Identifying Solutions for Nurses’ Health IT Pain Points...Identifying Solutions for Nurses’...
Transcript of Identifying Solutions for Nurses’ Health IT Pain Points...Identifying Solutions for Nurses’...
Identifying Solutions for Nurses’ Health IT Pain Points
March 1, 2016 at 2:30 PM
Nancy Staggers, PhD, RN, FAAN, Entrepreneur & Professor, Summit Health Informatics & University of Utah
Ellen Makar, MSN, RN, Program Official, AHRQ, Department of Health and Human Services
Ellen Makar
• Entrepreneur, Consultant & Professor,
Health Informatics
• Research program in UX for health IT
products
• IT executive, enterprise EHR projects
• Career Army officer
• 30 years in HIT
Nancy Staggers
About Us
• Sr Policy Advisor, Program Official, US Dept
of Health and Human Services
• 30 year RN; patient safety and nurses’ use
of health IT focus areas of interest
• Management in acute care, managed care,
telehealth, health care finance, analytics
• Board certified in informatics, case
management and executive nursing practice
• DNP Student, Texas Tech- class of 2017!
Conflicts of Interest
Nancy Staggers
Has no real or apparent conflicts of interest to report
Ellen Makar
Has no real or apparent conflicts of interest to report
Agenda
• Introduction
• Project background and methods
• Results
– Nursing UX pain points
– Recommended solutions
• Conclusions and next steps
Learning Objectives
• Define user experience terms
• Describe known Health IT "pain points" for nurses
• Analyze a summary of case studies/stories/interviews with real-world examples from the current project
• Identify potential solutions to nursing-specific UX issues at the individual, organizational and national levels
http://www.himss.org/ValueSuite
HIMSS Value Steps
Satisfaction improved by
avoiding potential pain points
Treatment and patient safety
outcomes improved
Electronic information is
secure when pain points are addressed
Patients and their healthcare
teams have access to pertinent information
Savings recouped from lower labor
costs, fewer inefficiencies, reduction in errors, litigation
Introduction & Background
Definition of Terms
Staggers, 2014
User Experience
A person's perceptions and responses
resulting from the use or anticipated use of
a product, system or service (ISO 9241-11)
Definition of Terms
• Usability: extent to which a product can be used in a specified context of use
– by specified users
– to achieve specified goals
– with effectiveness, efficiency and satisfaction (ISO 9241-11)
• User Centered Design (UCD): Process to build improved human performance into a system or device
http://www.nist.gov/itl/hit/upload/Guide_Final_Publication_Version.pdf
Introduction
Background
Staggers, Elias, Hunt, Makar, & Alexander, 2015
A Call To Action
Project Methods
Project Team Members
Nancy Staggers
Beth Elias
Jane Hunt Greg Alexander
Endorsements: HIMSS NI and AMIA NI
Ellen Makar
Methods
• Two phases
• Case studies, “story” submissions
• Interviews with experts
• Case studies/stories
• Requests to ANA, AMIA, HIMSS
• Interviews
• Snowball sampling of experts
• 30 - 45 min semi-structured interviews recorded
via Webex
• Two listeners, independent documentation of
findings via extensive notes
• Content analysis
Case Study/Story Submissions
• Handful of submissions despite wide requests
• Uneven cases
– A few on target
– A few not as clear
• Why?
– Nurses are in survival mode using health IT
– Time constraints
– Fear of retribution
– Consistent with another study in parallel to this one
• McBride and colleagues (2015)
Expert Interviews
• 27 experts
• Wide variety
– Acute and longterm care
– Federal, non-federal
– Multiple vendors, HIT tools, sites, regions of the U.S.
– Levels of leaders
• President of the ANA, ONC Nurse Executive
• Nurses who are/were Chief Medical Information Officers
– 9 Nursing and NI leaders
– 4 UX professionals/leaders
– 7 nursing researchers
– 7 site leaders
Participants
NI / Nursing
Leaders
UX Professionals NI Researchers Site Leaders
Pam Cipriano
Rebecca Freeman
Linda Harrington
Michelle Troseth
Marion Ball
Larry Wolf
Marcy Stoots'
Robert Nieves
Patti Abbott
Lorraine Chapman
Emily Patterson
Lauren Zack
Yan Xiao
Marjorie Skubic
Lindsey Steege
Susan McBride
Jane Carrington
Angela Ross
Constance Johnson
Marge Benham-
Hutchins
Theresa Brown
Ann O’Brien
Stephanie Poe
Ann Lyons
Renee Alford
Mike Ludwig
Katherine Taylor-
Pearson
Project Results
Case Studies/Stories Sample of the Rich Data We Hoped For
- Theresa Brown (2015), The Shift, p. 117
Word Cloud (Expert Interview Results)
Major UX Pain Points/Issues
Categories
• Health IT Design
– Lack of fit to workflow/cognitive processes
– Extensive data entry
– Handoffs & care transitions
– Work-arounds
• Interoperability & integration
• Missing voice of nursing
• Significance of the impact on the work of nurses
– Patient safety
– Inefficiencies
– Cognitive burden
Health IT Design
“EHRs are not designed to support nurses’ professional
practice and work or the way they think and do work”
- Michelle Troseth
Health IT Design – Fit to Workflow
• RNs work is non-linear
• Clustered tasks
• Caring for > 1 patient
• Highlighting new, stat info
• The tale of continually
pressing “refresh”
• Central point of contact for
care teams
Health IT Design – Fit to Workflow
• Support for cognitive processes
– At the core of nursing practice
– “Critical nursing activities are not related to orderables” - Emily Patterson
– eMARs/BCMA process does not support cognitive tasks for medication management
• “Is this the right medication for this patient?”
• Team-based care
– Versus “my device, my data, my documentation, my work, my task” – Larry Wolf
Health IT Design – Extensive Data Entry
• Documentation – extensive requirements
– Admission assessment example (Patty Sengstack)
• 532 clicks, 14 screens, 30 minutes to complete
• 500 lines, 1 hour to complete
– Completing requirements from others
• HEDIS, MU, quality measures
– Documenting the same information in multiple places
• Especially in rural settings
• “EHRs are over-built” - Linda Harrington
– Too many functions, many not used
– Functions added at user requests but never pruned
– Describing mucous using 20 items
• Light green, medium green, dark green
“The data entry burden
is ridiculous.”
Stephanie Poe
Health IT Design – Handoffs, Transitions
• Handoffs and care transitions
– Difficult for the nurse to construct and transmit the patient’s story
– Nurses do “information foraging” to create shift reports – Emily Patterson
– Nurses’ use of paper “brains”
• Frames the whole shift
• Supports workflow, cognitive processing, tasks across patients
• Represents a “covert work system”
• Care transitions
– Between shifts, providers and units
– Across facilities, entities like long-term care
– More than just an issue of interoperability, lack of standards
Interoperability, Integration
• Connectivity issues, non-integrated systems for care
– Within and across facilities
– Longterm care
– Recognizing nurses as information hubs
• Devices and EHRs
– Vital sign machines not integrated
– IV pumps difficult to integrate into e-documentation
– New equipment purchases and integration not considered up front
– Information is silo’ed and isolated
• Hybrid systems
– Fragmented systems due to paper and technology
– Missing functions, integration supported by paper
Missing Voice of Nursing
• Missing voice
– In purchasing
– In design
– In tailoring and customization
– Point of care nursing needs not represented
• “No win” for nurses – Yan Xiao
– Systems and HIT tools often “simply appear”
– Nurses must use whatever system is implemented
– Training only at implementation
Significance
• Across all sites, all vendors
• Patient safety risk
– Goals can get lost (BCMA and scanning)
• Inefficiencies
– Pain med delay x 1.5 hours during downtime
• Increased cognitive loads
• Time away from the patient
• Reduction in productivity
• Disruptions
– Study on CPOE, mortality & length of stay
– Spikes in mortality during implementations
Recommended Solutions
Recommended Solutions
• We need a new vision
• Voice of nursing
• Leadership and UX Ownership
• Design
• UX tools
Continuing the Transformation
• Looking beyond the installed base
• Health IT is not a project, but a process of continual transformation
• Partnering required among
– Nurses
– Vendors
– Organizations
– UX professionals
• Opportunities exist moving forward
• Solutions are across individual, organizational and national levels
We Need a New Vision • Nursing needs a “digital strategy” - Linda Harrington
– Focus on “why are we using this technology?”
- Robert Nieves
– Understand the evolution of nursing practice and HIT
• Create a vision of EHRs/health IT
– Communication system
– Patient-centered approach
– The triad – patient, nurse, health IT
– People at home vs “aggregated people”
- Larry Wolf
• Consider the ecosystem – Lorraine Chapman
– Step up a level and examine health IT as part of an ecosystem
– Where does work intersect?
– Where are the high risk areas? What will be gained?
I
C
U
Patient
Health
IT
Nurse
We Need a New Vision
• New vision for education & training
– Continual training versus just at “go live”
– New model including workflows, thought disruptions
– Reduce variability in training quality, especially over multiple systems
– The myth of no training
(Karsh, et al., 2010)
• Training need is huge due to the complexity
Voice of Nursing
• The voice of nursing is needed
– At all levels in organizations
– In purchasing
– In design
– In tailoring
• Nurses need to know they have a voice
• Educate senior nurse leaders about the critical leadership need
• Nurses’ role as patient advocate extends to HIT
Leadership & Ownership
• Who owns nursing UX issues
– Locally? Nationally?
– Assign a home for UX issues
– Advocacy opportunities to enable full scope of practice
• Increased nursing leadership needed on UX
– Establish CNIOs as critical positions
– Have more nurses be CMIOs
– Nationally, need more nursing Informaticists in leadership roles
Design
• Understand nurses as cognitive workers especially goals
– Have managers, programmers shadow nurses
– Mine current data to understand what’s happening
– Use complex activities as models, e.g., nurses’ “brains”
– Have activity connectors – dressing change and patient education and/or assessment
• Redesign legacy systems in modular fashion
– Goggle uses this approach
• Create innovation labs
• Standardize!
– Design guidelines, national standardization, e.g., assessments
– Create best practices
UX Tools
• Integrate UX professionals, practices and methods
– Do assessments throughout health IT lifecycles
– Implement a Usability Maturity Model
– Use NIST usability documents
(7804, 7865)
– Employ SAFER guides
• Attend to the 6 UX components – Yan Xiao
– Infrastructure, optimization, integration, policies, training & support
• Create a national clearing house for
nursing UX issues and solutions
Conclusions
• Convergence of thinking about UX and national needs
– e.g., NQF report
• Timing is right
– Nurses are the largest group of health IT users
– Focus on UX
– UX makes a difference to nurses
“Every nurse has a role in
informatics to move this
forward." - Lindsey Steege
Thank You, Participants!
• Pam Cipriano
• Rebecca Freeman
• Linda Harrington
• Michelle Troseth
• Lorraine Chapman
• Emily Patterson
• Marion Ball
• Lauren Zack
• Yan Xiao
• Marjorie Skubic
• Lindsey Steege
• Susan McBride
• Jane Carrington
• Marge Benham-Hutchins
• Mike Ludwig
• Marcy Stoots
• Robert Nieves
• Patti Abbott
• Teresa Brown
• Ann O’Brien
• Stephanie Poe
• Larry Wolf
• Ann Lyons
• Renee Alford
• Angela Ross
• Katherine Taylor-Pearson
• Constance Johnson
http://www.himss.org/ValueSuite
HIMSS Value Steps
Satisfaction improved by
avoiding potential pain points
Treatment and patient safety
outcomes improved
Electronic information is
secure when pain points are addressed
Patients and their healthcare
teams have access to pertinent information
Savings recouped from lower labor
costs, fewer inefficiencies, reduction in errors, litigation