How detailed and integrated are your clinical records? Silvercrest Center for Nursing and Rehabilitation, a 320-bed skilled nursing facility in Briarwood, N.Y., has spent the past few years creating an electronic health record (EHR) system that knows its residents almost as well as the staff does. The OPTIMA Award-winning site’s hospitalization reduction program relies on deep IT customization of clinical templates to document the right chart notes with the right level of detail at the right time for clinical intervention.
Documenting Silvercrest’s unique resident population (almost half the residents uses a ventilator or has a tracheostomy tube) requires a fully integrated EHR, including medication administration notes, computerized order entry, nursing assessments and dietary/feeding notes. During the hospitalization reduction initiative, the site’s health IT and staff development team worked with New York City-based Sigmacare, the site’s EHR provider since 2008, to create dozens of specialized templates for high-acuity care that could track detailed caregiver notes, including documentation relating to vent therapy, speech/language therapy and diet/hydration, explains Enrique Carmona, Silvercrest’s health informatics analyst. “It’s one thing to do basic data collection. But if you start seeing a trend, maybe you need to study the labs,” he says. “You could never do that by searching through reams of paper and reports.”
The IT system has raised the bar on the organization’s clinical documentation, since the data becomes a crucial factor in the decision of whether to transport a resident to the hospital or not. Silvercrest’s adoption of the “know it all before you call” protocol—gathering all the data needed before an emergency call is placed—relies greatly on health IT systems that can provide simultaneous data access to multiple users, Carmona says.
Sigmacare is actively working with Silvercrest to develop the features needed. "No two nursing homes are the same," Carmona says. "We still have some work to do on better mapping and eliminating some data redundancy."