Data Abstraction from EHR for Performance Improvement

Purpose:
This presentation will focus on the use of the electronic health record to collect valid, reliable nurse sensitive outcome data.

Significance:
Electronic Health Record (EHR) data are vital when analyzing patient outcomes for performance improvement. We have moved from manual data abstraction by nursing staff to abstracting key quality nursing outcome metrics from the EHR for performance improvement.

Strategy and Implementation:
The measurement of nurse sensitive outcomes can be improved through the abstraction of the electronic health record (EHR). The EHR is a vast repository of data and with our EHR implementation it was our goal to use electronic aggregate data to positively impact patient care and outcomes. Perhaps the most important lesson learned along the journey to using this pool of very rich data is the validation of abstracted EHR data. Abstracting data from EHR requires tracking of data elements from the EHR to the data source back to the work flow to assure the data elements are reliable. The data elements that we are abstracting from the EHR include documentation and nursing process metrics, i.e. fall and skin risk assessment data. The abstraction of documentation data elements on the admission health assessment and throughout the encounter is a vital step in providing aggregate data to direct care staff and implementing performance improvement.

Evaluation:
By recognizing the benefits of a data rich health care facility we've significantly decreased the data collection burden of direct care staff and have increased the reliability of the data. We have been able to demonstrate documentation and process improvement.

Implications for Practice:
Prior to EHR implementation, our direct care staff spent approximately 133 hours per month completing documentation audits. We have eliminated this and those hours are placed back into patient care.