All User Bulletin - Copy-Paste Dangers

All-user-bulletins highlight stumbling blocks that all prescribers need to be aware of when using the Connect Care clinical information system.

Inter-System Copy-Paste Dangers

Copy-paste of clinical content from one health information system (e.g., Netcare) to another (e.g., Connect Care) is not appropriate and should not be done. There are a number of dangers, including:

• Copy-paste between discrete health information systems is subject to legislated requirements of the Alberta Health Information Act.
• Copied text may have encoding dependencies that differ between systems, causing pasted material to change appearance in ways that could change its meaning.
• What can be copied is but part of the source health information data, missing properties essential to confirming the right patient and encounter.

There are alternative workflows that protect against these and other dangers:

• Manual: Copy-Paste

BBHR: Interactive Patient Lists

Building a Better Health Record (BBHR)

As part of our documentation quality improvement initiative, we promote practical ways for clinicians to comply with minimum use norms.

Interactive Patient Lists

The Connect Care clinical information system (CIS) includes powerful tools for accessing, personalizing, building and sharing patient lists.

Those working on inpatient ward, consult or service teams can benefit from the creation of one or more personalized lists. Unfortunately, it can be daunting to know which columns (often with many similarly named options to choose from) to line up for a specific clinical need. 

A clinician-led working group has established standards for Patient List design and has used those to produce a growing set of high-performing, validated and clinician-recommended list columns (easy to recognize as descriptors start with "[AHS]"). In addition, a set of 6 patient list templates can help users initiate personal lists with preferred columns.

To start or adapt a "My List" personal list:

• Use the "Edit List" menu (top left of Patient Lists activity) to pick the "Properties" submenu.
• Look for a "Copy" button at the bottom left of the "Available Columns" section in the list editor. Click this.
• Note the list templates with names that start with "++AHS IP MD..." (near the top of the pick-list) and select a template fitting the clinical workflow (e.g., ward rounds, ward consults, emergency consults).
• Either use the patient list configuration as is, or add/remove columns to personalize. Columns that have descriptors starting with "[AHS]" are preferred.

A number of enhancements respond to user requests:

• Content - Columns display succinct information that is formatted to comply with AHS standards.
• Hover - Hovering over columns within patient rows triggers pop-up displays of relevant information.
• Double-click - Activating a column within a patient row will either open a relevant editing tool within the list or will open the patient chart to a relevant activity.
• Sorting - This is optimized for clinical use case.
• Report - Again defaulted to best fit the clinical use case.

A number of Patient Lists resources have been updated:

• Manual: Patient Lists
• Tip: Managing Patient Lists
• Crib-Sheet: Patient List Templates
• Demo: Patient List Templates
• Reference: Preferred Patient List Columns

BBHR: RAPID Rounds Report Consolidates Transition Planning Information

Building a Better Health Record (BBHR)

As part of our documentation quality improvement initiative, we promote practical ways for clinicians to provide clear and actionable communication at transitions of care.

RAPID Rounds Report

When a patient (row) is selected in a Rapid Rounds patient list, a "report" displays either below or to the side of the list (user preference). The default report for Rapid Rounds is a transition planning report. The same report can be viewed as a pop-up by double-clicking within the Room/Bed or Length of Stay (LOS) columns in the patient list. And the report is always available from inpatient chart sidebars.

The new report functions like a planning dashboard. It gathers in one place all information that might be needed when preparing for discharge or transfer. More importantly, the report is interactive. The displayed information can be selected (click or tap) to view deeper layers of related information. And the data (e.g., pre-admission community supports) can be edited in-place, allowing work to be done in patient lists without having to open individual charts.

• Tip: Rapid Rounds Report
• Guide: Rapid Rounds
• Demo: Rapid Rounds Report
• Manual: Transition Planning

BBHR: RAPID Rounds Patient List Supports Multidisciplinary Discharge Planning

Building a Better Health Record (BBHR)

As part of our documentation quality improvement initiative, we promote practical ways for clinicians to provide clear and actionable communication at transitions of care.

RAPID Rounds Patient List

"RAPID" (Review, Assess, Plan for Imminent Discharge) Rounds is a CoACT Collaborative Care activity that fosters communication within and between care team members, including patients and families. It facilitates timely coordination of care and decreases overall lengths of stay.

Connect Care provides a number of informational supports for Rapid Rounds, including:

• Rapid Rounds Patient List - For use during multidisciplinary discharge planning rounds, this allows quick information access and documentation while reviewing a panel of inpatients.
• Rapid Rounds Report - Provides a compressed summary of discharge planning information together with interactive tools for updating key data and multidisciplinary discharge readiness "traffic lights".
• Transition Planning Sidebar - For use when a chart is opened to an inpatient encounter, replicating much of the information found in the Rapid Rounds report while speeding access to information best updated during day-to-day care.

Connect Care's patient lists serve as a gateway to inpatient workflows. A uniquely interactive list has been developed to support RAPID Rounds. This exposes information needed for discharge planning while allowing much of it to be updated without leaving the patient list.

• Primer: Rapid Rounds
• Tip: Rapid Rounds Patient List
• Guide: Rapid Rounds
• Demo: Rapid Rounds Patient List
• Manual: Transition Planning

BBHR: Introducing the Connect Care Transition Planning Package

Building a Better Health Record (BBHR)

As part of our documentation quality improvement initiative, we promote practical ways for clinicians to provide clear and actionable communication at transitions of care.

Connect Care Transition Planning Package

Preparing for discharge begins at admission. Some admissions are straightforward, with dates and dispositions unfolding as expected. Others are complex and require coordinated multidisciplinary planning to facilitate safe transitions. 

Connect Care provides a new set of integrated supports that can help clinicians with complex discharges, while improving communication with healthcare providers for all discharges. These tools comprise a "transitions planning package" that includes:

• Improved Admission and Discharge Navigators
• Expected Discharge Date (EDD Management) tools
• Daily Checklists
• Rapid Rounds Lists and Reports
• Transition Planning Sidebars
• Transition Planning Documentation blocks
• LACE Readmission Index calculations and recommendations
• Provincial Standardized Discharge and Transfer Summaries
• Communications to Electronic Health Record (Netcare) and Electronic Medical Records (eDelivery)

The next series of BBHR postings will focus on transition planning tools, highlighting how they work with tips, guides and demonstrations. 

• Manual: Transition Planning
• Presentation: Connect Care Transition Planning Package

BBHR: Bloat Busters - Avoid Superfluous Data

Building a Better Health Record (BBHR)

"Note bloat" is a health record affliction that decreases the signal-to-noise ratio of clinical documentation and frustrates clinical decision-makers. As part of our documentation quality improvement initiative, we promote practical ways for clinicians to promote succinct, clear and actionable charting. 

Bloat Busters - Avoid Superfluous Data

It can be difficult to break paper-based habits when going paperless. A number of data elements -- such as patient names, birthdates and identifiers -- are important to insert on physical pages because embedded identifiers helps lost pages get back to the right chart and location.

It's okay to let Connect Care take care of this!

Connect Care notes do not benefit from embedded identifiers. They are digitally anchored. More importantly, any act of printing, copying or otherwise moving information causes headers and footers to be generated with any needed patient, encounter and event identifiers. This includes the date and time of documentation and other situating information. 

• Manual: Change (Progress) Documentation

BBHR: Bloat Busters - Link, Don't Copy

Building a Better Health Record (BBHR)

"Note bloat" is a health record affliction that decreases the signal-to-noise ratio of clinical documentation and frustrates clinical decision-makers. As part of our documentation quality improvement initiative, we promote practical ways for clinicians to promote succinct, clear and actionable charting.

Bloat Busters - Link, Don't Copy

Copy-paste excess is a big bloater. On average, about a quarter of all notes contain content copied from elsewhere (other notes), with about a fifth of all note content duplicating other documentation. Understandable, since clinicians may think that, as with paper-based records, it is a service to use a progress note like a scrapbook, sparing the reader from having to flip through dense records.

Unfortunately, notes cluttered with copied-forward content make it unnecessarily difficult for the clinical reader to figure out what's new, trending or important. Connect Care documentation norms emphasize referencing prior documentation, in preference to copying into current documentation. The current note should highlight, not obfuscate, change.

There is a workflow that helps! 

Progress notes can refer to prior notes (being specific about the note type, service and date; e.g., "see GIM Consult from 2021-09-20"). Even better is the ability to create an automated link to the prior documentation that will allow users to quickly see it in a popup window without losing context. The same trick works for referencing diagnostic imaging, laboratory result or other information found in Chart Review lists.

• Tip: Using Active Document Links
• Manual: Change (Progress) Documentation

BBHR: Bloat Busters - Expose Note Sources

Building a Better Health Record (BBHR)

"Note bloat" is a health record affliction that decreases the signal-to-noise ratio of clinical documentation and frustrates clinical decision-makers. As part of our documentation quality improvement initiative, we promote practical ways for clinicians to promote succinct, clear and actionable charting.

Bloat Busters - Where did a note's content come from?

Clinicians reviewing the clinical documentation of others may not always appreciate who authored the parts used to assemble the note, or how those parts were generated. It can be important to know, for example, that content was facilitated by text automations (e.g., SmartPhrases).  

There is a documentation tool that helps! 

When a documentation object (e.g., progress note) is open for review, look to the top right of the note display to find a hovering option menu with checkboxes for "Hide copied text" and "Hover for details" (click on icon to view screenshot).

Select the "Hover for details" checkbox, position the pointer over a piece of text and note how blocks of text are highlighted with a superimposed descriptor indicating how the text was generated, by whom and when. The personalization icon can be used to have this feature persistently enabled.

• Manual: Change (Progress) Documentation

BBHR: Bloat Busters - Use Interval H&P Notes

Building a Better Health Record (BBHR)

"Note bloat" is a health record affliction that decreases the signal-to-noise ratio of clinical documentation and frustrates clinical decision-makers. As part of our documentation quality improvement initiative, we promote practical ways for clinicians to promote succinct, clear and actionable charting.

Bloat Busters - Use Interval H&P Notes

A common "bloater" is unnecessarily duplication of clinical documents. For example, a patient may be seen by a consultation service in the emergency department, where a consult note is completed. A decision is made to admit and the consult note includes relevant information that might otherwise be placed in an admitting history and physical (H&P) note. 

Given a requirement that all inpatient encounters have an admitting H&P, the admitting service may be tempted to copy the consult note into a separate H&P note, or to place a comment in the H&P referencing the consult. However, both the Consult Note and the H&P are shared with external systems (e.g., Alberta Netcare), creating unhelpful duplication beyond Connect Care.

There is a workflow to avoid this! 

An "Interval H&P" note can be created to point to a source document (e.g., Consult note) that takes the place of a H&P note. This avoids duplicate documentation while satisfying a documentation requirement.

• Tip: Using Interval History & Physical Notes
• Tip: Changing Interval History & Physical Notes
• Manual: Required Documentation
• Manual: Documentation Norms

BBHR: Bloat Busters - Interpret, don't Replicate

Building a Better Health Record (BBHR)

"Note bloat" is a health record affliction that decreases the signal-to-noise ratio of clinical documentation and frustrates clinical decision-makers. As part of our documentation quality improvement initiative, we promote practical ways for clinicians to promote succinct, clear and actionable charting.

Bloat Busters - Interpretation >> Replication

The clinical value of progress (non-summative) documentation relates to a ratio of signal (clinically important new information reflecting developments in a patient's experience) to noise (information related to the patient, but not directly related to clinical progress) multiplied by interpretation (application of clinical expertise to advance understanding and support decision-making):

Digital health records make it easy to amplify noise in progress documentation. Copy-paste and text automations ("SmartStuff") pull data blocks (e.g., lab result flowsheets) into a note. These can bring signal at the cost of excess noise. Authors can be lulled into thinking that documentation is done; but the note has little clinically helpful interpretation. The reader of a progress note needs to know what the writer thought and did for patient care.

• Manual: Change (Progress) Documentation

Building a Better Health Record: Where's the Bloat?

Building a Better Health Record (BBHR)
Bloat Busters - Where's the Bloat?

Our Bloat Busters series can help clinicians prevent "note bloat", a digital health record affliction that decreases the signal-to-noise ratio of clinical documentation. 

Clinicians reviewing others' notes may not always appreciate how much of it is copied from elsewhere and how much is original to the current note. The author may have copied-forward a prior note and then edited it to reflect current state and saved it as a new note. But the reader's interest may focus on how the patient's condition is changing or progressing. 

There is a documentation tool that helps. 

When a documentation object (e.g., progress note) is open for review, look to the top right of the note display to find a hovering option menu with checkboxes for "Hide copied text" and "Hover for details" (click the icon to view screenshot):

Select the "Hide copied text" checkbox and note how content copied from elsewhere is greyed. This helps the reader get a quick sense of what is newly authored in the current note. The personalization icon can be used to have this feature persistently enabled.

Better still? Provide feedback to the author that their documentation of important changes might be clearer if they were to focus progress notes on what's new and use tools like the Hospital Course or links to other notes to reference what is stable.

• Manual: Change (Progress) Documentation

Building a Better Health Record (BBHR)

BBHR: Building a Better Health Record

Well into our Connect Care journey, it is time to take stock. 

We've successfully launched hundreds of sites with thousands of users using a powerful clinical information system (CIS) supporting patient care in diverse settings. We've seen widespread adoption of innovations like mobile-access and in-system dictation. 

However, there are indications that we may need to do more to protect ourselves from potential digital health records harms (mostly identified pre-launch). Indeed, misuse of the Connect Care CIS could make it more difficult for us to quickly discover what is important in a patient's experience. 

Connect Care continues a documentation quality improvement initiative (DQI). This started with background work to optimize charting tools, express provincial documentation standards, clarify documentation norms and find workflows that decrease clinicians' informational burdens. Early products of this work were evaluated with volunteers in late 2021 and then improved and implemented in 2022. 

Wider DQI awareness is supported with a series of blogs, tips, FAQs, Manual update and StreetSmart Training modules. Documentation quality indicators can help front-line users benefit from more efficient and effective charting tools. These appear in minimum use and meaningful use dashboards.

BBHR: Charting Efficiencies - Sidebar Aids for Transition Planning

Building a Better Health Record (BBHR)
Charting Efficiencies - Sidebar Aids for Transition Planning

Improvements to the Hyperspace inpatient chart Sidebar include aids for quickly finding, displaying and editing information in either the main (central), Sidebar (right) or pop-up chart spaces. The first set of tools appear by default when the inpatient Sidebar opens to its "Index & checklists" view. These nicely illustrate how the Sidebar can help users quickly access and update chart data that otherwise would require more familiarity with less-used parts of the chart.

The focus of the checklists view is on transition planning, whether that relates to discharge, transfer or a move to a different level of care (click on icon to view screenshot; numbers below refer to numbers in screenshot). 

1. If not already displayed, select the top-left "Index & checklists" link to display the "Checklists" and "Transition Planning" Sidebar tools.
2. Daily, Admission and Discharge Checklists are presented. These function like task managers, reflecting important unfinished tasks and changing to completion status when the relevant work is done. The few highlighted tasks closely match Connect Care minimum use norms.
3. Checklist items are "active". When selected, the user is taken to a relevant documentation or ordering tool directly relevant to the listed task.
4. The Transition Planning section summarizes relevant information, including expected transition and discharge dates, social supports, community care needs and patient goals. Where information is missing or incomplete, the title or bracketing text appears in a (dark) blue font, indicating that it can be selected to activate data entry tools in-context where the associated information can be updated. Use the Sidebar "refresh" icon (top left of Sidebar) to update the display if this does not happen automatically.

• Manual: Inpatient Sidebar Index
• Demo: Sidebar Transition Planning

BBHR: Charting Efficiencies - Other Clinical Systems Sidebar Views

Building a Better Health Record (BBHR)
Charting Efficiencies - Using Other Clinical Systems Sidebar Views

New patient assessments offer important opportunities to initiate core clinical data in the patient chart. This decreases the work of documentation thereafter, when clinicians can revise or validate information already entered. 

Sidebar tools can help clinicians when they review information from other clinical information systems (e.g., Netcare) or from prior unstructured Connect Care documentation (dictated notes that, for example, did not include updated problem lists). The user needs to review and document at the same time, ideally without jumping back and forth between different windows. 

The Sidebar can help in two ways, either when used to review information that informs documentation performed with main panel tools, or when used to enter information gleaned from the main panel. 

Sidebar views of other clinical information system content are especially helpful when doing problem, adverse reaction or medication reconciliation, as explained in a recent Manual addition.

• Manual: Other Clinical Systems Sidebar Tools

All User Bulletin - Inpatient Sidebar Enhancements

All-user-bulletins highlight information that all prescribers can benefit from when using the Connect Care clinical information system.

Inpatient Hyperspace Sidebar Enhancements

Users may notice changes to the "Sidebar" (rightmost panel appearing when a patient chart is opened to an inpatient encounter in Hyperspace) starting noon September 30, 2021. The best way to learn about new functions is to select the embedded help link to gain access to a quick overview.

All the same Sidebar information is available. However, many Sidebar views have been enhanced with better clinical summaries. The Sidebar index now uses information about the current provider, patient and clinical setting to conditionally display the most relevant information. In addition, new features make it easier to use the Sidebar to access charting tools that complement what one may be using in Hyperspace's main (centre) panel. 

The biggest change relates to how the Sidebar summary index works. The index will always appear at the top of Sidebar views (default "Index" tab) and can be used to jump between different views. Index items have three parts:

1. Clicking on a left arrow will open relevant information in the main Hyperspace panel.
2. Clicking on the index title will open a Sidebar summary view with information matching the title topic.
3. Clicking on a right arrow (when present) will open a charting tool (with data-entry capabilities) in the Sidebar itself.

The enhanced Sidebar better supports a number of charting needs, including:

• Quickly find a tool not among one's defaults (and so not having to seek in menus).
• Enter and update problem lists within the Sidebar while reviewing past notes in the main Hyperspace panel.
• Gain rapid access to discharge planning tools.
• Find and use supports for problem-oriented charting.

Time-saving charting efficiencies become possible with effective use of Sidebar tools. We will post tips and tricks in the Building a Better Health Record series of this blog.

• Manual: Sidebar Charting Tools
• Blogs: Building a Better Health Record (ahs-cis.ca/bbhr)

BBHR: Minimum Use for Maximum Utility - Adverse Reaction Documentation

Building a Better Health Record (BBHR)
Minimum Use for Maximum Utility - Allergies and Adverse Reactions

Connect Care Minimum Use Norms highlight a few essential activities that all clinicians must share in order to promote patient safety, improve charting efficiency and minimize any one clinician's information burdens.

One norm relates to validating a patient's list of allergies and adverse reactions at appropriate intervals. We've noticed room for improvement.

Prescriber supports have been improved to clarify how allergy reconciliation can occur with minimum fuss and maximum benefit. Emerging problem oriented charting tools reward minimum use compliance with easier preparation of standardized clinical documentation.

• Manual: Adverse Reaction Documentation
• Tip: Documenting Adverse Reactions

Documentation Quality Improvement

The Connect Care Documentation Quality Improvement initiative seeks to enhance the utility of summative documentation templates for history & physical, consult, discharge, transfer, and operative notes. Oversight is provided by the Clinical Documentation Quality Improvement Workgroup, reporting to the Clinical Documentation Committee.

While Builders, Power Users, Super Users, Informatics Leads and Superusers actively participate in much of the improvement work, any Connect Care user can have input. A presentation provides context and a plan. "Work packages" emerge from time to time on our Informatics channel, each containing a presentation on a documentation topic and instructions about how interested users can provide feedback.

• Presentation: Clinical Documentation Quality Improvement
• Slides: Clinical Documentation Quality Improvement
• Informatics Blogs: DQI Work Packages