PGodfrey_Automation of Plan of Care_Practicum1_ Project

Running Head: PLAN OF CARE AUTOMATION

Plan of Care Automation for Care Management Organization.

Paul Godfrey, MBA, BSN, RN, MSN Candidate

Rutgers University, Newark NJ

School of Nursing

NINF5305: Nursing Informatics Practicum

Faculty Advisor: Rose P. Estrada, DNP, RN, BC, CPN

Preceptor: Deidra Brown, RN, MSN, NP

Facility/Address: Montefiore Care Management, 200 Corporate Blvd, Yonkers, NY 10701

December 3, 2014

PLAN OF CARE AUTOMATION 1

Abstract

When a patient comes to the hospital or any of the health care institutions, the

interdisciplinary team (IDT), which is made up of nurses, physicians, pharmacists, social

workers, etc., will in most cases assess the patient physically before any plan of care is initiated.

The nurse will follow the nursing process of assessment, diagnoses, planning, intervention, and

evaluation. The plan of care is documented electronically or manually in some cases and the

nurse charts periodic activities showing patient progress and interventions provided. Discharge

planning begins the day of admission as is the case in traditional health care institutions. The

complexities of performing these functions is multiplied if not quadrupled while performing care

plans for patients you can neither see or touch. While using communication sources such as a

telephone, electronic email, manual mail, and other communication mechanisms, efforts are

made to apply the nursing process for the ultimate health of the patient.

The nurse being the patient advocate and leader of the IDT chairs the task of coordinating

the activities of the IDT. This is enormous and daunting task. The complexity is exemplified

with the fact that some of the nurses may have hundreds of patients/members to manage.

“President Obama is pushing to establish EHR for all Americans prior to 2015 by making $17

billion available to e-health projects and programs. Database companies will be investing

significant effort in developing health and medical database systems that are accessible on the

Internet” (Stair & Reynolds, 2012, p138). The automation of plan for members/patients of care

coordination entities will help to provide all needed interventions effectively and also foster the

efficient and detailed documentation of all triggered problems which should be made part of the

Electronic Health Record (EHR) for members.


Project Scope

Within the scope of this project, issues relating to the possible economic impact of care

coordination and resource allocation will be addressed. This project will also highlight possible

information technology issues affecting care coordination outside traditional health care

institutions and offer possible solutions. The application of nursing science to care coordination

outside of traditional health care institutions will be highlighted to show how different it is from

the traditional health care institutions. Montefiore Care Management Organization (CMO) will

be used as an example, to show some of the efforts that have been made in the area of

automation of Plan of Care with regards to care management outside traditional health care

institutions. Lastly, this project will highlight leveraging information technology in educating the

clinicians to become effective in performing their attributed task toward achieving positive

health outcomes.

Project Goal/Purpose

The goal of this project is to show how automating the process of care planning for

managing patients outside a traditional health care institution will help to drive the enormous

inherent tasks of patient care management. This function will add decision support to the care

management application system. Some of the domains of care for care management and care

coordination outside of the traditional health care institutions includes the following: Palliative,

Hospice, Behavioral Health, Benefits/Entitlements, Care Access, Care-Giving, Functions,

Housing, Legal, Life Planning, Preventative, and Psychosocial. A patient presenting with many

problems originating from many of the aforementioned domains of care, presents a challenge as

to which problem should take precedent before the other. Automating a plan of care will help to

drive the problem, goals and intervention into an automated task system. Tasks can be collected


within a workbasket shared by a group of clinicians responsible for providing care to the

patient/member. The tasks in the workbasket can now be automated to be divided among the

team using round-robin logic to drive the tasks into worklist. These tasks are to be called

interventions which may lead to interactions between patient/member and the clinician. “The

promise of fully realized EHRs is having a single record that includes all of a patient's health

information: a record that is up to date, complete, and accurate. This puts providers in a better

position to work with their patients to make good decisions.” (www.healthit.gov). Some of the

benefits of EHR are listed by www.healthit.gov as the following: improving the quality and

convenience of patient care, increasing patient participation in their care, improving accuracy of

diagnoses and health outcomes, improving care coordination, and increasing practice efficiencies

and cost savings.

Project Objectives

The objective of this project with regards to the related health care industry is to highlight

the difficult task of care management outside traditional health care institutions. Acknowledging

the involved daunting task will lead to solutions related to automation of the process of care

planning for members/patient enrolled in care management outside traditional health care

institutions. The solution will center on task driven logic that will help the clinicians to manage

multiple tasks for members/patients of care management. To effectively accomplish the ultimate

goal of positively affecting patient/member health outcome, educating the IDT on the usefulness

and benefits of utilizing information technology will be invaluable. Identifying the competency

of the IDT in utilizing the provided technology and suggested ways of providing needed

education will be discussed as one of the objectives.

http://www.healthit.gov/

http://www.healthit.gov/


With respect to accomplishing the course objectives through this project, the role of

information technology in care management is addressed. The concomitant relationship between

positive patient care outcome and utilization of information technology is paramount in this

project. After the completion of this project, I would have demonstrated how to initiate a project;

manage the triple constraints of a project which are time, resources, and scope; and finally,

demonstrated how to maintain the quality of a product as the ultimate end goal of the project.

Project Stakeholders/Organizational culture

The umbrella project for an application that will be capable of encapsulating care

planning automation will be a replacement of CMO legacy care management system called

CCMS. Several stakeholders will include outside vendor, Montefiore Information Technology

Team (Montefiore IT), CMO Data Reporting Team (DAR), CMO Care Management Process

Engineering Team (CMPE), CMO Center for Innovation and Learning Team (CIL), CMO

Management Information Systems Team (MIS), and CMO Clinical Subject Matter Experts. The

CIL is responsible for assessing computer competency of CMO clinicians and providing

educational strategy and training to address the identified deficiencies. The component of a

Decision Support System, which is a primary focus of this project, is the Plan of Care

Automation.

Project Schedule/timeline

Work Breakdown Structure (WBS) is a technique used for organizing and subdividing all

the tasks and deliverables attributed to a project into more manageable components (Gido and

Clements, 2012, p107). Deliverables in this project is derived from the scope of the project in

alliance with triple constraints of a project. The following will be the deliverables within this

project: discuss enormous economic impact of care coordination without automation of care


planning, discuss information technology issues affecting care coordination outside traditional

health care institutions, discuss and relate the application of Nursing Science to the possible

domains of care, and finally using Montefiore Hospital as an example without divulging

proprietary information, I will explain and show the efforts that have been made in the area of

automation of Plan of Care with regards to care management outside traditional health care

institutions.

Project Cost Analysis (Tangible and Intangible Benefits)

Montefiore is planning to implement an application for CMO entity to be used for Care

Management and also planning to implement Epic Application for the Hospital Inpatient and

CMO Utilization Management. The cost of implementing plan of care automation is expected to

be assumed within Care Management project. The automation of Plan of Care has enormous

intangible and tangible benefits. When intervention tasks are automated, clinicians can reach out

to members more effectively and better manage their work load; these will inevitably have a

positive effect on care outcome. More members can be reached within a reasonable time period

when scheduling tasks are automated. The turnaround time is greatly improved between

assigning a member to a care manager and being able to reach out to the member.

Project Monitoring and quality management

Negotiation is ongoing for vendor selection. Staff education will be ongoing and

subsequent meeting with clinical subject matter experts are also ongoing to foster buy-in and

assurance that the system will meet the goals of the clinicians. The ultimate test of quality will

also be established when the clinicians are able to manage their work load more effectively

through the effective deployment of the automated care planning process.


Project

Start Date

Project

End Date

Project

Duration

(Total Days)

Project

Duration

(Total

Hours)

Project

Plan of Care Automation: Information Technology

Solution to Coordination of Care Management

Outside Traditional Health Care Institutions.9/2/2014 12/18/2014 17 100

Task # Task Name Start Date End Date

Duration

(Days)

Duration

(Hours)

100

Highlight issues relating to the possible economics

impact of care coordination and resource allocation 9/2/2014 9/4/2014 3 9

101 Brainstome with Preceptor 9/2/2014 9/2/2014

102 Literature Review 9/3/2014 9/3/2014

103 Document findings 9/4/2014 9/4/2014

104 Review documentation with Preceptor 9/4/2014 9/4/2014

200

Highlight possible Information Technology issues

affecting care coordination outside traditional health

care institutions and offer possible solutions 9/9/2014 9/11/2014 3 10

201 Brainstome with Preceptor 9/9/2014 9/10/2014

202 Literature Review 9/10/2014 9/10/2014

203 Document findings 9/11/2014 9/11/2014

204 Review documentation with Preceptor 9/11/2014 9/11/2014

300

The application of nursing science to care

coordination outside of traditional health care 9/16/2014 9/18/2014 3 9

301 Discuss Domains of Care 9/16/2014 9/17/2014

302 Discuss Problem Domains 9/17/2014 9/18/2014

303 Discuss Goals related to Problems 9/18/2014 9/18/2014

304 Discuss Interventions 9/18/2014 9/18/2014

400 Analyse and Produce As-is Workflow 9/25/2014 10/9/2014 2 18

401

Use legacy CCMS System to produce as-is

workflow 9/25/2014 9/25/2014

402 Discuss workflow with select Clinical Team 9/25/2014 9/25/2014

403 Discuss workflow with Preceptor 10/9/2014 10/9/2014

404 Validate content with CLI Team 10/9/2014 10/9/2014

500 Analyse and Produce To-be Workflow 10/23/2014 11/6/2014 2 18

501

Review ZeOmega Jiva Application Task

Management Proposition 10/23/2014 10/23/2014

502 Produce workflow with select Clinical Team 10/23/2014 10/23/2014

503 Discuss workflow with Preceptor 11/6/2014 11/6/2014

504 Validate content with CLI Team 11/6/2014 11/6/2014

600

Propose Education method for Clinician Adaptation

to New Care Planning Process 11/20/2014 12/4/2014 2 18

601

Propose Ongoing Method of Assessing Current

Level of Staff Computer Competency 11/20/2014 11/20/2014

602

Propose ways of addressing Staff Computer

Competency deficiencies 12/4/2014 12/4/2014

603 Discuss Suggestions with CLI Team 12/4/2014 12/4/2014

700 Deliver all documentations and findings 12/11/2014 12/18/2014 2 18

701

Deliver documentations and obtain feedback

from all stakeholders. 12/11/2014 12/11/2014

702

Sign off and obtain feedback from all

stakeholders. 12/18/2014 12/18/2014

Project SchedulePlan of Care Automation: Information Technology Solution to Coordination of Care Management Outside Traditional




Project Executing Process

Consultation with CMO clinicians and the vendor will be ongoing in the process of

executing this project. Following the system development life cycle, there will be a period when

super users will be trained on the new process of care planning. The super users will in turn train

the general staff. There will be a process in place to train the incumbent staff on the new

workflow for care planning using the new system when fully implemented. There is a need also

to leverage hands-on self-paced training for reinforcing knowledge of the staff. There will also

be a process in place to train new staff and establish their level of computer proficiency. Plan

will also be in place on how to address deficiency because proper utilization of the automated

tasks and care planning will be dependent upon staff ability to use the system effectively.

Project Communication/Reporting

Communication during the project development is mostly through meetings and emails.

Remote meeting is regularly scheduled to review the status of the project between the vendors,

and other stakeholders.

Ethical and legal considerations

The project is mostly centered on the content of Electronic Medical Record and does not

present information to be shared with outside entity without the consent of the member. Member

is consented to be enrolled in the program managed by CMO. The automation of the Plan of

Care simply provides a better way of performing the necessary task to help provide the best care

for the member. The legal department of Montefiore takes care of all legal issues but the

clinician upon communicating with the member seeks consent for the service to be provided. All

HIPAA and other related regulations are adhered to accordingly.


Conclusions/Analysis of Project Outcome and Success

Much of the analysis of the outcome of the project will be centered on the delivery of the

product with the automated care plan process. The success of the project will be attributed to a

task driven intervention process where all clinicians can have a portion of their task in their

work-list and also the system can transfer work from one work-list to another using an algorithm

to decide who has the most/least task, absenteeism, and other business level decision factors. The

system will also successfully offer a set of goals and interventions when a problem is identified

for a member. The clinicians will also have proper training on how to use the system and also

show proficiency in utilizing the functions of the system to provide the best care for the

members. Vendor selection is still ongoing for this project. Most project do not succeed because

of ineffective vendor performance. Montefiore is still performing vendor selection. In the United

States, about $275 billion is spent annually on software projects and it is estimated that about

50% of these project encountered more cost than originally estimated and about 23% of these

project fail outright (Chiang & Mookerjee, 2004, p3). This is the reason Montefiore is

reconsidering the original vendor selected, to increase the chances of completing this important

project.

Care Planning

Montefiore anticipated that the automation of care plan will give the clinicians the ability

to update the status of intervention against each goal it is linked with. It is expected that there has

to exist a strong rule not to allow clinicians to close problems without first closing the

intervention linked with the problems. The most daunting task is gathering all the domain of care

and identifying all possible problems, associated goals, and interventions. It is anticipated that a

member can present with many problems from different domains of care (heart failure, diabetes,


behavioral, access to care, financial assistance, etc.). Each problem can have many goals

associated with it and also many interventions. Interventions are geared towards reaching goals

associated with the problem.

Goals are preconfigured with priority which will help to drive the priority of associated

interventions. The interventions will become tasks which will be assigned to a workbasket. It is

anticipated that the system will not allow a member to be assigned the same problem from the

same domain at the same time. Preventing duplication of item to be placed in the member’s care

plan is an invaluable expected function. “The dynamics of communicating resident needs and the

associated interventions of the written resident care plan to direct caregivers confound the

effectiveness of care planning and delivery” (Adams-Wendling et al, 2008, p54).

Intervention Task Management

Montefiore is anticipating that this system should provide some functionality which will

automate the process of care management after care planning has been established. Montefiore

anticipated that the system should provide the ability to allow configuration of possible outcomes

which will be displayed to the end users upon selecting task. The anticipated system must have

the ability to automatically close certain type of member tasks, for example, intervention, goals,

and problems, when there is a change of status for the member with the outcome of the task

showing the new status. “One of the other benefits of using electronic systems is the potential for

automating activities and processes as well as streamlining clinical workflow.” (Hosker, 2007,

p393)

The system should allow users to filter their assigned tasks and show the status of the task

as either outstanding or completed. The system must have dynamic window popup which should

take the user to a required window or screen to complete a task and toggle back to the original


screen as needed. The system must also use auto assignment to stratify which workbasket should

contain what type of task, for example, tasks for physicians should be auto assigned to the

physician’s workbasket and tasks for the registered nurse should be auto assigned to the

registered nurse workbasket. “Electronic care planning, assessments and referrals are other areas

which offer opportunities for automation. For example, if a patient has a care plan for a central

venous access device created in the system this can trigger an automatic referral to the

appropriate specialist nurse which reduces the potential for human error or confusion.” (Hosker,

2007, p394) Montefiore anticipates that the system will provide a logic which will move

intervention task from one work queue to another based on set rules. When a clinician is not

available for a reasonable time, the changing of a status for clinician availability will trigger the

system to automatically move intervention task to the other group members in that queue.

Plan of Care Automation as an attribute of a Decision Support System (DSS)

Stair and Ralph (2012) explained that DSS “is an organized collection of people,

procedures, software, databases, and devices used to help make decisions that solve problems”

(p288). Problem solving support is the hallmark of DSS. Manipulation of repository of

information is utilized to offer opinions or possible solutions to a problem. In patient care, most

diseases have established signs and symptoms using evidenced based practice, and when these

signs and symptoms are stored in a system, suggestion could be offered to the user when similar

signs and symptom are manifested and presented. The plan of care automation will follow

similar concept. Information will be linked with logics and suggestions will be disseminated to

the clinicians when similar problems are presented. In that manner, the goals and interventions

options will be presented to the clinicians as well. The ultimate decision is left for the clinician to

make using a DSS.


Sookyung et al. (2013) presented a research that involved the School of Nursing at

Columbia University, which was conducted in 2002. In this research, it was stated that Advanced

Practice Nurse (APN) students will keep a clinical log which will contain patient encounter data

documentation, patient diagnoses information relating to nursing and medical diagnosis, and then

documentation of nursing interventions using mHealth platform. It was concluded that by

incorporating evidence based practice into the workflow within mHealth DSS, it can invariably

assist nurses in managing a smoking cessation plan of care and potentially expand the nurses’

roles in making referrals and providing helpful information to smokers with the ultimate goal of

encouraging smoking cessation (Sookyung et al., 2013).

Addressing the Clinician’s Resistance to Plan of Care Automation

Nursing process includes assessment, nursing diagnoses, planning, implementation, and

evaluation. Evidenced based practice is the pivot upon which the wheels of nursing process

rotate. A DSS cannot implement the nursing care plan but will offer a suggestion based on

repository of information which supports the decision. Weber (2007) estimated that the first

computer based DSS was developed in the 1980’s. In different practices of nursing, there are

established workflows when certain actions related to a care plan are carried out. These

established workflows can be automated and presented as a DSS to help the nurse in making

decisions relating to patient care effectively. Wills et al. (2010) explained that “a variety of

systems and technologies support knowledge creation in the clinical environment, including

neural networks, data mining techniques, Bayesian methods, and many others. These

technologies make it possible for knowledge to be created from disparate data sources and used

to support the clinical processes of diagnosis, treatment, monitoring and prognosis” (p569).


User initial involvement in the development process is critical towards creating an

environment where migration to the new system could be with minimal resistance. User

confidence level is increased with proper migration plan. Change is never a seamless process but

detailed training plan and supportive user manual increases the user confidence level and the

ability to be productive with minimal resistance. “Every executive is responsible for ensuring

the highest quality of care provided in the most efficient manner, therefore, planning for any

restructuring must seriously consider plans for concurrent efforts to develop and maintain staff

competencies” (Miller & Arquiza, 1999, p49). The quality of care has a direct relationship with

the efficiency of the process. The process is improved with automation which helps to streamline

the workflow and remove redundancies and unnecessary process bottlenecks, which contributes

to waste. Limited resources demand that scale of preference and opportunity cost analysis must

be done in order to maximize resource output. Cost containment can be achieved when DSS is

properly utilized and the users can see the need for improved process.

The CLI department in CMO is tasked with assessing the competencies of the nursing

staff and providing proper training to bridge the identified gaps and foster productivity. Explain-

show-hands-on approach is highly utilized in a classroom setting for ongoing nursing staff

training. With respect to implementing a new system, super users are selected from different

departments within CMO under the guidance and leadership of CLI. “According to MacBride &

Nagle (1996), it is of essence that positive attitudes towards computers be promoted among

nurses if they are to use computers at optimal levels in both educational and practical setting

(Kivuti & Chepchirchir, 2011, p2). Negative attitude towards change is detrimental to successful

implementation of a new system. The automation of a care plan will rely on the clinician’s

ability to use the system options as intended.


References

Adams-Wendling, L., Piamjariyakul, U., Bott, M., & Taunton, R. (2008). Strategies for

translating the resident care plan into daily practice. Journal Of Gerontological

Nursing, 34(8), 50-56. doi:10.3928/00989134-20080801-11

Chiang, I. R., & Mookerjee, V. S. (2004). A Fault Threshold Policy to Manage Software

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doi:10.1287/isre.1040.0012

Gido, J., and Clements, J. P. (2012). Successful project management, Fifth Edition,

South-Wester Cengage Learning, Mason, Ohio.

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Kivuti, L. W., & Chepchirchir, A. (2011). Computerization readiness. Online Journal Of Nursing

Informatics, 15(1),

Miller, E., & Arquiza, E. (1999). Improving computer skills to support hospital

restructing. Journal Of Nursing Care Quality, 13(5), 44-56.

Sookyung, H., Hodorowski, J. K., Nirenberg, A., Perocchia, R. S., Staats, J. A., Velez, O., &

Bakken, S. (2013). Mobile Health-Based Approaches for Smoking Cessation

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Stair, R. & Reynolds, G. (2012). Fundamentals of Information Systems. (6th

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Boston, MA: Course Technology

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http://www.healthit.gov/providers-professionals/benefits-electronic-health-records-ehrs


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Nurse Practitioners, 19(11), 580-590. doi:10.1111/j.1745-7599.2007.00262.x

Wills, M. J., Sarnikar, S., El-Gayar, O. F., & Deokar, A. V. (2010). Information Systems and

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Documents

PGodfrey_Automation of Plan of Care_Practicum1_ Project