Section 4.12 Implement
Implementation Strategies for Physician
Documentation
Identify the automation support available for physician documentation in a skilled nursing facility.
Time needed: 40 – 80 hours
Suggested prior tools: 2.8 Workflow and Process Redesign for EHR and HIE
Automation support is available for physician documentation, including annotation of information as
well as ordering treatments and medications. This tool distinguishes between order entry systems,
computerized provider order entry (CPOE) systems, and e-prescribing (e-Rx) systems, and describes
various strategies for implementing these similar, yet different, applications.
How to Use
1. Engage physicians who frequently admit residents to your skilled nursing facility in
identifying the functionality your facility should have in (health information technology) HIT
and (electronic health records) EHR that will be most helpful to them. Although they may
continue to prefer manual documentation, there are increasing mandates and incentives for
physicians to adopt at e-Rx and CPOE in an EHR. You can remind them that such tools can
not only improve medication safety but can support remote use better than a phone call
(which requires them to remember to sign the order the next time they are in the facility).
Other forms of documentation for the skilled nursing facility EHR can greatly aid timely
completion and accuracy of physician history and physical exams, physician progress notes,
consultations, and discharge summaries. Increasingly, transfer records and other transition of
care documentation can be exchanged electronically—not only with hospitals but with
physicians.
2. Conduct workflow and process improvement mapping to determine how physician-oriented
applications being implemented may change current workflows and processes. Ideally,
during planning for HIT and EHR acquisition, you have mapped current workflows and
processes and you can now identify processes you want to include in the new applications,
including how improvements can be made. Work with physicians to ensure they understand
potential changes and have input into their efficiency and efficacy. E-prescribing systems, at
a minimum, support drug-drug, drug-allergy, and formulary alerts. Ideally, Beers Criteria for
Potentially Inappropriate Medication use in Older Adults should be included in e-Rx for
physicians and in your electronic medical administration record (EMAR) system (see:
http://consultgerirn.org/topics/medication/want_to_know_more ).
3. Offer full training opportunities for physicians and others who support their documentation.
If your facility also uses a pharmacy information system (PIS), laboratory information system
(LIS), nutrition and food services information system (NFSIS), radiology information system
(RIS), or any other ancillary system that will have orders directed to it automatically from the
order entry system, ensure that the staff members who support these processes work with
physicians to ensure coordinated processes. Nurses and physicians should work together to
ensure that treatment orders flow from the physician order to the nursing documentation
component of the information system. Ideally, the physician documentation systems should
Section 4 Implement—Implementation Strategies for Physician Documentation - 1
prompt for specific documentation requirements. Ensure that these meet your state
requirements as well as accreditation requirements if you are Joint Commission accredited.
Determine how physicians will access the reminders. If the skilled nursing facility continues
to accept verbal orders because remote access is not provided for physicians, consider
adopting a portal where physicians can enter orders directly, or at least affix electronic
signatures to orders.
4. Monitor usage after go-live. There are many issues associated with physician documentation
and ordering systems. They include the length of time it takes to enter an order, alert fatigue,
keeping the drug knowledge base and formulary for e-Rx up to date, training new or
infrequent users, and monitoring goals achievement.
Forms of Ordering Systems
 Order communication systems enable nursing staff to transcribe a handwritten physician
order (or verbal order documented by nursing staff) into a system that routes components of
the order to its destination information systems. For example, if the physician writes an order
for a lab test and special diet, the order entry system can transmit the lab test component to a
laboratory information system and the diet component to a nutrition and food service
information system. This type of order entry saves nursing staff time, ensures accuracy, and
improves timeliness in communicating orders. The paper order signed by the physician is the
formal documentation; however, the destination systems may retain the information received
for internal quality checking purposes for some period of time.

Computerized provider order entry (CPOE) enables providers to enter orders for lab tests,
other diagnostic/imaging studies, therapeutic services, nutrition and food services, and
nursing services. They also have clinical decision support (CDS) that has many patient safety
and other benefits. For instance, diagnostic studies orders can be checked for duplication of
orders and associated orders, such as special dietary or preparation provisions. Reminders can
be provided for other skilled nursing facility treatment requirements. With some CPOE
systems, the physician can enter an order for a medication that goes through the e-Rx system.

e-Prescribing (e-Rx) enables a provider to write a prescription to a retail pharmacy or
pharmaceutical mail order house. These systems provide CDS for patients, as well as
formulary alerts. Some e-Rx applications also support medication renewal and the ability for
prescriptions to be put on hold, cancelled, or changed electronically.
In the nursing home, the CPOE system can be used for e-Rx with a special pharmacy
interface. CPOE systems are designed to communicate with other internal information
systems, such as PIS, LIS, RIS, etc., whereas CPOE and ancillary systems are designed using
a common protocol (from the standards development organization, Health Level Seven
[HL7]). E-Rx systems, however, have two significant differences. First, they must be
designed with a protocol from the National Council for Prescription Drug Programs
(NCPDP) that retail pharmacy systems use. Second, the exchange of prescription information
must happen through a secure gateway or exchange service. SureScripts is the primary
company providing such a gateway. It certifies e-Rx users as well as the recipient retail
pharmacy systems for secure transmission of the prescription and connection to formulary
information from pharmacy benefits managers (PBMs). The e-prescribing gateway is
illustrated and described below:
Section 4 Implement—Implementation Strategies for Physician Documentation - 2
Copyright © 2014, Margret\A Consulting, LLC. Used with permission of author
E-Rx is increasingly being used, although some physicians continue to handwrite prescriptions. By
2009, all pharmacies serving Medicare Part D patients were required to accept e-prescribing
transactions. Today, all state boards of pharmacy permit its use for all medications except for
controlled substances. There are, however, still some issues that need to be addressed:

Physicians should ensure that their e-Rx systems are kept up to date with new drug
knowledge through a subscription to a drug knowledge database service. This assures access
to new drug information, alerts, recalls, etc.

Local pharmacies that are not members of large chains may not yet have made the conversion
and become certified with Surescripts to support receiving electronic prescriptions. Although
the e-prescribing gateway can convert prescriptions to a Fax for these pharmacies, part of the
benefit of reducing transcription errors at the pharmacy is lost.

Not all PBMs, especially small ones and some state Medicaid agencies, are fully enabled to
support the formulary checking function in e-Rx.

Use of e-Rx for controlled substances is still being addressed. In 2010 the Drug Enforcement
Administration (DEA) changed its rules to permit electronic prescriptions for controlled
substances under very specific requirements for authentication and transmission, where
consistent with state boards of pharmacy requirements. Subsequently, SureScripts has begun
to certify e-Rx systems in states that have approved the functionality. If the physician’s e-Rx
is not yet certified or if you operate in a state that does not yet permit e-Rx of controlled
substances, physicians can still use their e-Rx system for its reminder and alert functionality
and generate a printed prescription to reduce legibility errors. The paper copy must be
provided to the pharmacy with a hand- written signature until the e-Rx and/or state boards are
aligned with the new requirements. State boards of pharmacy may also have stringent
requirements for printing on tamper-proof paper, printer security, generic substitution, and
other reporting elements for Schedule II drugs.
Section 4 Implement—Implementation Strategies for Physician Documentation - 3
Nursing Home Implementation of Automated Documentation Systems
Critical success factors for implementing automated documentation systems for use by physicians in
a skilled nursing facility include the following:
□ Engagement of physicians. Despite strong evidence to the contrary, many organizations still
wait to engage physicians until training is necessary. Physicians must come to understand and
trust these systems, believe they are a part of developing the CDS rules embedded therein,
and believe they play a role in selecting the system that is most user-friendly. Following are
examples of ways to engage physicians:

Indicate that the nursing home has specific plans to move to an EHR—including
physician documentation, CPOE, and e-Rx—by a certain date and wants the physicians
engaged from day one. This puts the physicians on notice that the home is serious, but
gives them ample time to participate. Physicians are not likely to find many other places
that are not moving toward more automation.

Ask physicians to participate in measurable goal setting, product assessment, standing
order development to build their own order templates, and review of clinical
effectiveness and efficiency using decision support rules.

Institute a regular communication process with the physicians who admit to your facility,
illustrating your commitment to gaining their engagement and adoption.
□ Engagement of nursing staff. In some cases, physicians are more interested and
knowledgeable about clinical information systems than nurses. There are significant
workflow changes for nurses, who must be involved in engaging physicians and the revising
complementary workflows. Ways to engage nurses include:

Provide dedicated time for education about HIT, CPOE, and electronic medication
administration record (EMAR), building computer skills and exploring the impact of
automation on nursing practice in general. This will pay off in many ways:gaining
adoption of their own documentation and EMAR components; getting invaluable
input from nursing for overall medication management workflow and point of care
documentation support; and ultimately encouraging and supporting nurses in their
professional work.

Have nurses work one-on-one with physicians in preparatory steps and during
implementation. Their functions are complementary, so their involvement in HIT
should also be complementary.

Provide dedicated time for workflow and process improvement activities, which will
provide immediate benefit where there are non-standard practices, and ultimately in
the HIT systems. Nurses are typically process-driven, which can be both an
advantage and a disadvantage. However, having nurses work on process mapping
themselves, early in the consideration phases of all aspects of HIT, helps them see the
areas where change is needed, and will help ensure adoption of new processes.
□ Pharmacy’s role in CPOE. While many skilled nursing facilities have limited or no direct
pharmacist support, attention should be paid to pharmacy interactions, e.g., notifying those
pharmacies you use regularly of your e-Rx adoption.
□ Determination of source and destination systems needed for CPOE to work for all items
being ordered. For each of the following systems, you may need to evaluate whether they are
prepared to receive orders, notify staff members of an order, and acknowledge receipt of the
Section 4 Implement—Implementation Strategies for Physician Documentation - 4
order. The presence and capabilities of information systems need to be reviewed for the
following departments:

Laboratory

Nursing

Nutrition and food service

Radiology

Therapy services

Social work
If orders are placed for a service that does not have an information system, or will not be linked to
the EHR, exception processing will be needed. In evaluating systems, determine how the exceptions
are routed within the system, or if they need to be handwritten by physicians.
Workflow and Process Improvement to Set Goals
Chart the flow of information within the facility and with the physician office and retail pharmacy to
understand what structures will work best.
As current workflows and processes are mapped, providers and other stakeholders should be able to
establish measurable goals. Record these in a manner that illustrates how they can be accomplished
with HIT and when you will know you have achieved the goals. Review the goal-setting tool (see
1.X Visioning, Goal Setting and Strategic Planning) for specific examples. The following are
examples of high-level objectives. Modify or add to these, and make them specific and measureable
for your organization:
 Reduce errors of omission and commission in ordering to improve patient safety by using
CPOE and e-Rx.
 Decrease variation in standards of care to improve quality through use of template-based
documentation protocols.
 Achieve more effective dosing for improved response time to therapy through more precise
ordering and EMAR systems.
 Increase turnaround time for ordered services that are electronically transmitted directly to
their destinations and do not need to be manually entered to facilitate resident response.
 Respond more rapidly to changes in resident health status using monitoring from the EHR
and other HIT.
 Improve downstream productivity by reducing time to address follow-up issues that are
alerted or generated from the EHR or other HIT, such as immediate notification of missing
data.
 Reduce health care cost by monitoring risk for hospital readmission/emergency department
use through alerts in an HIT dashboard.
Other Physician Documentation Considerations
All of the above should position your facility to select the system that best meets your needs, or at
least to recognize what a system you are evaluating does not address. Skilled nursing facilities may
not have a great deal of choice when it comes to the products that serve this market. However, if you
recognize what may be lacking in these systems, you can encourage your vendor to support those
functions in subsequent product releases and address these deficiencies in your new workflows and
Section 4 Implement—Implementation Strategies for Physician Documentation - 5
processes. There is no perfect product for any one environment. As much as you want a product that
fully meets all your goals, you may need to compromise. Recognizing where to compromise is half
the battle in addressing product management.
The following are important functional requirements for physician documentation:
□ System characteristics
 User-friendly interface

Sub-second response time

Reliability

Ubiquitous workstations (desktops, tablets, or other devices)

Ability to modify decision support rules and assessments

Ability to create favorites lists

Ability to create standing orders, if permitted in your state
□ Functionality for general documentation

Alerts to certification and re-certification requirements

History and physical exam component for admission and annually (if required by
state laws or accrediting bodies)

Support for documenting assessments for dementia

Support for monitoring nursing and interdisciplinary care plans

Progress notes, including reminders for frequency per state requirements

Consultations, such as from podiatrists, dentists, optometrists, audiologists,
radiology, and other specialists (e.g., internists, cardiologists, pulmonologists)

Documentation from specialty physicians

Documentation of ICD codes for diagnoses

Discharge summary (if required by state laws or accrediting bodies)

Transfer form documentation, as applicable
□ Functionality for CPOE and e-Rx

Duplicate therapy checking

Drug-drug checking

Drug-allergy checking

Drug-formulary checking

Drug-lab checking (general)

Dose-renal function checking

Dose-age and weight, or BSA

Dose-height and weight, or BMI

Drug-disease indications
Section 4 Implement—Implementation Strategies for Physician Documentation - 6

Corollary orders for adjunct drugs and tests

Corresponding monitoring orders/secondary orders

Expiring order alerts

Alerts with options to facilitate response

Exception documentation for alert overrides

Links to reference material

Links to education material
Provide ongoing support for longer than you think necessary and provide the same level of training
and support for changes as you would for initial rollout. Where training is typically considered to be
a step-by-step instructional program, support is a person who can answer a question or point out an
aid or tip. Support is often the function of a super user who is a person who has a knack for
computers and has received both special training and more time to “play” with the system to learn its
ins and outs.
Super users generally are those who actually use the system to perform their regular duties, but who
may be allocated a smaller number of patients or other form of relief so they will have time to aid
others in their use of the computer system—at least for some period of time after go-live of an
application or major change in an application.
Copyright © 2014
Section 4 Implement—Implementation Strategies for Physician Documentation - 7
Updated 03-19-2014