Building HIT tha

Supports Continu

of Care at the Po

of Delivery

Gail Keenan, PhD, RN Gail Keenan, PhD, RN

University of Illinois Chicago

Colle

ge of Nursin

g

g g
Continuity at Point of 

 Definition: 

the high quality coordination and delivery of care that results when delivery of care that results when

communication across clinician a

setting transitions is efficient and setting transitions is efficient and

continuously builds on a shared 

understanding of past care and tunderstanding of past care and t

“dynamic team’s” * goals for pati

outcomes.

• Team membership includes the patient and health who provide care Membership naturally expands awho provide care. Membership naturally expands a

across time and settings
General Goal for Today’

 To share my team’s science and o

To share my team’s science and o

you language to advance VA as th

premi “ bli h lth ti 

ier 

“public 

health care option

achieves continuity and high qual

preci l b f th d i i t 

isely 

because o

f the a

d

minis

tr

HIT, and research infrastructures. 

VA t i lli VA sys

tem is a compelling examp

how full interoperability - done righ

prod hi h li h i duce hi

g

h quality care t

hat is co

effective.
Specific Objectives fo

Today s Talk ’s Talk

 Examine why many currently 

im

p p lemented EHRs do not im

prov

continuity of care (COC)

 Describe important items to cons

Describe important items to cons

developing tools to promote COC

 Present findings from HANDS an

Present findings from HANDS an

research regarding the use of HIT 

promote COC promote COC
Poll: Please tell me about 

Select 1 answer from each category: 

 Health Discipline

Nursing

 Primary Role

– St ff– Medicine

Other

– St

aff

– Administratio

– Other R h

 Degree

B hl

–

Researc

h

–

Bac

h

elors

– Masters

 Major job foc

informatics

– Doctorate

– Other

– Yes– No
ARRA* Feb.17.2009

Includes Health Information Techfor Economic & Clinical Health (HAct

1. Set forth a plan to advance use of H

improve care quality serve as a foun

Act

p qy

health care reform

2. Establish Office of National Coordina

Establish Office of National Coordinawithin HHS

3. Authorize CMS to administer incentiv

to administer incentiv

“meaningful use” of EHRs

*ARRA - American Recovery and Reinvest
ONC

 Federal entity charged with coord

the effort to implement an HIT the effort to implement an HIT

infrastructure for use and exchan

health information in electronic fohealth information in electronic fo

that ensures “meaningful use” of 

 Advised by 

1. Health IT Policy Committee Health IT Policy Committee2. Health IT Standards Committee
Health IT Polic

y Comm

 Meaningful Use Health Outcome

Polic

y Priorities 8.20.2009

1. Improve quality, safety, and red

health disparities health disparities

2. Engage patients and families3

. I di ti Improve care coordination

4. Improve population and public hea

5. Ensure adequate security & privac
Current EHRs & Contin

 Many existing EHR systems d

adequately consider that

– Patients typically access a number of h

Patients typically access

a number of h

care settings for their care

– The main purpose of documentation is 

efficiently support team decision makincommunication across time and space

– Data collected by clinicians that does n

immediate value at the point of care hareduced reliability & validity
Current EHRs & Contin

 Many existing EHR systems d

adequately consider that

– Each extra “click” needed to locate o

Each extra “click” needed to locate o

information is a burden to the clinician 

– Information that is not consistently rep

in documentation and communication errors

– Systems need to be regularly updated 

accommodate new knowledge but this if done organization by organization
Current EHRs & Contin

So too, documentation– meets the organization’s needs not the 

needs for concise, high quality, and easaccessible information to support PATIEaccessible information to support PATIE

– is not designed to support nurses in the

front line coordinators, implementers, anfront line coordinators, implementers, an

of the interdisciplinary team’s care 

– is frequently recorded on “scraps” carrie

clinician’s pocket and shared at the han

often NOTentered into the patient’s reco
Current EHRs & Conti

The Plan of Care should help to coord

should help to coord

interdisciplinary team’s communication ab

but DOESN’T because:– the format is cumbersome and variable – it is hard to keep current – accountability is not delineated accountability is not delineated– there is no good tool to support interdisc

work fl ( h di i li d it “ 

k flow 

(eac

h discipline 

does its 

“own 



What do EHRs nee

1. To be intero

p ( erable on three levels 

(tec

semantic, and process) so 

1. Continuity of care is supported through dat

i f ti th t in

formation th

a

t

1. is gathered in the same way2. Is always available and easily accessible Is always available and easily accessible

3. is in a consistent format 4. Retains the same meaning for those who use it 

2. System can be cost effectively maintained 

sustained over time

3. System can automatically generate new ev

System can automatically generate new ev

from the data collected and deliver it immeto the point of care
What do EHRs need

Compelling scientific evidence that the funcfeatures, and content enables clinicians to gCOC that is the hi

g qy hest of 

qualit

y across tim

settings Need an accurate “Bi

g Picture” of care t

regularly updated and used to guide the of information at handoffs 

 that has shared meaning  directed at achieving the team’s goals for ca

 Need to fully test all new features using 

Need to fully test all new features using 

methods under real time conditions
Interop y erability Defi

Concept allows us to communicate abConcept allows us to communicate ab

well systems interact with one anothe

specifi d d i f i f ti 3 ified domain of information on 3

interconnected levels

1.Technical-TI-conveyance of inf2.Semantic Semantic-SI-persistence of me

persistence of me

3.Process-PI-integration into wor

1HL7 EHR Interoperability Work Group. (February 7,2007).

Coming to terms: Scoping interoperability for health care 
Technical Interoperabil

Example: Strong versus WeaExample: Strong versus Wea

Conve

y g ance of “Bi

g Picture” information 

across EHRs: Strong TI

: the database architectures an

software programs for storing, retrieving 

di l i l t d d t t th displaying elemen

ts nee

d

e

d

to crea

te the 

Picture” are the same for multiple system

 Weak TI: the database architectures and 

programs for storing, retrieving, and dispprograms for storing, retrieving, and disp

data elements for the “Big Picture” differ significantly across multiple systems (Priv
Semantic Interoperabilit

Example: Strong versus Weak Example: Strong versus Weak

Persistence of Meaning of the BIG PICcomponent of EHRStrong SI: the content is represented in 

way (e.g. same taxonomies are used to 

represent the concepts included in the represent the concepts included in the 

PICTURE with each concept having a suni

q g) ( ) ue meaning) across EHRs 

(VA

)

Weak SI

: the content is re

p 

resented in m

ways within and across EHR systems (narrative, variable use of taxonomic ter(Private)
Process Interoperabilit

Examples: Strong versus Weak Examples: Strong versus Weak

The integration of The BIG PICTURE of The integration of The BIG PICTURE of 

component of the EHR into work flow

Strong PI: rules pertaining to use of BIG 

component are the same across systemwhen to enter data, how, by whom, use interdisciplinary and disciplinary handoff

Weak PI: rules pertaining to use of BIG PI

component vary by system.component vary by system.
Conclusions about I

Thus, the GREATER the 

– Technical Interoperability

– Semantic Interoperability

– Process interoperability Process interoperability

The GREATER the overall interoperability and likelihood that the information needed and likelihood that the information needed promote the continuity and quality of care transfer seamlessly across organizations/stransfer seamlessly across organizations/sIt will take a major overhaul of our laws anIt will take

a major overhaul of our laws an

funding for the private sector to achieveinteroperability comparable to the VA leveinteroperability comparable to the VA leve
Questions & 

Answers
HANDS “Big 

Picture” 

Com

ponent of t

EHR
Poll: Please answer YES or NO abo

familiarity with NANDAI, NOC, and 

I have at least some understanding of the following I have at least some understanding of the following1) HANDS Plan of Care Method Plan of Care Method

YES NO

2) The NANDAI Nursing Diagnosis Classification

YES NO

3) The NOC Nursing Outcome Classification

YES NO

4) The NIC Nursing Intervention Classification

YES NO
HANDS Method Defi

A l t i ll t d An elec

tronically suppor

t

e

d

communication and care mana

syst d i dt t tem 

designe

d

to promo

te CO

handoffs within and across syst

– developed and refined through 1

of research 

– provides 3 levels of interoperabili

technical, semantic, and 

process
HANDS: Technical Fea

Electronic tool

– D t b hit t d ft 

D

a

t

a

base architec

ture an

d software su

capture, storage, retrieval, and display 

el t d th i l ti hi t 

lemen

ts an

d th

eir relationships 

to eac

(e.g., diagnoses, outcomes, and interv

– Centrally deployed through ASP (Appl

Server Provider) mechanism

– HIPAA Compliant– Connects to EHR through an HL7 adm

Connects to EHR through an HL7 adm

discharge and transfer (ADT) feed

Central data repository

– Central data repository
HANDS: Semantic Feat

 Utilizes complete NANDAI, NOC, and 

NANDAI, NOC, and 

taxonomies to represent the “Big Pict

care and facilitates shared meaning ocare and facilitates shared meaning o

clinical diagnoses, outcomes, and inte

 Content of training and competenc

Content of training and competenc

assessment designed to ensure “Big 

is properly represented and used by cis properly represented and used by c

to guide SHARER handoff communic
HANDS: Process Fea

 Learn - train the trainer model train the trainer model

• 1/3 didactic - 2/3 independent on-line stud• C 0 hampions 4

0 hr - S ff 8 ta RNs 

8 hr 

 Document - an admission or u

pdate 

each of RN’s patients into HANDS tool )at every formal handoff tool )at every formal handoff

 Communicate - use POC to structu

“ t/h d ff” di l ti “report/han

d

off” di

alogue conversati

(SHARER)
HANDS

Finding pp s: HIT Suppor

Safe Nursing Care

1 R01 HS015054-01- HHS PHS NIH AHRQ (2004-

Gail Keenan PhD RN PI Gail Keenan, PhD, RN PI

Elizabeth Yakel, PhD / CO-PI

Dana Tschannen, PhD RN ,

Laura Szalacha, PhD

Mary Mandeville MBA Mary Mandeville, MBA
HANDS Research Base

Conceptual Framewor

Organization Communication Clinici

Factors Intervention Ou

Standardized Handoff Structure Culture Readiness

•High Trust •Safety Culture Focus •Expects Clinician Mindfulness, H df l I t l ti d C ll ti

Handoff Structure Using HANDS Promotes Heedful Interrelating & Mindfulness about HANDS story 

dF t C i t d

PCC

Heedful Interrelating, an

d

C

ollective S

Mind•Infrastructure Supports Change•Engages in Continuous Learning

an

d

Future 

Care among inter an

d

intra-disicplinary team members

SSN

df df J 

Commitment to Change•Adopts Standardized Plan of Care Standardized 

J

o

VE

df df

Method •Provides Ongoing Education•Provides Resources to Implement•Provides Resources to Sustain

Documentation in HANDS Electronic Tool Provides a Consistent , Dynamic, Up-to-date Synopsis of Care: The Clinicians’ CollectiveSynopsis of Care: The Clinicians Collective

Mind

© G.Keenan, E.Yakel, D. Tschannen, & M. Mandeville, 2007
Study Aim

T d t i if f ll i t bl To determine if a fully interoperable 

method of creating g and maintaining 

current “Big Picture” plan of care (Pbased on High Reliability Organizaprinciples can be implemented in 8 principles can be implemented in 8 units located in 4 organizations (generalizability)
Sample = 8 “RIPE” U

4 ORGANIZATIONS/ 8 UNITS/ 700 R4 ORGANIZATIONS/ 8 UNITS/ 700 R 4 organizations

–1 university, 2 community, 1 s

community

 8 units - 4 - ( ) 24 mo & 4 -( 

12 

–Med-surg , neuro, thoracic, IC

progressi ld d lt/ 

ive care, older adult/

acute care elderlyacute care elderly
Sample

Unit Time/study Org Beds 

A 24m a 32/48 

B 24m b 42 C 24m c 22 D 24m d 22 

A2 12m a 60/44 B2 12m b 42 B3 12m b 10 C2 12m c 23 
Multiple Methods Us

 Ob ti servations

 Surveys

 It i n erv ews

 Meetings

 F G ocusroup

 IRR checks for outcome ratings 

 T i li bilit h k Term meaning reliability checks

 Think-alouds of system usage

 W b l ti Web analytics (A l i f t ti 

(Analysis of transacti
Timeline & Measure T

Pre Post

0m

Post

6m

Post

12m

G l eneraApplication FunctionalityTraining Competencies

XX

XXX

Training, CompetenciesSafety CultureObservations Errors Observations, Errors

X

X

X

X

Culture, Trust

XX

X

X

XX

MindfulnessThoughtful Plans of Care (POCs) XXHeedful Interrelating Heedful InterrelatingRich handoff dialogue with POCs X X C ll ti Mi d C

ollective Mi

n

d

Shared understanding of POCs X X 
Findings
Baseline Observatio

 Shadowed 18 RNs (minimum of 2/unit) t

Shadowed 18 RNs (minimum of 2/unit) t

24 hour work flow relative to documentatcommunication 

p pg ractices 

pre 

go-live 

Findings 

– Observed enormous variation in documentat

Observed enormous variation in documentat

communication across individuals, units, & o

– RNs used from 5-11unique forms each shift

– RNs indicated plan of care brings little value – RNs focused on details and rarely connected 

bi i t g p

c

ture

– RNS WERE NOT ALWAYS CONSCIOUS O

BEHAVIOR
Application Functiona

 Conducted 7 think-alouds to identify inter

b i arr ers 

 Asked questions about functionality in int

focus group and informal phone meetingfocus group, and informal phone meeting

champions

Findings:

– Identified problems with the software and ma

to improve usability 

– RNs WERE NOT ALWAYS CONSCIOUS OF 

PROBLEMS THEY EXPERIENCED WITH T

SOFTWARE

– RNS suggestions for improving software freq

not work
Mindfulness Measure

thoughtfulness in plan of care documethoughtfulness in plan of care docume

 Conducted web anal

ytics on HANDS

– RN patterns of use – types of NANDA, 

NIC updates features used sequence NIC updates, features used, sequence 

– NOC rating analyses 

Fi di Fi

ndings:

– RN entr

yp g atterns of chan

ges across tim

indicated sustained mindfulness in upd( g) si

– % patients meeting expected outcomes 

over time (sig)over time (sig)
Collective Mind Measu

evidence of shared meaning among evidence of shared meaning among 

 NANDA NOC NIC term meaning exercis

NANDA, NOC, NIC term meaning exercis

– conducted at 3 points in time (n RNs =105)

• IRR NOC ratings 3 raters/NOC (n RNs =6

IRR NOC ratings

3 raters/NOC (n RNs =6

• Compliance with entry of POCs at hando

• Total POC entries for 8 units = 275,628

Findin

g

s

– .74 IRR for term meaning exercises– IRR .95 o e pected at g a d 86 o cu e 

 f

or 

e

xpected ratin

g

a

n

d .86 f

or curr

e

n

both within 1

– 78-91% com

pliance rate for POC entries
Heedful Interrelating Mea

consistency in use of handoff protoconsistency in use of handoff proto

 Interviews (n Interviews (n 77 =

- 2 different time p

2 different time p

focus group, regular phone meetin

champions (repeated across time) champions (repeated across time), 

observations final 6 mos of study (

Findings 

– Handoff training inadequate revised 

Handoff training inadequate revised 

– Observations in Y2 indicated RNs di

regularly use SHARE protocol to guidregularly use SHARE protocol to guid

– RN interviews indicated desire to use 

b t anted more training and s pporb

u

t wanted more training and

s

uppor
Other Major Finding

 78% - 91% compliance with POC 

submissions 

( p literature re

ports arou

50%)

 Surveys pre (n=419) post (n=241): Surveys pre (n=419) post (n=241):

– RNs found HANDS significantly more 

than previous care planning method 

– RNs significantly more familiar & sati

NNN than at baseline (p<.001)
Anecdotal Findings 

 All units indicated desire to keep HANDS 

study 

 RNs set up use group in 1 organization RNs reported successful use in rounds RNs reported successful use in rounds New unit gives handoff at bedside and in

patient

 1 Chief Nurse Executive reported appre

how HANDS enhanced the critical thinkihow HANDS enhanced the critical thinki

her RNs
Facilitators of 

HANDS Adoption

Chief Nurse Executive and organization-wide endorsemen

– Belief that change will bring desired go– Well constructed flexible chan

g 

e mana

strategy that addresses 

• Technical, Training, Implementation, Continuous E

Improvement

– Adequate resources to carry out and s

strategi l c p ans 

• Personnel & Funding 
Limitations/Barrie

– Impact on MDs was not directly exami– Commercial vendors business models 

“vendor neutral” standardization at the 

– Studying technology adoption “in the w

mess

y

– Since HANDS was a “research project

limited # of units per organization) systlimited

# of units per organization) syst

benefits could not be examined
Benefits to Administra

Communication 

 G t t d di d d t f l i Genera

tes s

tan

dardize

d

d

a

ta use

f

ul in 

supporting administrative decisions, ca

–

ch t i ti tt ’ 

harac

terize practice patterns on one’s un

(clinical dx, outcomes, interventions)

– examine compliance with plan of care (PO

examine compliance with plan of care (PO

submission 

– evaluate individual, unit, or organization’s 

in meeting expected outcomes 

– contrast workload of nurses and units

–

st t d j tif t ffi d h d li truc

ture an

d justify s

t

affing an

d sc

h

e

d

ulin

practices
Revised “SHARER” Han

S - Sketch: 

p p gg rovide 

patient name, a

ge, 

g

medical diagnoses, code status, allerand other pertinent information and other pertinent information

For each problem repeat HARE:

H

- HANDS: review HANDS: review

“Plan of Care Plan of Care

” histor

histor

current plan at computer screen add 

details only details only

A - Aim: discuss focus of care for next sh

R

- Rationale: explain your thinking Rationale: explain your thinking

E - Exchange: invite questions, debate, dR Reconcile: present closing remarks

 - Reconcile: present closing remarks
H

B

((interface))

B

Inte

Pl

CPRS

BCMA

GHUI 

Narcotics

Han

Patient 

Sh

(compl

Assessment Treatment 

Record/

Progress 

Nurs

(activ

((interface))

Outpatient 

Encounters

Notes

((interface))

Vitals/Measurements

Wo

Pa

Flow sheet Sta

((interface))

((interface))

Patient 

Scheduling

Sta

a 

Intake/Output

Nursing Integrated Information System Data & Work Flows Schem

Sta
Example Reports 

Generated from Reposi

 RN patient load & differences acros Top problems interventions and ou

Top problems, interventions, and ou

by unit

 Number of unique RNs per patient e Compliance with Plan of Care subm

Compliance with Plan of Care subm

 Unit success rate in meeting expect

outcomes at discharge




Conclusions 

 All aspects of the HANDS interventions wo

All aspects of the HANDS interventions wo

planned with the exception of the handoff p

 Valid testing of EHRs requires the use of m

Valid testing of EHRs requires the use of m

methods including unobtrusive observation

 HANDS s a ou dat o o c eat g a d 

 is a foundation for creating and m

feasible and valuable “Big Picture” of care interoperable on three levels and 

– allows the seamless transfer of key patient car

needed to support COC

– provid d t b f lti l ides a data base for multiple uses

– provides the infrastructure to cost effectively u

sustain itself over timesustain itself over time
Next Research

 T t l i d h d ff d Test newly revised handoff procedu

“SHARER” and on-line training mate

incorporate findings from fully analyzha do data ndoff data

 Test data mining techniques and sta

al ith f ffi i i lgorithms for efficiency in 

– targeting best practices – supporting an evidence based staffing 

methodology
Next Research 2

 I d tif dd d t t f t 

Indentify, add, and test new features 

– increase the use of HANDS among all 

of the interdisciplinary team

– strengthen the decision support and en

immediate usefulness of it to the clinic

– provide the means to seamlessly deliv

evidence generated from the data colleHANDS (e.g., benchmarking, data-minst ti ti l l i ) b k t th li i i 

tatistical analysis) back to the clinician

immediately useful format
Questions & 

Answers
Contact & Disclosur

Information

Gail M. Keenan, , PhD RNAssociate Professor College of Nursing College of Nursing

University of Illinois

312-996-7970, gmkeenan@uic.eduDisclosure: In 2008 HANDS was mad

for 

p g urchase through HealthTeam IQ, L

Keenan is the current President and ChExecutive OfficerExecutive Officer.
HANDS Core Project Te

Support Team

Administrative Tea

Support Team

– Christine Anderson, PhD, RN,– Elizabeth Brough, PhD, RN

 Gail Keenan, PhD,  Beth Yakel, PhD, C Mary Mandeville, M

– Brook Ayad, BSN, RN– Sally Decker, PhD, RN– Sharie Falan MS RN

Mary Mandeville, M

 Dana Tschannen, 

Site Director

– Sharie Falan, MS, RN

 Yvonne Ford, PhD

– Crystal Heath, MS, RN– Mary Killeen, PhD, RN

Yvonne Ford, PhD

Specialist

 Laura Szalacha, P

– Deanna Marriott, PhD 

– Rachelle Ramos, BSN, RN

– Santosh Udupi MS

National Advisory  Catherine Rick, RN Marilyn Chow RN 

Santosh Udupi, MS

– Julia Stocker, PhD, RN– Kathleen Sutcliffe, PhD, RN

M T d BSN

 Marilyn Chow, RN

 Connie Delaney, P Ada Sue Hinshaw, 

J Sh PhD 

–

Marcy 

Tre

der, BSN



Joan Shaver, PhD

 Judy Storfjell, PhD
Key References

 Keenan G Tschannen D & Wesley M (20

Keenan, G, Tschannen, D, & Wesley, M. (20

Standardized nursing terminologies can tranpractice. JONA, 38 (3), 103-106. 

 Keenan, G., Yakel, E. & Tschannen, D. (200

Documentation and the nurse care planning Documentation and the nurse care planning 

In Hughes, R. (Ed). Patient safety and qualievidence-based handbook for nurses. AHRQ

 Anderson, C., Keenan, G., & Jones, J. (20

Using pp y bibliometrics to support your selection nursing terminology set (CE Offering). CompInformatics, Nursing (CIN), 27 (2). 82-92.