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Show ADVANCED DIRECTIVE SRS AND DASHBOARD Advanced Directive Software Requirements Specification and Dashboard for UHealth Mykel Winter, BSN, RN, CCRN University of Utah In partial fulfillment of a Master of Science Degree College of Nursing Major: Nursing Specialty: Nursing Informatics ADVANCED DIRECTIVE SRS AND DASHBOARD 2 Introduction Advanced care planning (ACP) has been linked to an increase in patient autonomy and the utilization of palliative care, while decreasing costly end of life treatment, hospitalization, family distress and decision-making burden (Carr & Luth, 2017; Detering & Silveira, 2018). One of the crucial components of ACP are advanced directives (AD) which are documents (Living Will, Durable Power of Attorney for Health Care, Combined Directives, Physician Orders for Life Sustaining Treatment ), that a person completes while in decisional capacity about possible treatment options, if at some point the ability to communicate their desires is no longer an option (Detering & Silveira, 2018) . Despite the significant impact, there is inconsistent data regarding completion (Detering & Silveira, 2018; Yadav, et al,. 2017) with some studies showing only thirty to fifty percent completion rates (Detering & Silveira 2018; Walker, et al., 2018; Yadav, et al., 2018). Efforts to improve the completion of AD started in 1990 with the Patient SelfDetermination Act (PSDA), which required healthcare facilities to question patients about advanced directives and provide additional information, if the facilities were receiving payment from Medicare or Medicaid (Carr & Luth, 2017). In addition to the low completion rate, there are inconsistencies in where the information is documented. The electronic health record (EHR) has improved documentation efficiency, but in some instances, has also increased variability in documentation, contributing to difficult data retrieval and fragmentated information (Chao, 2016). A cross-sectional study conducted at the Veterans Affair Medical Center in San Francisco showed that 55% of ACP discussions were not easily accessible (Walker, et al., 2018). A study done at Kaiser showed that with the implementation of a standardized location for documentation, AD documentation increased by up to 9.6% (Turley, Wang, Meng, Kanter, & Garrido, 2016). ADVANCED DIRECTIVE SRS AND DASHBOARD 3 Stage two of the Meaningful Use Requirements aim to use the EHR for continuous quality improvement and to exchange information in the most structured format possible (Centers for Disease Control and Prevention, 2019). The University of Utah Healthcare (UHealth) Nursing Quality team uses Software Requirement Specifications (SRS) to design dashboards to track quality measures. SRS are done during the development stage of a project to translate stakeholder needs, expectations, and any constraints into a set of software requirements (Schmidt, 2013). This process allows for specifications regarding software, computing environment, and post-development to be designed (Schmidt, 2013). A dashboard is a clinical decision support (CDS) tool that provides visual representation of performance measures in a single report (Livernois, 2019). Dashboards integrate evidence-based quality indicators and have been shown to decrease time and effort to gather information, reduce error rates, and improve quality of care, patient safety, situational awareness, usability and navigation. (Livernois, 2019; Schall, et al., 2017; Stadler, Donlon, Siewert, Franken, & Lewis, 2016). Dashboards also allow for standardization of analysis, ensuring the same metrics and processes are used for comparison among healthcare facilities (Schall, et al., 2017). The current compliance evaluation process at the UHealth has many locations where information can be entered, making it difficult to track quality metrics. There are also multiple places within the EHR that managers have to navigate to see the various quality measures. The goal at the UHealth is to have all of this information presented in one place to ensure increased accessibility and use. The current AD assessment includes two main topics with multiple subtopics: 1. Does patient have an Advance Directive? • Type of document ADVANCED DIRECTIVE SRS AND DASHBOARD 4 2. Location of Advance Directive • Is Advance Directive up to date? • Date of Advance Directive • Would you like additional information or assistance to complete an Advance Directive? • Was information about Advance Directive given to the patient? UHealth currently uses one piece of documentation to determine compliance: "Does patient have an Advance Directive?". To be considered compliant, an acceptable value has to be entered within a defined interval which is determined by location. If the nurse documents that the patient would like additional information or assistance, social work is triggered to follow up. The objective of this project will be to improve the current SRS and dashboard for advance directives so that nursing leadership is able to track the completion of AD assessments as a quality measurement. This will allow for the identification of processes that need improvement to increase compliance for the institution. Methods The implementation of the AD dashboard will be done at the UHealth and Huntsman Cancer Institute (HCI) in all inpatient areas, emergency and procedural areas. UHealth is the only academic healthcare system in the Mountain West, providing care to five surrounding states (University of Utah Health). HCI treats more than 142,000 patients annually and is the only designated National Cancer Institute Comprehensive Care Center in the Mountain West (Huntsman Cancer Institute, 2018). ADVANCED DIRECTIVE SRS AND DASHBOARD 5 UHealth has a current process for AD compliance in place. The process was reviewed to determine what information is missing, unnecessary, or needs to be altered, to better suit the stakeholders need. The current process used to view compliance is a reports tab available in EPIC. This tab is linked to a SAP Crystal reporting system, which allows the user to view compliance based on the institution as a whole, individual unit, or patient. The information displayed varies depending on the level chosen. The most detailed report includes unit, patient name, if they have an advance directive, admission date and time, initial advance directive time, initial assessment, reassessment time and if the reassessment was completed within the required window depending on location (emergency department, inpatient, or procedural area). UHealth has decided to transition all reports to a Tableau dashboard. An SRS has to be designed and submitted for the data warehouse engineer (DWE) to design the dashboard. After evaluating the current process, a meeting was held with the informaticist who had determined the requirements for the currently-used Crystals report, to ensure any limitations or constraints were understood in the current AD compliance report. The previous SRS for AD compliance was used as a template to build upon, rather than starting from scratch. Trends were noted when viewing the Tableau site with how UHealth chooses to display their quality metrics regarding layouts, filters, colors and representation. To ensure the compliance report would meet all needs of the stakeholders and regulations of the accreditation body, the AD policy and NIAHO Accreditation Requirements and Interpretive Guidelines (DNV GL Healthcare) were reviewed and referenced in the report. To develop the logic for the report, business process model and notation (BPMN) was used to define the logic steps that need to be implemented to establish compliance (White, 2004). In the development of the logic for procedural areas, inpatient, and the emergency department ADVANCED DIRECTIVE SRS AND DASHBOARD 6 (ED), flow objects (events, activities, and gateways), connecting flows (sequence flow), and artifacts (annotation) were used. The logic was designed using Lucidchart. Initially three separate logic diagrams were constructed to determine which steps were consistent despite the area. The final product combined all three diagrams into one logic flow, ensuring no steps were duplicated and that the process would be easy to follow, for any audience. For the development of the mock up for the Tableau Dashboard, the current nursing reports were referenced. UHealth uses a standard set of filters that is placed on the right side of the dashboard and a standard set of colors, to maintain consistency and allow for easy identification of the interpretation of results. Additional UHealth dashboards were referenced to determine which results should be shown on the page to give nursing leadership adequate information. Balsalmiq and Photoshop were used to create the visualization for the dashboard. After the SRS was written and the mock up was designed, an additional meeting was held with the other members of the nursing quality team to ensure all areas were complete. Next, a meeting was held with the DWE who was assigned to the project to discuss the data requirements needed for the dashboard. The information was presented to ensure that the SRS was easy to understand and that further clarification could be given where needed. Education was provided to all potential users of the dashboard prior to the roll out of the Tableau General Nursing Dashboard as this was the first-time nursing leadership would see the site. Future Activities to Implement and Evaluate the Dashboard Due to time constraints, all steps of the project were not completed. The next steps of the project would be as follows: after the dashboard is designed, testing should be performed to determine the efficacy of the tool. The nursing quality team and DWE should run compliance ADVANCED DIRECTIVE SRS AND DASHBOARD 7 reports to ensure that the information displayed in the EHR and the report are identical. If there are any discrepancies, further investigation will need to be done to determine which data requirements needed alteration. To determine the effectiveness of the dashboard, a System Usability Scale (SUS) should be sent out to users of the AD dashboard, including all management and nursing leadership. The SUS is a quick and reliable tool for measuring usability and has become a standard for the industry. (See Appendix A for SUS) (U.S. Department of Health & Human Services). With the implementation of the dashboard, nursing quality would expect to see an increase in the use of the report to evaluate compliance, appropriate interventions to increase compliance rates throughout the institution, and an increase in the advance directive compliance numbers due to these interventions. To address any ethical concerns, the project was reviewed and determined to not be human subject research, therefore it did not require an IRB approval. For the work described in this report, no patient charts were reviewed. In the future, when testing the system and reviewing patient charts, all measures should be taken to ensure patient safety and privacy are maintained. When the reports are generated by nursing leadership, the query will be global to remove the likelihood for discrimination. Results This project resulted in a comprehensive SRS with a mock up, that allowed for an AD Tableau dashboard to be built for all inpatient (except UNI and 5W), ED, and procedural areas of the UHealth. The dashboard will be used to monitor compliance for over forty units across nine different UHealth facilities. ADVANCED DIRECTIVE SRS AND DASHBOARD 8 The logic for running the compliance report is shown in Figure 1. When a patient is admitted to the ED or procedural area, the admission time triggers the compliance timer to start. The defined interval to complete the assessment is two hours for these areas which does not include time spent out of the area for the ED. At the end of the defined interval of two hours, the encounter status is checked. The system looks for any reason to exclude the patient from the report. Reasons for exclusion include if the patient expires, transfers, or discharges within the defined interval. If the patient has an ‘active' status, the system will continue to look for the value found in the AD assessment row. If there is no value found, the assessment is ‘noncompliant'. If a ‘Not Applicable (NA)' is found, it is excluded from the report. If the value found is ‘Unable to assess (UTA)', the setting is checked and determined ‘compliant' if it is in for the ED or procedural area. If a ‘yes or no' is found it is considered ‘compliant'. When a patient is admitted to the hospital as an inpatient, the admission time triggers the compliance timer to start. The defined interval for the inpatient setting is 48 hours which does not include any time spent out of the unit. At the end of the defined interval of 48 hours, the encounter status is checked. If the patient expired, transferred, or discharged within the defined interval, they are excluded from the report. If the status is ‘active' the AD assessment value is examined. If a ‘NA' is found, they are excluded from the report. If the row is blank, it is considered ‘noncompliant'. If ‘'UTA' is found for the inpatient setting, it is classified as ‘noncompliant'. If ‘yes or no' are the row value, it is considered ‘compliant'. ADVANCED DIRECTIVE SRS AND DASHBOARD Figure 1. Logic for implementing the Advance Directive compliance report, by type of setting 9 ADVANCED DIRECTIVE SRS AND DASHBOARD 10 System Description: Key product function and features Similarities: • When a patient arrives to the designated area, the logic is initiated. If a patient is admitted to UNI (University Psychiatric Institute) or 5W (Psychiatric Acute Unit) they are excluded from the report • Patients that meet the following criteria are excluded regardless of setting: In custody, minors, or a medical incapacity hold, inpatient hospice, or donor within 48 hours of admission. In the assessment, they are documented as ‘not applicable' • Each area has a defined time interval that starts when the patient arrives in the unit. Time spent outside of the designated unit does not count towards the compliance timer • At the end of the defined interval, encounter status will be checked to determine if the patient meets exclusion requirements. If a patient expires, transfers, or discharges during the defined interval in any setting, they are excluded from the report Differences: • The defined interval for the inpatient setting is 48 hours, whereas the defined interval for the ED and procedural area is two hours • An ‘UTA' does not count as compliant if it is the only documented value after the 48-hour window for patients in the inpatient setting Design and Implementation Constraints: • The data included in the report will be current as of the previous day ADVANCED DIRECTIVE SRS AND DASHBOARD • 11 To deal with the possibility of patients being excluded because their admission date being within 48 hours of the end of the month, the report will be run on the 4th day of each month • Currently, it is difficult to determine who is responsible for the advance directive assessment, this problem will continue until the EPIC assignment tool is used consistently. The assignment tool assigns the primary nurse to the patient in EPIC so that the quality metric is linked to the nurse responsible for the assessment. Mock Up The AD dashboard will be available on the UHealth network along with many other dashboards used for quality metrics (Figure 2). The dashboard will have tabs at the top to allow for switching between different views. A dialogue box will be placed on the right side to allow for filtration of results. Below the line graph will show total number of admits for selected area, the number of compliant cases, number of ‘UTA', and the compliance rate. Patient specific data will be included at the bottom of the page and contain information about admission dates, unit, assessment results, and classification of ‘noncompliant or compliant'. ADVANCED DIRECTIVE SRS AND DASHBOARD 12 Figure 2. A proposed display for an Advance Directive compliance report Key points about the dashboard: • A line graph will be used to trend results with months on the X-axis and percentage of compliant reports on the Y-axis • A dialogue box will be available to filter by facility, area, specific unit, or assessment result • Data shown on the report includes: MRN, unit, compliance window start and end, if the assessment occurred and the value of the results, and if the assessment was determined to be compliant The system may be used by nursing leadership, report managers, auditors, nursing support services, social work, or the business intelligence group. It is assumed that staff has been trained ADVANCED DIRECTIVE SRS AND DASHBOARD 13 on the AD competency guideline and that leadership is monitoring the compliance based on the policy. For quality assurance, nurse managers should run daily and monthly compliance reports and report these results at Nursing Leadership Group. Limitations While completing the project, a few limitations were found. The first limitation happens if nurses are not accurate in what they document into the EHR. This can be an issue if the nurse chooses the incorrect answer for the assessment or documents ‘NA' at incorrect times. Documenting ‘NA' will exclude the patient from the report which will artificially inflate the compliance rate. The team can monitor misuse of the term and provide education to correct the problem or alter the SRS if the problem persists, despite added education. The second limitation is that with the questions that are currently included in the AD assessment, there is no way to determine the quality of the ACP conversation. The last limitation of this project is if unit leadership does not follow-up with the results shown in the dashboard, there will be no motivation to improve this documentation and enhancements will not be realized. Sustainability To ensure sustainability of the project, education should be performed as changes are made to the system to guarantee that nursing leadership is familiar with the tool and how to use it. As problems are noted with the running of reports, nursing quality and the DWE should work together in resolving the issue to change any data requirements needed for an accurate and complete system. Education about the dashboard, how to complete the assessment, and expected compliance rates based on the NIAHO standard should be provided to nurses at a Clinical Staff ADVANCED DIRECTIVE SRS AND DASHBOARD 14 Education (CSE) meeting prior to the release of the dashboard. The goal for AD compliance at UHealth is at least 95%. If reports show that compliance is already at 95%, the goal will change to 98% to allow for University wide improvement, and continue to increase until they have reached 100% completion of AD assessments. The rates are expected to increase after implementation due to appropriate interventions based on report results. It is important that nursing leadership gives time appropriate feedback and education to staff to improve rates. Ongoing use of the tool will only be motivated with consistent monitoring from nursing leadership. Discussion The SRS and proposed visualization were successfully developed, but the system cannot be evaluated in the context of this project due to time constraints. The required development cannot start until this project is finished. Nursing leadership is critical for the success of the report to ensure frequent monitoring and appropriate interventions are initiated based on results. The report is currently designed to ensure that a conversation is started about AD and that additional information can be provided to the patient as needed. The current assessment is inadequate in addressing or verifying the quality of the ACP conversation. This report also does not examine the EHR to determine if needed documents have been scanned in. In the future, it may be beneficial to alter the assessment to include a question that helps to address the quality of the conversation and to alter the logic to evaluate if needed documents are available in the EHR. Implementing in other settings The current SRS and dashboard only apply to the ED, procedural areas, and inpatient areas. When the ambulatory areas can come to a conclusion about the expectations of the AD ADVANCED DIRECTIVE SRS AND DASHBOARD 15 assessment in the ambulatory setting, then the same SRS template and dashboard could be used, although some of the logic may need to be modified. Most of the information would be the same for the various settings and minimal information would need to be changed to fit the needs of the ambulatory areas. The dashboard could be filtered to see the results of the ambulatory area or to include both the ambulatory and inpatient areas. As more units are added to the hospital, the SRS will need to be updated to ensure the correct logic is used for each area. Lessons learned and implications for nursing practice Feedback from all users of the report will be essential in its success. All users will need to be informed on how to complete a work order for any issue they encounter or who they can contact. It is extremely important that the nurse completing the assessment ensures accurate information is documented into the EHR. Inaccurate information can skew the results of the report causing an artificial inflation in compliance and cause patient's wishes to remain unknown. The completion of all sections of the AD assessment allows for the nurse to initiate a high-quality conversation regarding the patient's wishes and allows for the nurse to advocate for the patient in their most vulnerable time. The assessment is a basis for running a compliance report but in and of itself, does not assess or improve quality. Conclusion The implementation of the AD dashboard can have a significant impact on the institution if used regularly by nursing leadership to provide education to the nurses responsible for these assessments. The leadership team will be able to view the completion rate of AD each day, allowing the institution to meet the goal provided by the regulatory body and to determine areas that need further improvement. The increase in AD assessments will allow staff to ensure they ADVANCED DIRECTIVE SRS AND DASHBOARD are meeting the wishes of patients at all times, and in turn reduce unnecessary costs, use of supplies, procedures, and distress for the patient in critical situations or end of life care. 16 ADVANCED DIRECTIVE SRS AND DASHBOARD 17 References Carr, D., & Luth, E. A. (2017, August 28). Advance Care Planning: Contemporary Issues and Future Directions. Retrieved January 30, 2020, from https://www.ncbi.nlm.nih.gov/pubmed/30480109 Centers for Disease Control and Prevention. (2019, September 9). Public Health and Promoting Interoperability Programs. Retrieved January 30, 2020, from https://www.cdc.gov/ehrmeaningfuluse/introduction.html Chao, C.-A. (2016, June 30). The impact of electronic health records on collaborative work routines: A narrative network analysis. Retrieved February 3, 2020, from https://www.sciencedirect.com/science/article/abs/pii/S1386505616301484 Detering, K., & Silveira, M. J. (2018, May 4). Advanced care planning and advanced directives. Retrieved February 2, 2020, from https://www.uptodate.com/contents/advance-care-planningand-advance-directives DNV GL Healthcare. (n.d.). DNV GL NIAHO® Standards. Retrieved February 5, 2020, from https://www.dnvglhealthcare.com/dnv-gl-niaho-standards Huntsman Cancer Institute. (2018). Quick Facts. Retrieved February 19, 2020, from https://healthcare.utah.edu/huntsmancancerinstitute/news/press-kit.php Livernois, C. (2019, January 23). Visualization dashboards for EHR data improve situational awareness, decrease errors. Retrieved January 30, 2020, from https://www.aiin.healthcare/topics/business-intelligence/visualization-dashboards-ehr-dataimprove-situational-awareness Schall, M. C., Cullen, L., Pennathur, P., Chen, H., Burrell, K., & Matthews, G. (2017, June). Usability Evaluation and Implementation of a Health Information Technology Dashboard of ADVANCED DIRECTIVE SRS AND DASHBOARD 18 Evidence-Based Quality Indicators. Retrieved February 1, 2020, from https://www.ncbi.nlm.nih.gov/pubmed/28005564 Schmidt, R. F. (2013). Software Requirements Definition. Software Engineering, 291-303. doi: 10.1016/b978-0-12-407768-3.00017-3 Stadler, J. G., Donlon, K., Siewert, J. D., Franken, T., & Lewis, N. E. (2016, June). Improving the Efficiency and Ease of Healthcare Analysis Through Use of Data Visualization Dashboards. Retrieved February 1, 2020, from https://www.ncbi.nlm.nih.gov/pubmed/27441717 Turley, M., Wang, S., Meng, D., Kanter, M., & Garrido, T. (2016). Impact of a Care Directives Activity Tab in the Electronic Health Record on Documentation of Advance Care Planning. Retrieved January 30, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4867824/ University of Utah Health. (n.d.). About Us. Retrieved February 19, 2020, from https://healthcare.utah.edu/about/#organization U.S Department of Health & Human Services. (n.d.). System Usability Scale (SUS). Retrieved February 20, 2020, from https://www.usability.gov/how-to-and-tools/methods/system-usabilityscale.html Walker, E., McMahan, R., Barnes, D., Katen, M., Lamas, D., & Sudore, R. (2018, September 22). Advance Care Planning Documentation Practices and Accessibility in the Electronic Health Record: Implications for Patient Safety. Retrieved February 1, 2020, from https://www.ncbi.nlm.nih.gov/pubmed/28943360 White, S. A. (2004). Introduction to BPMN. BPtrends, 1-11. Retrieved from https://www.bptrends.com/bpt/wp-content/publicationfiles/07-04 WP Intro to BPMN - White.pdf ADVANCED DIRECTIVE SRS AND DASHBOARD 19 Yadav, K. N., French, E. B., Weil, A. R., Ornstein, K. A., Aldridge, M. D., Bradley, E. H., & Meier, D. E. (2017, July 1). Approximately One In Three US Adults Completes Any Type Of Advance Directive For End-Of-Life Care. Retrieved February 1, 2020, from https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2017.0175 ADVANCED DIRECTIVE SRS AND DASHBOARD 20 Appendix A |
