TIGER WG#4 Homework

TIGER WG#4 Homework

Gretchen A. Moyer, DNSc, RN (Content in Black)

Debra M. Wolf, PhD, MSN, BSN, RN (Content in BLUE)

Ryan Bramhall, RN, BSN (Content inGREEN)

Human-Computer Interaction Theories or Human Factors Theories/Human Information Processing

What are the workspace needs?
EDUCATIONAL TRAINING WORKSPACE NEEDS: Cool atmosphere that is quiet; over head projector- clear crisp image; large view screen; preferably - monitors which are regressed into desk tops so the instructor can see the learner’s facial expressions; large communication board to list login information for continuous view (when users are thrown out of system, information is readily available); education on ergonometrics regarding how to position (height) level of computers on wheels/walls or desk top to promote good posture
CLINICAL ENVIRONMENT WORKSPACE NEEDS: quick accessibility if real time charting is to be accomplished; be proactive in decreasing the competition for computers between clinicians/students and nurses; easy access into system – sensor sign on (badge or bar code), finger print (multiple problems with staff memorizing multiple passwords and usernames for various systems;

Comprehensive evaluation of # of devices per # of users.
Evaluate “zone” or “team nursing as best solution for # staffing/ # devices
Assess PC automatic log-out setting.
Assess simultaneous loginsetting.
Such as a ”single sign on” – limiting the number of password/usernames one needs to remember per to one
Availability of a training environment for end-users that mirrors the live environment to ease learning.
Users are provided written instructions or Key training tips to enhance understanding.
Consider the Change Theory, and assess user’s preparation for change, and begin early in preparing the end-user of the upcoming change in workflow/processes.
Need to consider Color blindness and defiencies of end users utilizing computers (i.e.: handhelds not appropriate for nurses due to much scrolling or page changes, whereas work great for physicians)

Will mobile devices be used? What type of mobile devices – consider the screen display on these devices – will staff be able to read them? Is font size adjustable?
Consider the battery life and where they will be stored/charged. DOH regulations restrict the storage of equipment in hallways that are not in use.
Consider the usage for all shifts, night shift lights are dimmed, difficult to see unless brightness altered on screen, daylight has difficulty seeing during day when lights are brighter. Need process to accommodate both quickly.
Need clarity on variation of mobile devices, handheld, computer on wheels, lap tops, etc
Consider infection control, cleaning process
Consider weight of machine – one will be pushing/carrying for several hours, are wheels multidirectional/circular rollers, if hand held, is there a comfortable strap to secure to waist when not using;
What are the policies for IT checking accuracy of these devices, when – how often – how will confirmation of performance be maintained and by whom?
Consider ergonomic features of mobile device. COW adjustable?
Assess battery fan location. Does overheating occur? Our devices act like vacuums. Always overheating due to fan placement. Filters need cleaned every two (2) weeks. Routinely have 1-2 devices out of service.
Consider “device fair” to involve staff in selecting best device.
Consider a variety of devices based on End User processes, (i.e.: physicians = tablets, and Nurses: Larger mobile carts).
Ensure spare equipment is available in case of failure, breaking, user damage, etc.
Are policies in place for downtime, and have all end users been instructed and made aware, to resolve anxiety in case of occurrence.

If wireless devices are to be used, assure sufficient access for the system. Need careful walkthrough of areas to assess for potential dead space.
Consider CC units vs. OR department – will system interfere with other electronic systems; what if system goes down
Consider wireless site survey/ evaluation. Heat maps/spectrum analysis of area.
Observe workflow. Who, what, where, when, why – Who are the participants? What information are they collecting? With whom do they share the information? Where are the observations/assessments/ordering processes done? What time(s) does the activity occur? Why is this information needed?
Multidisciplinary groups working collaboratively is most effective – must include MD if CPOE is to be included. Key players are nurses, pharmacists, physicians, OT, PT , Respiratory, Dietitians
Identify champions from each ancillary department. Imperative to include all services affected .
Require technology walk through test in all areas, for dead spots. Prepare for unexpected drops after live and have a backup plan in case of occurring even though tested.

Develop process flow charts to diagram the results of the observations and use them to review with the team to verify accuracy
Found VISIOs/process flows of current state, compared to proposed future state followed by a gap analysis was a great process to prepare for change and define educational content
We contracted ISH to assist in mapping current and future state. Great exercise.
Need separate committee/process to also redefine policies and procedures for all will change with new electronic format for documentation
Form Nursing focus group to keep outside departments informed and encourage discussion.
Include End-users and stakeholders in flow charting their processes, at least on paper to ensure all areas have been captured.
Printing – will staff be expected to access information on-line or will printing be done?
Very difficult issue for HIPAA reasons – not all medical records depts. Are open 24/7, case management will need to print for faxing purposes for quick placement of patients, could limit this assess by user position/title
Can application print to receiving unit?
Can application fax report to receiving unit?
Nursing focus groups can assist in making this decision.
Consider using one machine for all report printing scenarios, for privacy and consistency reasons
Take each area performing electronic documentation and their need for either printing, or system view only of documents. Each end user department may have a variety of printing needs, that needs reviewed with all stakeholders.
Downtime planning – how will staff obtain clinical information? Need to define parameters for data entry following downtime; how frequently are software updates done – and is downtime required?
Need yearly competencies for individuals responsible for printing reports (if used) or overseeing a planned or unplanned downtime; Need defined criteria to declare a downtime (IT dept and nursing do not always agree on when to call) need clear process to communicate quickly and effectively; Need policy that lists every type of a downtime, for every system. Most facilities have multiple systems running all interfacing into each other. Need clear direction on what to do if EHR interface to lab system is down, how will lab get orders etc, defining various levels of downtime addressing every possible type of downtime is critical. Main point is clinical (nurses) must be major part in deciding this process/communication for IT dept is not always aware of patient safety issues
What if internet/network is down, but EHR is up?
How does an EHR visualize to end-users that part of the electronic chart is on paper? That a downtime occurred and information may be missing, especially if paper documents are not being scanned into system or data completely reentered?
Downtime documentation critical. This should include paper documentation, requisitions, and communication as to what system(s) will be affected and how it will affect their department. Example: ADT available but lab/radiology results NOT available.
The ultimate world should have downtime forms that mimic the electronic forms, very difficult having nurses return to old processes on paper that are foreign. Need to include paper documentation as part of yearly competency how to document on paper.
Are all end users instructed on downtime, statuses, and understand the approved procedures.
All Software updates include adequate testing periods with sign off of HC Provider and the vendor.
Vendors provide adequate support for scheduled updates/upgrades to ease concern of provider facility and staff.

Requirements Analysis

Avoid the tendency to do a one-for-one replacement of existing paper forms. Analysis is needed to determine which forms can be combined, which are reports, which are no longer needed. Much duplication can be avoided.
Need to consider how systems will support EBP/EBR; need ability to pull documentation quickly
Should free texting be allowed? How can you quantitatively collect critical data from this?
Agree, need to reduce redundancy in asking the same information multiple times
Consider reporting capabilities of system.
Can forms be printed from the system? Do they meet standards of organization?
All paperforms need pulled with a workflow analysis, and reviewed with End-Users to ascertain what is legally/procedurally required, and ensure it is placed in the electronic record.
Completion of a workflow analysis is required for each user touching the electronic medical record.
As little free text as possible should be used, in order to better extract data for reports, and to decrease typing which slows the nurse in documenting.
Work towards a common language dictionary (if not a standard ‘Snomed’ dictionary, for the entire facility and to be used as standard for the Healthcare facility. Have a policy which only allows use of this language and the standard abbreviations that meet regulations and Healthcare Standards.
What is the vision of the department? Is this something that will be done incrementally or “big-bang” style?
Must consider change theory – Everett Rodgers –Diffusion of Innovation – has key attributes I found very supportive and helpful for successful integration
Must do focus groups to assess end-user feelings beliefs etc.
Must conduct readiness assessment to identify educational needs, resistance, basic computer skills etc
Physician champion, strong executive leadership/support, and dedicated clinical analyst/liaison vital if taking big-bang route.
Also need to consider the Nursing Champions and availability. Consider the throughput of a patient through the facility and ensure all those areas come up in an orderly manner.
Consider doing live either in well organized phases, or on the less populated or less busy units first.
Take time to define the requirements – the staff needs to know the functionality/capability of the software in order to appreciate the benefits they can anticipate. Requirements should be defined very specifically – not in general terms. Project Management staff are responsible for making sure that the identified requirements match the need – if the requirements are not clearly and correctly defined at the outset of a project, user satisfaction is threatened as an outcome.
Must have excellent and strong communication plan and educational plan. Must have executive sessions so project details are communicated to all VP/Cos of organization. You do not want to assume one department is being included in planning session/designs sessions at the last minut. Experienced this first hand, was difficulty to regroup, required a great amount of time to recover and include critical points.
Must strategically plan for a department to support EMR post go live. Informatics Nurse, Nurse educator, IT support and designers? All must be readily available in order to continue positive change.
Involve staff and end-users from the beginning and throughout to obtain less resistance to change.
Consider the outcomes that are desired. What reports will be needed? Does the user have access to design reports as needed – i.e. NDNQI reports, for example?
Massive issue to address, need the ability to customizes reports quickly by various departments and staff; organizations need this ability within their own employees, should not depend on Vendors
Process needed to store reports in data base system for future usage without the manual process of saving
Any new integration should be able to replace all existing actively used reports, must be considered prior to any go live
Consider automation of reports.
Ensure there are adequate clinical and financial reports available as used in the paper reporting.
Make certain that HC Provider has capability to customize or develop other than standard reports VS only accepting Vendor specific standard reports.
Will the application be managed in-house (ICO) or remotely (RCO/ASP) from the vendor stand-point? What are the implications of this decision?
Also consider downtime issues if application stored remotely? What will the communication process system be?
Does the vendor recommend hiring clinical analyst to support application.
Taken inhouse, consider training available for help desk support staff to manage applications.
What is the availability of the vendor help desk and support needs to be 24/7 if inhouse or maintained remotely.
How does the product meet the needs of the Health Information Management department? Consider definition of an Electronic Medical Record; storage; visit data retrieval for medical-legal reporting.
Consider what the primary medical record is (if you have several applications interfaced into each other, which one is the primary record?); Key to printing the EHR is what data files will be printed – all (orders, meds, nrsg notes, MD notes, etc) what is the hospitals current policy on what is sent out via paper? Will this be mirrored electronically in print format
Who has the ability to print the Med Record, how long will it take, how many servers/printers are needed to accomplish quickly for critical transfers to another facility; need policy and procedure for this
How does the CDR accept scanned images?
Have all processes been identified as to ID of patient and all forms, and is the MR completely scanned or printed and maintained.
Do all prints become final, and lock any end users from re-accessing and changing or completing documentation after discharge printing, or scanning.
If MR charts are scanned do they continue to add additional copies of the same forms/documentation if modified, or do they overwrite the existing form/documentation already there?

Usability Design

Be sure to include representation from all levels of nursing staff involved – the design should be “owned” by nursing, not the IT department
AGREE 250% - but must have administrative support to post Nurse Informatics position that reports to nursing, not IT; Very tricky question on who she/he should report to or should it be a dual reporting structure; what are the credentials; ANA’s Informatic Nurse Specialist Scope and Standards of Practice great document to guide much of this discussion. I believe the new revision will be out soon.
Nursing staff needs to indicate what is required in the system, and allow nursing to maintain and enter or change the requirements, to meet their standards and legal requirements of documentation.
Remember to include unit secretaries, for example, as their work is likely to be impacted by decision being made
Major concern is their fear of job loss, they see the EHR/CPOE taking over many of their roles when in fact their role changes to an entirely new job description/needs
Great point. They are the “captain of the ship”. Clinical sec. New responsibilities must be created. I.e. running reports, scanning (if part of system), etc…
House keeping also critical in caring for system between patients or daily cleaning process
Need to consider any health care provider and/or stakeholder that ever touches a patient chart and documents or extracts data when doing workflow and designing.
Consider color Blindness, and ergonomics, not only in the build, but also in design of the end user’s equipment.
Need to ensure presence of a spellchecker with a common dictionary in any fields that allow for free text.
Be responsive to the suggestions made by the group – making timely changes, as appropriate, in response to their recommendations help to show them that you are listening to them
What is process for issue resolution on a daily basis, what is the process of prioritization of how issues and requests will be addressed; what is the process of communicating changes to all clinicians including faculty and students; Committee assigned should be a multidisciplinary team for one change in code/form/order will affect multiple departments
Weekly email notification to all end-users “Weekly issues update” has been successful for me
We have weekly ED planning meeting comprised of staff nurses, charge nurses, Director, and ED medical director.
End-user support is critical for success, not just during go-live. Need rounder on a regular basis to assess end-users, answer questions, identify issues or errors in how they are using (unwelcomed workarounds end-users find that are illegal or unknown to IT dept). This helps keep them engaged further supporting additional functionality or changes.
What governing group within the organization has final oversight decision making on what occurs?
Must also consider individual facility issues vs. system needs? How do you standardize documentation processes/ functionality/ orders/ order sets/rules /alerts/positions/etc; this is critical especially if physicians or clinicians travel between different facilities within one system. What about downtime (if all on same server) if one facility is down but others are not, do you call a downtime for all?
Must have a ‘Change Control’ policy and procedure in place, and only one or a department that handles those changes for either each department or for the facility (i.e.: and Informatics Department)
Consider the number of “clicks” needed to complete a process - this is often in contrast to the need to scroll on a screen. Which process is favored by the users? If too much scrolling is required, users have expressed concern that items may be missed.
Recommendations for required fields need to be carefully considered
Use of clinical decision support via rules and alerts must also be used with caution. Who has the authority to turn them on or off? MD group, nursing or both?
YES. Advise not to drown end-users with rules.
Hard stops: choose carefully.
Consider whether data should be templated or not. Often end users prefer templating for ease of documenting, however, with that comes the tendency to ignore, and end up documenting inaccurate information. (i.e.: Patient comes in comatose or sedated, and template data says Alert and Oriented X3.)

Safety/Error prevention

Failure mode effects analysis is a valuable, but time-consuming exercise. This involves a step-by-step process analysis from start to finish of all that could potentially go wrong with identification of steps to mediate the effects.
Used this process when we first went live to address physicians were canceling and reordering medications, they were not altering the start times and patient were receiving double doses of meds for one day.
Free texting medication orders and/or allergies vs. choosing drug/allergy from formulary. Does this prevent allergy interaction interruption?
What measures will be needed for infection control? How will devices be cleaned?
Need competency for this also
There needs to be availability of making fields mandatory, not allowing to sign off until those required fields/documentation has been completed.

Usability Testing

Work sessions should be held with users who created the design to assure that the product that is being delivered meets their needs. Hands-on experience by all members of the design team is strongly recommended.
Need to form Clinical Informatics council that is multidisciplinary that meets monthly to design/discuss all new functionality.
End Users need to have hands on in the Testing with the clinical Informatics Nurse, as they are the only ones that can let you know what happens when, and if all fields and documentation are present. They can also immediately identify those ‘What If’ situations when testing, that lead to improved quality in charting and maintains quality as well as legal and regulated standards.

6. Legality of EHR