ABSTRACT
Several years ago, a group of researchers conducted a 2-year test of an electronic care planning and documentation tool under real-time conditions in four different hospitals. The application was web-deployed and, though not directly connected to each organization’s electronic health record (EHR) during the study, it appeared seamless to users. Links to the patient’s EHR and the care plan application were readily accessible through tabs located on the central computer screen, enabling the effective workflow. Moreover, since the care plan information was not redundant to or directly dependent on items in the EHR, it was not necessary to build a complicated interface between the two. Patient demographic information was the only redundancy and was entered separately into the care planning system on the first admission to avoid needing to create separate HL7 admission/discharge/transfer (ADT) feeds from each test site’s EHR before full testing was completed. Prior to using the application, each staff nurse at the pilot sites was trained to represent patient problems, outcomes, and interventions with standardized terms and measures and to keep the patient’s plans of care current. Once competency in the application was established, the nurse was required to enter an initial care plan or update at handoff on every patient cared for by the nurse during the previous shift.
