing them on a small
Section 6 Optimize—Optimization Strategies for Use of EHR and HIE in Assessment, OASIS, Care Plan, Visit - 1
screen—such as found on a personal digital assistant (PDA)—is not ideal. Many mobile
devices for use with home health agency EHRs are able to capture a client’s (digitized)
signature (see Section 6.11 EHR and HIE Security Risk Analysis) directly on the device.
□ Assessment completion guidance. A system that guides staff on what assessment
information is required and validates entries as accurate can significantly improve user
satisfaction, speed assessment performance, eliminate errors and omissions, reduce
turnaround time for orders and billing, and make it easy for surveyors to review
Outcome and Assessment Information Set (OASIS) data. Many systems indicate the
percent of the assessment that has been completed and can help with staging completion
over multiple visits. When the OASIS assessment is completed, a home health resource
group (HHRG) score should be able to be displayed. Based on the initial assessment,
your staff should be able to select care plan templates for each individual patient. Some
systems enable you to customize these in accordance with your own standards of
practice and/or payer rules. The care plans should also include or link directly to goals
and interventions.
□ OASIS data collection should be able to be initiated by data collected on admission and
completed with data collected during the assessments. Field-by-field checks for
completion of the OASIS data set should be able to be performed as the assessments are
documented. Information should also transfer to the Plan of Care (CMS-485) from the
home health assessment to minimize duplication of efforts and reduce the likelihood of
errors. Once validated electronically, the OASIS data set can be submitted
electronically.
Documenting Care Plans
Electronic plans of care can be achieved through most EHR systems. Many of these systems include
point of care (POC) templates specific to your patients’ problems. They should reflect all disciplines
treating the patient. Some EHR products enable you to create new templates or customize templates
to your standards of practice, physician expectations, or payer requirements. As care ensues,
clinicians can update the POC by adding, deleting, or modifying goals and interventions. When there
is a change in medications, visits, or other treatments, orders should be able to be generated from the
POC—in 485 or generic format as desired. These orders should then carry forward to the physician
dashboard for review and modification or approval.
Visit Notes
When field personnel conduct a client visit, a notes template can be pre-populated with patient
demographics and other pertinent information received from the referring provider and through an
HIE, such as current medication list and lab results. Special alerts or reminders for that 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 for field
personnel to use to document wounds, pain, incisions, etc. This documentation should be able to be
converted into a narrative summary that will be available when you click on an icon for all
summaries or a specific summary. Variances from care plans as a result of patient findings and
changes in actual services should generate variance codes and result in adjustments to the POC. The
system should encompass checks and balances to ensure that any such changes to the POC are
reviewed and signed off appropriately.
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In addition to documenting findings, medication management can also be documented. EHRs should
provide a list of the medications, dose, and route. Sometimes alerts functionality is added that helps
monitor adverse drug reactions. These may provide additional information about the drug or enable
staff to link to further information.
Patient Information and Education
Patient information and education can be generated from an EHR. This can be patient specific,
including a digital photograph. Teaching materials can illustrate 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 services can also be guided as to whether the teaching is reasonable and necessary and
regarding how to impart such information.
Engaging the patient in providing a trend line or other type of report card documenting blood sugar
or blood pressure management, etc. can be a powerful motivator for the patient. Such report cards
can also be used—in aggregate form—to demonstrate the quality of care your organization provided.
Copyright © 2013
Updated 11-20-13
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