Jennifer Herout

Understanding barriers and facilitators to the use of Clinical Information Systems for intensive care units and Anesthesia Record Keeping: A rapid ethnography

OBJECTIVE This study evaluated the current use of commercial-off-the-shelf Clinical Information Systems (CIS) for intensive care units (ICUs) and Anesthesia Record Keeping (ARK) for operating rooms and post-anesthesia care recovery settings at three Veterans Affairs Medical Centers (VAMCs). Clinicians and administrative staff use these applications at bedside workstations, in operating rooms, at nursing stations, in physicians rooms, and in other various settings. The intention of a CIS or an ARK system is to facilitate creation of electronic records of data, assessments, and procedures from multiple medical devices. The US Department of Veterans Affairs (VA) Office of the Chief of Nursing Informatics sought to understand usage barriers and facilitators to optimize these systems in the future. Therefore, a human factors study was carried out to observe the CIS and ARK systems in use at three VAMCs in order to identify best practices and suggested improvements to currently implemented CIS and ARK systems. METHODS We conducted a rapid ethnographic study of clinical end-users interacting with the CIS and ARK systems in the critical care and anesthesia care areas in each of three geographically distributed VAMCs. Two observers recorded interactions and/or interview responses from 88 CIS and ARK end-users. We coded and sorted into logical categories field notes from 69 shadowed participants. The team transcribed and combined data from key informant interviews with 19 additional participants with the observation data. We then integrated findings across observations into meaningful patterns and abstracted the data into themes, which translated directly to barriers to effective adoption and optimization of the CIS and ARK systems. RESULTS Effective optimization of the CIS and ARK systems was impeded by: (1) integration issues with other software systems; (2) poor usability; (3) software challenges; (4) hardware challenges; (5) training concerns; (6) unclear roles and lack of coordination among stakeholders; and (7) insufficient technical support. Many of these barriers are multi-faceted and have associated sub-barriers, which are described in detail along with relevant quotes from participants. In addition, regionalized purchases of different CIS and ARK systems, as opposed to enterprise level purchases, contributed to some of the identified barriers. Facilitators to system use included (1) automation and (2) a dedicated facility-level CIS-ARK Coordinator. CONCLUSIONS We identified barriers that explain some of the challenges with the optimization of the CIS and ARK commercial systems across the Veterans Health Administration (VHA). To help address these barriers, and evolve them into facilitators, we categorized report findings as (1) interface and system-level changes that vendors or VA healthcare systems can implement; (2) implementation factors under VA control and not under VA control; and (3) factors that may be used to inform future application purchases. We outline several recommendations for improved adoption of CIS and ARK systems and further recommend that human factors engineering and usability requirements become an integral part of VA health information technology (HIT) application procurement, customization, and implementation in order to help eliminate or mitigate some of the barriers of use identified in this study. Human factors engineering methods can be utilized to apply a user-centered approach to application requirements specification, application evaluation, system integration, and application implementation.

Investigating the need for clinicians to use tablet computers with a newly envisioned electronic health record

OBJECTIVE The Veterans Health Administration (VHA) has deployed a large number of tablet computers in the last several years. However, little is known about how clinicians may use these devices with a newly planned Web-based electronic health record (EHR), as well as other clinical tools. The objective of this study was to understand the types of use that can be expected of tablet computers versus desktops. METHODS Semi-structured interviews were conducted with 24 clinicians at a Veterans Health Administration (VHA) Medical Center. RESULTS An inductive qualitative analysis resulted in findings organized around recurrent themes of: (1) Barriers, (2) Facilitators, (3) Current Use, (4) Anticipated Use, (5) Patient Interaction, and (6) Connection. CONCLUSIONS Our study generated several recommendations for the use of tablet computers with new health information technology tools being developed. Continuous connectivity for the mobile device is essential to avoid interruptions and clinician frustration. Also, making a physical keyboard available as an option for the tablet was a clear desire from the clinicians. Larger tablets (e.g., regular size iPad as compared to an iPad mini) were preferred. Being able to use secure messaging tools with the tablet computer was another consistent finding. Finally, more simplicity is needed for accessing patient data on mobile devices, while balancing the important need for adequate security.

Rapid Heuristic Evaluation: Ensuring Fast and Reliable Usability Support

The U.S. Department of Veterans Affairs (VA) Human Factors Engineering (HFE) office developed a usability testing method called “Rapid Heuristic Evaluation” (Rapid HE) that offers benefits to users of the Agile development process. Rapid HE addresses the need to combine fast, reliable usability support with feedback from clinical subject matter experts (SMEs) during the design and development of an electronic health record (EHR). The Rapid HE process leverages established EHR heuristics to accelerate wireframe review and approval, and merges a traditional heuristic evaluation (HE) with an expert review by two SMEs. Our application of Rapid HEs has maximized use of resources and minimized the amount of time needed to provide feedback during Agile development cycles. This paper describes the Rapid HE process, deviations from traditional HEs, and reports on data from 16 HEs that our group conducted on an EHR platform currently being developed by VA.

Function-specific Design Principles for the Electronic Health Record

This practice-oriented paper provides a collection of design principles that are specific to certain functions within the electronic health record (EHR). Design principles for EHRs tend to be broad rules of thumb rather than specific and actionable because the relevant literature is organized by specific EHR functions. That is, a good amount of research has been conducted on specific functions, rather than EHRs as a whole. Based on the relevant literature, we provide design principles with underlying rationale for progress notes, problem list, consults, clinical reminders, clinical decision support, medication list, medication alerts, and medication reconciliation. This paper is meant to offer a collection of practical guidelines for designers, grounded in the academic literature, that are more actionable than broad usability heuristics. Future work should include refinement of these principles through systematic literature review and the inclusion of additional EHR functions.

Developing a Usability Ranking System for Findings in Health Information Technology Products

Resources for addressing usability issues identified by practitioners are often limited and teams look to usability professionals for help in prioritizing the issues. Health Information Technology (HIT) products face an additional level of complexity due to the intertwined relationship between usability issues and potential patient safety issues. Human Factors Engineering (HFE) team within the Office of Informatics and Analytics of the Veterans Health Administration (VHA OIA) developed a usability ranking system, sensitive to the specific challenges of HIT products, to help teams prioritize resolution of usability findings. The system considers factors concerned with the findings themselves, including user experience impact, organizational impact, and frequency of the problem. Constructed with “checklist style” definitions for each level, the system helps practitioners more consistently select the appropriate initial ranking.

Minimizing the Impact of Interoperability Errors on Clinicians

There is little guidance in the literature on how health information technology (HIT) interfaces should be designed to inform clinicians of data availability. As the industry focuses on interoperability between systems and devices, and as more HIT products aggregate data from external sources, it becomes increasingly critical to identify methods to alert clinicians of the availability of data without negatively impacting clinician workflow or contributing to alert fatigue. This paper reports on a case study of a usability study done on the U.S. Department of Veteran’s Affairs (VA) Joint Legacy Viewer (JLV) to provide guidance to developers on communication of connection errors and interface status. The issue, process to explore the issue, and findings are discussed. As publicly developed software, the efforts behind VA’s JLV design choices and images of design solutions can be shared to further the field’s understanding.

Using a Narrative Format and Socio-Technical Systems Approach to Perform a User-centered Problem Analysis of the HIT in Present-day Clinical Environments

The Emerging Health Technology (EHT) service from the Office of Health Informatics (OHI) HFE office, as part of its operational mission, performed a study (Ruark, Hoover, McKee, Posnak, & Sandrow, 2016) to assess recent technology advancements for impact at the point of care within the Veteran Health Administration (VHA). The initial task was to understand current pain points with Health Information Technology (HIT) use in clinical workflow; however, it was difficult to present the origins of the HIT problems without also considering the dimensions of the Socio-Technical System (STS) with which users were interacting.

Transitioning from one Electronic Health Record (EHR) to Another: A Narrative Literature Review

This paper reports the results of a literature review of health care organizations that have transitioned from one electronic health record (EHR) to another. Ten different EHR to EHR transitions are documented in the academic literature. In eight of the 10 transitions, the health care organization transitioned to Epic, a commercial EHR which is dominating the market for large and medium hospitals and health care systems. The focus of the articles reviewed falls into two main categories: (1) data migration from the old to new EHR and (2) implementation of the new EHR as it relates to patient safety, provider satisfaction, and other measures pre-and post-transition. Several conclusions and recommendations are derived from this review of the literature, which may be informative for healthcare organizations preparing to replace an existing EHR. These recommendations are likely broadly relevant to EHR to EHR transitions, regardless of the new EHR vendor.

Gathering Information in Healthcare Settings: A Tool to Facilitate On-Site Work

The coordination of site visits to execute human factors methods, such as onsite usability tests, interviews, or observations, in clinical settings requires a high level of management to attain successful data collection outcomes. Members of the Department of Veterans Affairs (VA) Veterans Health Administration (VHA) Human Factors Engineering (HFE) team occasionally visit VHA medical centers or outpatient clinics to complete our work. We have developed a site visit checklist as a practice innovation to facilitate logistical coordination when gathering data onsite. This Practice-Oriented paper includes the full checklist, as well as discussion of its use to enable other groups to benefit from lessons we have learned in conducting onsite work in health care settings.

Using Scenarios Throughout The User-Centered Design Process in Healthcare

Context-specific descriptions of the intended user interactions with health information technology (HIT) systems provide an important perspective to the overall goals of HIT design. These descriptions — or scenarios — that represent the clinicians’ perspectives can describe how HIT should support users in providing patient care effectively, efficiently, and safely. Scenarios may improve the design of HIT systems by ensuring clinician needs are well-articulated for high-value patient-care situations. This Practice- Oriented paper presents suggestions for the development and application of clinical scenarios throughout a robust user-centered design (UCD) process. As a flexible artifact, different types of scenarios can be used at each point across the UCD process and the rationale for their use are discussed, and we suggest key aspects that must be included for each specific type of scenario. This practice innovation will be beneficial to practitioners working within UCD processes, as guidance on adding scenarios as a tool in their work.