Merlin.net Remote Care System: A Human Factors Approach to

Understanding WorkflowJoy Hamerman Matsumoto

St Jude Medical Cardiac Rhythm Management Division manufactures implantable cardiac devices◦ Pacemakers◦ Implanted defibrillators

Many newer devices are capable of remote communication between the device and a web-based data base

Clinicians perform both review of remote care data and in-clinic patient follow ups

Introduction

3

St. Jude Medical

Cardiac Rhythm Management Division focus on devices and platforms that diagnose and treat heart disease

St Jude deploys a web-based system, Merlin.net, for remote follow ups

Patient devices communicate through a transmitter in their home to the web portal

Clinicians use Merlin.net to enroll patients in remote care, to schedule remote care “appointments” and to review patient data

Clinicians log into Merlin.net on a regular basis to assess patient and device status

Merlin.net remote care system

5

Management recognized that users work with multiple computer systems to perform their work

Our understanding of the workflow that defines remote care of patients was limited to our product in isolation

To better integrate our product into the overall workflow, we needed to gain an understanding of users’ tasks and system interactions as it relates to remote care

Expand our knowledge

Most clinicians use multiple software systems to manage their patients◦ Scheduling programs◦ Electronic medical records◦ Device manufacturers web-based programs

Systems are not integrated and do not share information

The addition of these multiple systems has impacted the workflow for clinicians

What can we do to improve users’ workload and impact user satisfaction?

Value of the research

Teams of Human Factors and Clinical Systems Engineers conducted all research

Human Factors Engineers◦ Trained in cognitive psychology, interface design

and studying human behavior◦ Use these principles to guide design of equipment

and systems◦ Knowledgeable in structuring research and

analyzing results Clinical Systems Engineers

◦ Partners in working with our users◦ Knowledge of clinical applications and practices◦ Biomedical engineering background

Roles and definitions

Used a contextual inquiry approach◦ Puts the researcher in the users’ environments◦ User-centered design method that enables

collection of detailed work practices through observation and interview

◦ Used to understand how and why tasks are done Visited 13 clinics in the U.S. and 7 clinics in

Europe◦ Total of 28 participants

Summarized data to detail tasks, time, obstacles

How did we collect data?

Enrollment◦ Enter patient information so the patient can perform

remote transmissions Scheduling

◦ Arranging each patient’s schedule for remote follow ups and in-clinic appointments

Reviewing Transmissions◦ Patient data recorded on the device is available for

review Patient Management

◦ Follow up to ensure patients are complying, answering patient questions, reminders for appointments

What are clinicians doing?

Q: Do you perform these tasks?

Enro

llmen

t

Sche

dulin

g

Revie

wing

Tran

smissio

ns

Alert

Manag

emen

t

Billin

g Doc

umen

tatio

n

In-c

linic

*0%

20%

40%

60%

80%

100%

75%

96%86% 89%

46%

68%

Percentage of people interviewed who answered yes

Enrollment Workflow

Schedule next follow-up

Deliver letter to mail outbox

Patient Chart is completed

Update EHR; Update Schedule

Print patient reminder

Retrieve Patient Info

Receive Chart

Log-in to Remote Care System

Enrollment system

Schedule Workflow

Resource page

Transmissions page

Edit Schedule page

Scheduling is the most frequent task in remote care Multiple system interactions are necessary to schedule

Schedule page

Modify schedule

Update Schedule(s) EHR

Access RC siteCheck

transmissionDetermine next

date Access RC site

Manage transmission

Proliferation of electronic records and software systems have mixed results◦ Some tasks are easier and less error prone◦ Different user interfaces and need for multiple

passwords causes frustration Users learn multiple methods of

accomplishing similar tasks (little transfer of knowledge)

Clinicians are wary of Electronic health records – lack of integration; multiple data entry points

General Findings

Europe U.S.

More integrated electronic health records

Slow adoption of electronic health records

Physicians use our system with little help from SJM personnel

SJM personnel often available to provide on-site assistance to support physician

IVR systems are used and the translations are not optimal

IVR systems are used; some messages are confusing

Transmitters paired and given to patients in clinic

Transmitters mailed to patients’ homes (this has recently changed)

Differences between Europe and U.S. users and systems

Localization challenges Difficult to accommodate text expansion on

certain screens – technical constraints / character limitations

Support for locales in IVR format only – no written support for language

Dynamic web interface – ownership of content varies by placement of content (regulatory versus marketing)

Adequate review of content by local subject matter experts (Chinese champion reviews the Simplified Chinese GUI for correct usage)

Items identified as issues in the study are prioritized for implementation◦ Many concerns addressed in the current

development plan Positioned Human Factors team to be

included earlier in development planning◦ Identify key customer issues ◦ Design, iterate and evaluate changes to the user

interface Maintain awareness of customer workflow in

a broader sense to improve the experience and reduce inefficiencies

Conclusions

Thank you