White Papers

White Papers January 2009

Developing Efficient Electronic Inpatient Rehab Records: Enabling More-timely, Much-improved Client Outcomes

Saverio Rinaldi and John Challinor II

Abstract

Streamlined and efficient statistical data collection processes allow rehabilitation facilities to better manage and report such information to the Canadian Institute for Health Information (CIHI). In 2006, Hamilton Health Sciences (HHS) implemented such an electronic statistical data collection system for rehabilitation patients, integrating three independent legacy patient records databases in the process. Qualitative comments have been positive and implementation went as planned, with no technical problems reported. The following article describes HHS' experience with the implementation.

Background:

In 2001, Canada's federal, provincial and territorial governments created the Canadian Institute for Health Information (CIHI), which they established to forge a common approach to Canadian health information, including the collection of patient rehabilitation statistics. CIHI collects and analyzes information on health and health care in Canada and makes it publicly available.

In 2002, the Ontario Ministry of Health made quarterly reporting to CIHI by rehabilitation facilities within its jurisdiction a mandatory requirement. Since that time, CIHI has collected and analyzed information on health and health care in Canada from institutions like Hamilton Health Sciences (HHS) and, in return, provided accurate and comparable information. CIHI's data and reports influence future health policies and planning, support the effective delivery of current health services and raise awareness among Canadians about the specific factors that contribute to good health.

Hospital-based inpatient rehabilitation is an important component of the continuum of health services. By facilitating the collection of standardized information on rehabilitation patients, CIHI's National Rehabilitation Reporting System (NRS) provides an opportunity to enhance the knowledge surrounding inpatient rehabilitation services across the country. The NRS was developed to support data collection by facilities like HHS that provide services to adult inpatient rehabilitation clients. These rehabilitation services are typically provided in specialized rehabilitation facilities or in general hospitals with rehabilitation units, programs or designated beds.

These comparative reports provide the more than 95 participating inpatient rehabilitation facilities across Canada with information to assess client outcomes, to examine access to inpatient rehabilitation and to evaluate programs and services. By facilitating the collection of standard information, the NRS provides an opportunity to enhance the knowledge surrounding inpatient rehabilitation services across the country.

The NRS data consists of 75 data elements grouped into the following general, non-patient specific information, including demographics (sex, date of birth, vocational status), administrative (wait times for admission and discharge), health characteristics (diagnoses), and clinical assessment statistics. Facilities like HHS collect the data when patients are admitted and discharged.

Inpatient rehabilitation patients receive services provided by health professionals such as nurses, physiotherapists and physicians specializing in physical medicine and rehabilitation. These professionals assist patients in maximizing their physical and cognitive function through training and education and prepare them to return to the community following illness or injury. Patients reported in the NRS include only those with a primary health condition that is physical in nature. As such, the term rehabilitation in the context of NRS reporting does not include rehabilitation services provided for a mental health condition or for drug or alcohol addiction.

A cornerstone of the NRS is the concept of human function and the focus of rehabilitation in assisting individuals to achieve maximum independence in daily living, be it at home or in an assisted-living facility. The NRS indicators and reports provide a source of information for defining and describing functional outcomes for individuals who have received rehabilitation services.

Streamlined and efficient data collection and management processes allow rehabilitation facilities to better manage and report their data. According to a recent survey (Ontario Ministry of Health and Long-Term Care, 2007), only 24 percent of respondents indicated they were using electronic means as their sole means of data collection. About 53 percent had an internal data quality process and/or committee in place to manage data integrity. Approximately 21 percent of respondents indicated they had vacancies (and 50 percent of those positions remain vacant) in their organizations related to the personnel required to collect, manage and submit the data to CIHI.

And, given that almost 70 percent of respondents said they rely on CIHI data to evaluate outcomes and quality indicators for rehabilitation planning and ongoing management, cost-effective, accurate and timely CIHI data collection is a significant issue in the rehabilitation sector of the healthcare system.

About Hamilton Health Sciences

More than 2.3 million residents of Hamilton and South and Central West Ontario are served by HHS, a 1,000-bed healthcare complex composed of five unique hospitals and a cancer centre - making it the second largest hospital system of its kind in Ontario. HHS was established in 1996 through the merger of The Hamilton General Hospital, Henderson General Hospital, McMaster University Medical Centre, McMaster Children's Hospital and Chedoke Hospital. Juravinski Cancer Centre joined HHS in 2003. HHS is also affiliated with McMaster University and Mohawk College.

Amongst its many mandates, HHS is the regional centre for rehabilitation services. To support the community's specific rehabilitation needs, HHS has approximately 134 dedicated beds at its Hamilton General, Henderson and Chedoke hospital facilities.

More about Hamilton Health Sciences

Mission

To provide excellent health care for the people and communities we serve and to advance health care through education and research.

Vision

Leaders in exemplary care, innovation and academic excellence.

Values

Respect: We will treat every person with dignity and courtesy.
Caring: We will act with concern for the well being of every person.
Innovation: We will be creative and open to new ideas and opportunities.
Accountability: We will create value and accept responsibility for our activities.

Strategic Goals

  1. We meet or exceed our communities' expectations.
  2. We are internationally recognized for the excellence of our patient-centred care, research and education.
  3. We have a healthy work environment.
  4. We have a sound financial base to sustain our mission and achieve our vision.
  5. We create a sustainable and aligned system through action and leadership

Intervention

Since the beginning of the CIHI pilot project in 2001 and until 2006, HHS had been reporting NRS data to CIHI using a system developed with three separate databases - one for each rehabilitation facility at Hamilton General, Henderson and Chedoke hospitals. The need for a comprehensive shared system grew because clinicians and management found that the data was not accessible between sites and additional administrative staff was required. After evaluating a number of applications, HHS chose the Clarity Healthcare Solution for NRRS software developed by Consulting Cadre Inc. (CCI) of Toronto. The Clarity Healthcare Solutions family also includes complex continuing and long-term care, home care and mental health modules.

Clarity Healthcare for NRRS is a resident assessment solution for rehabilitation care providers. With intuitive user interface and data entry validation built in, Clarity Healthcare provides an integrated web-based solution for the capture and transmission of assessment data for CIHI reporting to NRS. It interfaces with existing systems and makes clinically-relevant information accessible to multidisciplinary care teams in multi-site organizations.

First implemented in April 2002, Clarity Healthcare Solutions for NRRS was the first to pass CIHI submission testing. As required by CIHI, submissions have been conducted continuously since the introduction of the Clarity Healthcare solution. HHS purchased CCI's rehabilitation module because it met the hospital's requirements for:

  • Standard HL7 interface with existing ADT legacy system;
  • Conversion and integration of three legacy databases;
  • Capture and transmission of data for CIHI reporting of Functional Independence Measures (FIM™) data to NRS;
  • Data flow from any number of workstations or locations, enabling multi-disciplinary clinicians to capture patient assessment data;
  • Data on performance available at any time at no additional cost;
  • Built-in audit trail to detail all activity, including inputs, changes, users ID, time and date;
  • Built-in report writer for ad hoc reporting;
  • Easy to use, easy to learn; and
  • Customization to capture additional assessment information.

Following a two-day program of comprehensive training of more than 100 HHS staff, the installation of the solution took place over a weekend and, within hours, was being populated with rehabilitation inpatient data in real time by HHS clinicians. As soon as all three independent legacy patient records databases were converted and integrated with the new centralized system, the Clarity Healthcare Solution was able to create both standard and customized reports. This allowed HHS to preserve and protect its legacy patient assessment information. And, within 30 days, it had evolved from test mode to full implementation within the HHS Information Technology infrastructure, integrating seamlessly and securely into HHS' existing systems. There were no compatibility or compliance issues with the application.

Conclusion

With Clarity Healthcare Solution for NRRS, HHS is provided with clinically-relevant information. Clinical assessment data can be entered in real time by clinicians, rather than by data entry clerks hired specifically to perform that role - as is the case in many other rehabilitation facilities across Canada today. That has also reduced data entry time and increased the likelihood of more accurate data being entered into the system - a quantifiable productivity improvement.

Clarity Healthcare Solution is also integrated with HHS electronic patient records. In future, the peer data can be compared with results from other facilities within the local health integrated network, other institutions in the province or across Canada.

The collection of accurate and timely rehabilitation data for more than 30,000 patients across Canada, including those served by HHS and similar participating facilities in seven provinces, has enabled CIHI to determine that, over the last five years, the average length of stay for patients in hospital rehabilitation has declined from 22 days to 18 days. Of the patients discharged from a rehabilitation hospital or facility, 91 percent were able to achieve their inpatient rehabilitation goals by the end of their stay and 89 percent were able to return home.

Most patients in rehabilitation (47 percent) were admitted for an orthopedic condition, while the second-largest group was those recovering from a stroke (16 percent). The vast majority (92 percent) of inpatient rehabilitation patients were transferred from acute care, and over half (55 percent) were admitted on the same day they were determined to be clinically ready for rehabilitation.

Information collected by CIHI from HHS, when integrated with data from across Canada, is helpful to HHS clinicians and managers as well as to system planners, policy-makers, researchers and the public who visit HHS in terms of evaluating the effectiveness of the service and identifying service gaps. While inpatient rehabilitation at HHS is only one part of the continuum of rehabilitation, the data collected suggests that it provides an important role in ensuring that Canadians maintain functional independence and autonomy after an injury or illness following surgery.

Hamilton Health Sciences Facts and Figures

  • HHS operates more than 900 beds and 70 bassinettes;
  • It supports about 3,100 births per year;
  • It handles approximately 108,700 emergency visits a year;
  • It processes more than 41,000 inpatient admissions a year including acute, rehabilitation and chronic care cases;
  • It manages more than 25,000 inpatient and outpatient OR cases each year;
  • HHS is the largest employer in Hamilton with more than 10,000 employees;
  • There are more than 1,400 physicians working at HHS;
  • HHS has approximately 1,500 volunteers, 450 of whom are students; and
  • Volunteers give more than 130,000 hours of service each year.

About the Author

Saverio Rinaldi, BIS, CMC, is President of Consulting Cadre International Inc., a firm he founded in 1996 that provides consulting, development and implementation services to a wide range of customers within the financial, healthcare and technology markets.

John Challinor II, BAAJ, APR, is Principal, Given Road West Communications, a firm he founded in 1988 that provides marketing communications consulting services.

References

Ansley, Barbara. Manager, Research and Program Evaluation, Rehabilitation/Seniors Program, Hamilton Health Sciences. Personal interview. May 22, 2008.

Consulting Cadre International Inc. Clarity Healthcare Solution for NRRS. Available www.consultingcadre.net. May 15, 2008.

Hamilton Health Sciences. About Hamilton Health Sciences. Available www.hamiltonhealthsciences.ca. May 15, 2008.

Ontario Ministry of Health and Long-Term Care. March 2007. Provincial Report on the State of National Rehabilitation Reporting System Practices in Ontario Hospitals.

Rinaldi, Saverio. President, Consulting Cadre International Inc. Personal interview. May 16, 2008.

The Canadian Institute for Health Information (CIHI). 2007. Inpatient Rehabilitation in Canada, 2005-2006.

The Canadian Institute for Health Information (CIHI). 2008. Inpatient Rehabilitation in Canada, 2006-2007.

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