Impact of Standardized Terminology and Evidence-Based Practice on Healthcare, Study notes of Nursing

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NR 361 Week 3 Graded Discussion: Standardized Terminology and Language

in Informatics.

This week's graded discussion topic relates to the following Course Outcomes (COs).  CO3 Define standardized terminology that reflects nursing's unique contribution to patient outcomes. (PO 3)  CO8 Discuss the value of best evidence as a driving force to institute change in delivery of nursing care. (PO 8)

1. What is the impact of Centers for Medicare and Medicaid Services (CMS) payment denial on the healthcare system?
2. What are the implications for our nursing practice related to use of standardized terminology for documentation?
3. How do evidence-based practice guidelines impact patient outcomes and necessitate improved practice care?

ANSWER

Hello Instructor and Class, Centers for Medicare and Medicaid Services (CMS) impact and reflect our Healthcare system every day. Payments from Medicaid to hospitals and other providers play an important role in hospitals’ financial condition and effect patient care as well. Denials of payment by Medicare usually occur because of hospital errors, such as hospital-accrued infections or patient re-admission to the hospital because of mistakes made. Previously, hospitals where reimbursed for hospital-accrued infection or patient readmission due to hospital’s fault. Medicare reimbursements for hospitals have changed in 2012. Medicare started to pay not only for services hospitals provide, but they require for those services to be high quality. CMS created several programs to improve quality of care. First, Hospital Re-admission Reduction Program was designed to reduce hospital re-admissions. Secondly, Hospital Value- Based Purchasing (VBP) program was created to expect better clinical results for hospitalized patients and improve their experience of care while they are in the hospital. Hospital quality of care effects the payment it gets from Medicare. A third program Hospital-Acquired condition (HAS) reduction program was created to encourage the health care providers to improve patients’ safety and reduce hospital-acquired conditions. These denials have a negative effect on the Hospital because they then have less money for the necessary resources. Using standardized terminology for documentation is essential for nursing practice. The implications of standardized terminology for nursing documentation will eliminate documentation mistakes and make others to understand information more easily. Standardized

terminology ensures that every nurse is educated to use specific words or terms that every other nurse will understand, regardless of where the care is provided (Lundberg et al., 2012). Standardized terminology is simply "structured and controlled languages that have been developed according to terminology development guidelines and have been approved by an authoritative body" and are in place for use in electronic medical records (Hebda & Czar, 2013, p. 298). EHRs utilizes standardized nursing terminology (SNT) in different kinds of information system and used for communication between medical professional. Standardized terminology is one of the main parts of interoperability in healthcare technology. The interoperability helps to put together information for easy formal communication and exchange “uniform” data format between multiple systems, elements, and between health care providers. The electronic health record starts to be the proof of health information technology interoperability. Evidence-based practice guidelines impact patient outcomes and improved practice care, because research has been continuously made and evidence has been used to make changes. For example, I work in the surgical unit where hospital initiated a pilot project on Modified Early Warning Score (MEWS) system for clinical patient condition deterioration after surgery. This project was initiated three years ago, and we can clearly see proof that MEWS system helps to determine patients’ deterioration condition yearly and prevent patients from developing sepsis. Ultimately, MEWS score became one of the standardized terminology which represents nursing diagnosis, intervention and outcome in our surgical department and is utilized by our EMAR that allowed to exchange data between nurses, doctors and rapid response team to provide safe and quality patient care.

Reference: Healthcare Information and Management Systems Society. (2013). What is interoperability? http://www.himss.org/library/interoperability-standards/what-is- interoperability (Links to an external site.) Hebda, T., & Czar, P. (2013). Handbook of informatics for nurses & healthcare professionals (5th ed.). Boston, MA: Pearson. Lundberg, C., Brokel, J., Bulechek, G., Butcher, H., Martin, K., Moorhead, S., & ... Giarrizzo- Wilson, S. (2008). Selecting a standardized terminology for the electronic health record that reveals the impact of nursing on patient care. Online Journal Of Nursing Informatics , 12 (2), 19p. Professor and Class, Healthcare costs are continuing to rise. Testing, consults, medicine - it is only increasing what it costs to stay in the hospital. Federal programs like Medicare and Medicaid were beginning to suffer and were forced to look for ways to conserve healthcare money. In Feb, 2006, President Bush enacted the Deficit Reduction Act (DRA) allowing for adjustments in payment from Medicare for inpatient services. It required at least two preventable hospital acquired conditions to be adjusted for reimbursement. Examples of such conditions would be falls, pressure ulcers, air embolisms, catheter associated urinary tract infections. All of the above can be avoided by the

following of evidence based practice, and were selected among others as adjustments in payment from Medicare. On admission documentation is required to identify all pre-existing conditions, so as to distinguish between what the CMS is responsible to pay for and what they may adjust. The program is called Hospital-Acquired Conditions and Present on Admission Indicator Reporting (HAC). (Morgan, 2018). In reading this article it was interesting to see the background of why some things are made such a big deal of in the practice setting. From a staff RN point of view, the extra documentation and forms proving we have done all we can and followed evidence based guidelines to prevent infections, falls, etc. can seem overwhelming and redundant. But in my reading it makes more sense why all of that is so important to the hospital system. Hospitals have to count every dollar too in order to stay afloat. It's always a balancing act between making improvements to remain competitive and reflect what research is finding, but yet not overspend and go belly up. Nurses must use the standardized terminologies in documentation for many reasons. It's important to be consistent with each other, between the shifts. We need to be able to see if there were changes when we compare our assessments with those who cared for the patient before. Also for those who are evaluating through these newer policies if a patients conditions ought to be reimbursed or not. Inconsistency would lead to errors and loss of more healthcare dollars. In addition to saving money, and rather most importantly, we as nurses need to follow evidence based practice guidelines to protect our patients! May it not be true what so many accuse us of that it's all about the money. May we do our Foley catheter care and change PICC dressings on time and remember our bed alarms to protect our patients from further infections or injury.

Dear ……., I like your post, and agree with you that evidence-based practice guideline one of the main factors in the Health Care System. I believe that it is not only nurses but all healthcare providers should be following evidence practice guideline and continue to conduct evidence-based research. This will enhance safe and quality patient care and also reduce amounts of insurance claims denials. For instance, we are a Trauma Hospital. We often get patients who are getting trauma due to suicidal attempts. By evidence-based practice we know that those patients have a high risk of being readmitted for suicidal attempts again. In order to prevent that, our hospital involves doctors, nurses, nurse’s assistant (as 1:1 observation), social workers, and family to insure that this type of patient remains in a safe environment and prevents patient readmission for the same reason. Guideline changes is an ongoing process and I hope in the near future evidence-based research will have universal guideline in every aspects of medical practice. “In fact, there are many opportunities for nurses, nurse leaders, and other healthcare professionals to be major stakeholders in planning, designing, implementing, and evaluating of information systems” (Hebda, Czar, 2013, p.544). Reference: Hebda, T., & Czar, P. (2013). Handbook of informatics for nurses & healthcare professionals (5th ed.). Boston, MA: Pearson.

Pain assessments and management has been incorporated in our EHR. We assess our patients on a daily basis and document their pain using a pain scale, type, duration and interventions provided. This is done on all patients from the admission to discharge. Our nursing practice includes observation skills and experience besides just interventions or treatments on patient care. The use of standardized nursing language can improve patient care and outcomes. It allows for better communication among nurses and other members of the health care team, enhance data collection to evaluate nursing outcomes and increase visibility of nursing interventions. Nurses will adhere to standards of care and competency. Reference: Rutherford, M., (Jan. 31,2008) Standarized Nursing Language: What Does It Mean for Nursing Practice?, OJIN: The Online Journal Of Issues in Nursing(13) 1, doi: 10.3912/OJIN.Vol3NoO1PPT Hello ……., I admire your post. I agree that Standardized Nursing Language can improve patient care and outcome. I work in the surgical unit where pain assessment and management is an essential process. Pain assessment is providing every four hours and hourly, if the patient on epidural or PCA pump management. Our EHR includes pain score based on pain with movement or pain in rest. Additionally, EHR will contain pain location, type of pain (acute, chronic or anticipatory), description, management, intervention (pharmacologic: PRN or standing medications), (non-

pharmacological: deep breathing, turning, massage, prayer, activity, music, warm/cold application). Also, nurses will enter in EHR sedation score (awake alert or drowsy, unarousable) sensitivity, alertness and reflection to pain score after medication administration. PCA and Epidural entrance have separate hourly parameters in our EHR, where we include an amount of boluses given and boluses attempted to show pain management team ether medication dose have to be change or patient doesn't need any more PCA treatment. It looks like we are charting a lot. However, our standardized nursing language, help doctors and nurses to provide safe pain management to our patients after surgery and make recovery process faster. "Nurses will benefit from using a standardized nursing language by enhanced efficiency, accuracy, and effectiveness, resulting in a significant improvement in patient care" (Hebda, Czar, 2013, p.316). Reference: Hebda, T., & Czar, P. (2013). Handbook of informatics for nurses & healthcare professionals (5th ed.). Boston, MA: Pearson.