Editor’s note: More than 40 hospitals and health systems clients presented at the recent Allscripts Client Experience (ACE) event held in Dallas, Texas. Here, clinical analyst working with Liberty Hospital discusses the journey to new rehab documentation.

At the recent Allscripts Client Experience (ACE) conference, I detailed how Liberty Hospital (Liberty, Missouri) is achieving success with rehabilitation documentation in the acute setting using Sunrise™ Aware Note.

My first duty as clinical analyst was to shadow Liberty’s nursing and acute rehab departments and document its processes and improvement needs. The hospital’s biggest concern was too many steps in the documentation process. Since Liberty bills by the minute, every minute spent documenting means less time with patients.

We started with validation sessions to determine where customization was needed. We wanted to prioritize Liberty’s needs of regulatory and patient safety.

Everyone has their own opinion on what should be required in a note

Liberty decided it needed education points, discharge planning documentation and plans of care.

We decided to focus on these three areas:

1. Copy forward/auto prefill – Shares information within same or different disciplines of therapies.
2. Aware Note order button functionality – Reduces clicks, completion time and errors in order/charge entry.
3. Aware Note conditional bar functionality – Enables options for what users need, reduces scrolling and supports patient-centered documentation.

Switching from flowsheets to Aware Notes

One big necessity was building a clinical summary tile. This enables Liberty to view a patient’s information from anywhere. Employees enjoy the personalization of saving clinical summary tiles to their desktop for easy use. Liberty has seen improvements in tracking a patient’s progress visit to visit.

For one clinical summary tile, Liberty wanted to combine Physical Therapy (PT) and Outpatient Therapy (OT) notes. For example, when tracking a patient’s gait distance, three caregivers can now enter what they see during their shifts. The PT can quickly glance at this before entering a patient’s room and see how far the patient walked over three days, instead of opening multiple notes. “It’s nice to have it all there so I can track all that data,” said Liberty Hospital Physical Therapist Jennifer Prockerish.

Testing, training and go-live

To test the build, our stakeholders helped me create test scripts. We tested it among the entire department to identify and resolve any issues before go-live. Staff was a little worried about losing their flowsheets, but seeing the solution in action eased their minds. We used several methods of training over multiple sessions. Go-live went seamlessly and trainers provided support for users by fixing any issues that arose.

How did workflows improve?

Moving Liberty from structured notes in a flowsheet to Aware Notes eliminated 7 documentation pain points. Allscripts and Liberty worked together to taper the documentation and improve efficiency.

We analyzed how usable the new changes were with the staff and made adjustments. This led us to create custom tabs, labels and several observations to discharge instructions within the Aware Note to improve usability.

Increasing accurate charging and more

Liberty’s streamlined workflow decreased time spent documenting and looking for patient data. A big outcome was the reduction of errors involved during documentation (double documentation, streamlined between tabs). Liberty saw an increase in productivity (counting usage of charges), revenue and decreased charging errors.

The keys to success for Liberty were an interdisciplinary workflow, department/analyst collaboration, standardization of data collection and entry and user buy-in/support.