MDS Alert

The road to an integrated EMR system is paved with payoffs...and trade-offs.

Do you ever dream about how great it would feel to ditch the mountains of flow sheets and other documentation required to complete each resident's MDS? Loch Haven Nursing Facility has made that dream a reality.
 
The Macon, MO-based facility is finding out firsthand the in's and out's of scrapping paper by converting to a fully integrated electronic MDS and medical record documentation system. The facility implemented a OneTouch Technology system in August 2003 as part of a Centers for Medicare & Medicaid Services' study looking at the impact of such technology on patient care and operational efficiency in nursing facilities.
 
The OneTouch System "flows" assessment data entered by CNAs or nurses on hand-held palm devices, laptops or personal computers (PCs) to all the right places on the MDS and the electronic medical record.
 
While the new system has presented MDS and nursing staff with a number of learning hurdles, it's revolutionizing how the facility does the MDS, according to Christy Riekeberg, RN, who is responsible for Loch Haven's Medicare MDSs.

Let Your Fingers Do the Coding
 
To code their assessments at the bedside, CNAs and nurses use PDAs that provide clinical check boxes and clinical drill downs that require the caregivers to answer questions. Each check box equals a phrase and an entry into the database in the form of a compressed code. "The relational database then connects the codes to the appropriate section of the MDS database," reports Robert Davis, president of OneTouch Technologies in Irvine, CA, which is the study's vendor.
 
The computerized system also identifies the caregiver using the PDA to do the coding - and the resident who is being coded. "Each staff member is assigned an 'iButton' that they use to log onto a PDA and code their care for the day," explains Davis. Residents also have iButtons on their wristbands that are designed to withstand almost any activity, including bathing. Thus, when the CNA or nurse enters the resident's room, she matches the PDA to the resident's wristband, which identifies the resident in the system.
 
Nurses also use the PDAs to do some coding, and they perform more extensive assessments using either a wireless notebook computer or a fixed personal computer at the nursing station.
 
If something doesn't fall into one of the assessments, the nurses can make what is called a "quick note" on the PC where they actually type in their own narrative charting, says Riekeberg, although nurses haven't ended up having to do much of that with the new paperless system. "The nurses individualize and edit care plans to fit each individual resident," she adds.
 
The PDA-based system also allows licensed rehab therapists and restorative nursing staff to easily capture exact minutes of care that flow to the MDS. For example, the restorative staff clicks on the type of restorative activity, such as range-of-motion for lower extremities, etc. Then they click on the start and stop times, using the PDA like a stopwatch.

Figure Out the Outliers
 
All of the information collected by CNAs, nurses, therapists and other caregivers becomes part of the master database and is coded automatically to the right MDS sections. "Once the MDS coordinator chooses an assessment reference date, the system searches the appropriate portion of history and retrieves all of the related information in seconds and presents it in the MDS form," Davis explains.
 
The system also generates an MDS audit report that tells the MDS nurse which fields are illogical or points out missing data required to transmit the MDS. A daily shift report flags "outlier" coding that's out of line for the shift when compared to the resident's usual parameters.
 
Of course, just because information gets flagged as illogical doesn't mean it's inaccurate, as the resident's status may have changed or staff may be assessing it more accurately than before. "The staff simply needs to double check that assessment information for errors," Davis says.
 
Once the MDS is prepared in draft form, the system tracks all manual changes along with the reason for the change and who made it, Davis adds.

Overcome Staff Objections
 
The new system is definitely cutting-edge, but implementing it hasn't been all roses for Loch Haven. For one, the facility had to train all CNAs on coding residents' activities of daily living (ADL) and behaviors using the PDA, Riekeberg relates. "We had to really make sure the CNAs understood what the coding meant."
 
CNAs expressed concerns initially that using the pocket-sized PDAs would be too time-consuming. So the administrators decided to phase in their responsibilities for using them.
 
"OneTouch wanted us to have everything the CNAs did documented on the PDAs up front but we decided to have the CNAs only document things for residents who had an MDS due in the next two weeks," Riekeberg explains. "Once the CNAs became more familiar with the system, we broadened the documentation to all of the patients, and the staff seemed to accept that better," she adds.
 
While Riekeberg views the system as "fantastic," she tends to worry about the accuracy of some of the information entered until nurses become more familiar with entering their assessments using the PC and laptops. For example, she has sometimes caught things charted on the wrong patient.
 
Thus far, the system's biggest impact has been to improve the facility's ADL scoring, which drives RUG payment. "The PDA-based system better captures ADL dependency on the night shift," Davis explains.