Federal and state initiatives are aligning around the goal that by 2014 all Americans will have electronic health records to support access to their health information any time and anywhere. As a key healthcare provider, nursing data must be included to enhance patient safety, effectiveness, and efficiency of care that is patient-centric. The purpose of this study was to test the feasibility of abstracting, integrating, and comparing the effective use of a standardized terminology, the Omaha System, across software vendors and 15 home care agencies. Results showed that the 2900 patients in this study had an average of four problems on care plans, with interventions most frequently addressing surveillance (39%) and teaching (30%). Findings in this study support the feasibility of integrating data across software vendors and agencies as well as the usefulness for describing care provided in home care. However, before exchanging data across systems, data quality issues found in this study need attention. There were missing data for 10.8% of patients as well as concerns about the validity of using the problem rating scale for outcomes. Strategies for effective use of standardized nursing terminologies are recommended.
Author Affiliations: School of Nursing, University of Minnesota, Minneapolis (Dr Westra, Mss Oancea and Savik); and College of Nursing, University of Wisconsin, Milwaukee (Marek).
This project was funded by a grant provided by the University of Minnesota Digital Technology Initiative and supported by CareFacts Information Systems and CHAMP Software.
Dr Westra is an owner in CareFacts Information Systems.
Corresponding author: Bonnie L. Westra, RN, PhD, FAAN, School of Nursing, University of Minnesota, 5-140 Weaver-Densford Hall, 308 Harvard St SE, Minneapolis, MN 55455 (email@example.com).