Maintaining a consistent big picture: meaningful use of a Web-based POC EHR system

Abstract

Objective: To test the hypothesis that Hands-on Automated Nursing Data System (HANDS) "big picture summary" can be implemented uniformly across diverse settings, and result in positive registered nurse (RN) and plan of care (POC) data outcomes across time.

Design: In a longitudinal, multisite, full test study, a representative convenience sample of eight medical-surgical units from four hospitals (one university, two large community, and one small community) in one Midwestern state implemented the HANDS intervention for 24 (four units) or 12 (four units) months.

Measurements: (a) RN outcomes-percentage completing training, satisfaction with standardized terminologies, perception of HANDS usefulness, POC submission compliance rate. (b) POC data outcomes-validity (rate of optional changes/episode); reliability of terms and ratings; and volume of standardized data generated.

Results: One hundred percent of the RNs who worked on the eight study units successfully completed the required standardized training; all units selected participated for the entire 12- or 24-month designated period; compliance rates for POC entry at every patient hand-off were 78-92%; reliability coefficients for use of the standardized terms and ratings were moderately strong; the pattern of optional POC changes per episode declined but remained reasonable across time; and the nurses generated a database of 40,747 episodes of care.

Limitations: Only RNs and medical-surgical units participated.

Conclusion: It is possible to effectively standardize the capture and visualization of useful "big picture" healthcare information across diverse settings. Findings offer a viable alternative to the current practice of introducing new health information layers that ultimately increase the complexity and inconsistency of information for frontline users.

Figure 1

The HANDS Ecosystem. Production (left side) environment - represents the people, structures, content, and processes involved in the real-world evaluation of HANDS (the focus of this study). The Development (right side) environment includes the people, structures, content, processes, connection to the Production environment, and interrelationships among them that build, maintain, and expand HANDS (shaded-not the focus of this study).

Figure 2

The Research Framework depicts the 1) antecedent criteria met by the organization and study unit participants; 2) facets of the HANDS intervention; and 3) outcomes evaluated in the study.

Figure 3

Six screens available in HANDS with arrows and numbers showing the connections among them: Central Access Screen provides entry to multiple parts of the system: (1) links to Central Data Entry Screen, the area where plans of care are created, updated, submitted through accessing search modes and templates; (3) links to last submitted Plan of Care, (4) links to the most current Episode History; and (5) links to Links to Patient Episodes where (6) current and all previous plans of care and (7) episode histories are accessible. The Central Data Entry Screen also links to (2) NOC Rating Screen where the clinician enters current and expected ratings.

Figure 4

The units a-d (left column) were in the study for 12 months and units e-h (right column) for 24 months. Graphs are truncated to the maximum POC changes per unit to better represent variation across time. Optional changes were computed by adding all of the following across an entire episode: a count of the items that differed from POC1 to POC2; POC2 to POC3, POC3 to POC4, etc. Item differences were defined as adding, deleting, resolving NNN terms or a change in a “current” NOC rating from that which was entered for the NOC on last POC.

Figure 5

Includes the combined top 5 NANDA-I Diagnoses for each of the 8 study units and all units and the rankings of these by unit and all units.

Figure 6

Includes the combined top 5 NOC Outcomes for each of the 8 study units and all units

Figure 7

Includes the combined top 5 NIC Interventions for each of the 8 study units and all units and the rankings of these by unit and all units.