Purpose: The demand for healthcare delivered in ambulatory care settings has increased. With value-based care programs, ambulatory care nurses increasingly work as care managers providing holistic, person-centered care that is integrated across settings. Specific electronig health record (EHR) tools, comprehensive training, and standard processes support care managers in coordinating care and transferring knowledge across the health system. However, at an academic medical center in the Pacific Northwest, there has historically been a lack of education, standardization, and training for ambulatory care nurses.

Description: An environmental scan of current care management processes was conducted through RN survey, contextual inquiry, and information technology discovery sessions.

100 ambulatory care nurses across primary and specialty care completed a survey about their practice. The majority (87%) stated their work involved care management. Most (69%) reported documenting care coordination activities within telephone encounters; however, participants also reported documenting in at least eight other areas of the EHR. Approximately half (53%) relied on tools within the EHR to describe patients’ progress and organize outreach; others relied on tools such as Excel, Outlook, or a notebook for these purposes.

These survey results were supplemented by an 8-hour contextual inquiry in one primary care and one oncology clinic. Notable observations included: 1) variation in management of incoming patient communication, 2) simple patient questions requiring 25 minutes of chart review and care coordination to reach resolution, and 3) nurses’ reliance on non-EHR tools to track complex patient populations.

Information technology discovery sessions with 33 primary care staff (including nurses, behaviorists, pharmacists, and medical assistants) revealed: 1) lack of a standardized method for referral into care management, 2) lack of consistency in tracking care managed patients, 3) inconsistent documentation of care plans (53%) and patient goals (63%) in inconsistent locations of the chart, and 5) lack of standard work for patient outreach.

Taken together, these data highlight variability of nursing practice, workflows, and EHR use in ambulatory care. These conditions negatively impact transfer of knowledge across settings, time needed to review charts in preparation for care management and patient experience and safety. This information was instrumental in bringing enhanced EHR care management tools and education to clinics in a phased approach, first in primary care and then in specialties.

Evaluation/outcomes: The ambulatory care informatics team recommended enhanced EHR tools for care managers including: 1) an order for enrollment into care management; 2) episodes of care, care planning/goal activities, and standardized patient assessments; 3) tools for planning and tracking outreach; and 4) expanded “at a glance” information.

Next steps include: 1) creating comprehensive education on these tools to enable standard processes; 2) designing reports to assess tool use, provide feedback to users, and enable data extraction; 3) improving visibility of ambulatory care managers’ work in acute, critical care, and emergency department settings; and 4) expanding use to care managers in specialty clinics.

Initial outcome data will focus on process metrics concerning consistency of standard EHR tool use in primary care.

Julie Johnson MSN, RN, CPN

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