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Designing the Optimal EMR User Experience Case Study on Hardware Selection and Placement Catherine Campbell, P.Eng, M.Des Business Systems Analyst Children’s.

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Presentation on theme: "Designing the Optimal EMR User Experience Case Study on Hardware Selection and Placement Catherine Campbell, P.Eng, M.Des Business Systems Analyst Children’s."— Presentation transcript:

1 Designing the Optimal EMR User Experience Case Study on Hardware Selection and Placement Catherine Campbell, P.Eng, M.Des Business Systems Analyst Children’s Hospital of Eastern Ontario, Canada

2 Conflicts of interest 2 Employed by Children’s Hospital of Eastern Ontario, Information Systems Department as a Business Systems Analyst – Human Factors Clinical Investigator, CHEO Research Institute Implementation of the EMR is partially funded by Canada Health Infoway CAE Professional Services – Human Factors Group None to declare Acknowledgements

3 What devices? Where to put them? How to support patient-provider interaction? 3 Image source:

4 Today’s presentation Implementing CHEO’s EHR: an Epic journey and how we are using human factors to help us get there. What is Human Factors? Case study: collaborative prototyping Outcomes Lessons learned Questions/feedback 4

5 Children’s Hospital of Eastern Ontario 167 bed tertiary care hospital; opened 1974 Academic institution, affiliated with University of Ottawa Referral Base: ~ 2 million 194,000 outpatient visits to 63 specialty clinics > 3000 medical patients admitted per year Regional trauma center Level III NICU Medical Staff >450 physicians Medical Trainees Nursing Staff Allied Health 5

6 Implementing an integrated EMR at CHEO 6 Phase 3: Anesthesia, Surgery, Oncology Phase 2: Emergency, Pharmacy, Inpatient Phase 1: Ambulatory, Lab, Registration, Billing Wave 1 Ambulatory Clinics Pediatric Medicine Rheumatology Infectious Diseases Genetics Ear, Nose & Throat Audiology Physiotherapy

7 Scope and Challenges Switch from paper to electronic Hospitals must purchase and install ++ resources Known EMR implementation challenges: –Highlights inconsistent practices within and between specialties –Workflow, process and task (re)design –System usability/complexity –Potential increase in workload –EMR avoidance/adoption –Privacy/Security 7 Image source

8 How do we ensure positive user experience? End user satisfaction with the EMR implementation begins with easy access to appropriate devices during their normal clinical activities. CHEO strategy: use human factors and design research methods to… –Identify and analyze current and future EMR workflows –Identify potential workflow issues and gaps –Identify solutions that meet workflow and technical requirements –Generate reusable guidelines for hardware selection and placement 8

9 What is Human Factors? The study of human behaviour, capabilities and limitations as they relate to the work environment –Physical (Ergonomics) –Cognitive –Organizational –Cultural Applies to the design and evaluation of safer and more effective tools, machines, systems, tasks, jobs and environments. 9

10 A Human Factors Framework 10 Source: A Human Factors Framework from Parush et al. 2011 Performance Human Factors Environmental Factors

11 When Human Factors are not considered 11

12 Using Human Factors to improve design 12 No labels required

13 Using Human Factors to improve design 13 BeforeAfter Cardiopulmonary bypass machine Baylor Healthcare System, Image source:

14 HF Methods & Tools Applied at CHEO  Today’s Case Study Three teams of Human Factors (HF) professionals working with clinic users –To study workflow Human-human, human-computer, human-environment interactions –To identify requirements for selection & placement of EMR equipment Methods & Tools: –Observations –Task analysis –Link analysis –Participatory design development –Simulation testing 14

15 What is participatory design development? 15

16 Participatory / Co-design Engages end users early in the design process Can be used to –Develop common understanding of requirements in multi- disciplinary teams / design problems –Validate requirements identified through observation, task analysis –Generate and test design ideas quickly Often involves –Sketching, prototyping (building/making models) sharing and developing ideas in a group 16

17 Co-design how-to (brief) Step 1: Collect information about the tasks and environment –Observations AND interviews Step 2: Engage users in co-design sessions –Organized sessions 90min – 3hours ++ –At the start of each session Introduce the problem (s) Make sure participants know they are the experts Provide reference materials, sketching/making supplies Do a warm-up exercise Make sure the session objectives are clear –If the group is large (6+) divide into multi-disciplinary teams –Schedule one or more “sharing” breaks –Facilitate: make sure everyone’s voice is heard, lead by example 17 Warning! Can be time/resource intensive Can also be scaled up/down

18 Co-design for EMR implementation at CHEO Step 1: Collect information about the tasks and environment –Observations, interviews in clinic –Task analysis Step 2: Engage users in co-design sessions –Physician-lead education sessions –Inter-professional meetings with clinic subject matter experts Objectives –To confirm requirements gathered from clinic assessments (observations and task analysis outcomes) –To get feedback on initial design ideas –To engage providers in identifying requirements and solutions for their own clinic spaces 18

19 Step 1a: Observations and interviews Two observers / clinic to maximize information capture –Shadow staff, observe clinic flow over 3 days –Document workflow, roles, tasks, tools, interactions, questions Interviews to review workflow, ask clarifying questions 19

20 Step 1b: Task Analysis Systematic decomposition of tasks –Observed tasks + expected changes based on EMR functionality Analyze users, locations, artifacts, interactions, requirements –human-human, human-computer, human-environment interactions 20 FunctionsTasksUsersLocationArtifacts/Equip Interaction Type PRE- EMR Requirements 7. Initial assessment a. Nurse conducts assessment, fills out chief complaint and past medical history section of the assessment form Nurse, Patient/Family Procedure room Otolaryngology assessment form H-H, H-AAbility to document assessment results real-time b. Nurse places chart in the chart holder outside the room to cue the resident that Jim is ready to be seen NurseProcedure room Patient chart, chart holder H-AVisual cue of patient ready to be seen Functions/Tasks Interaction AnalysisRequirements

21 Findings from Observations & Task Analysis 21 Requirement CategoryDescription Patient InformationElicit, document, and consolidate patient information; Line of Sight Maintain line of sight during patient/provider interaction while documenting patient information; Privacy Secure confidential patient information from patients’ or public view. Clinic Coordination Manage of incoming/outgoing patients, daily schedules, booking of new patients; Shared Awareness Provide shared clinic information to numerous people who may be co-located or distributed

22 EMR Hardware Options 22 Requirements Patient Information Line of Sight Privacy Clinic Coordination Shared Awareness Sit/Stand Combo Arm with Work surface Sit/stand Flush wall- mounted Enclosure Shared Desktop PC workstation Large Flat screen wall mount (no data entry) What about mobile?

23 Step 2a: Physician Co-Design Sessions All physicians (no other disciplines) Variety of specialties Working in different clinic spaces (physical environment) 90minute session –Handout requirements list, floorplans of each clinic, blank paper, pens, markers highlighters –Introduce the hardware design problem and identified requirements - for validation –Present possible hardware options –Present one or two clinic re-design ideas to get things going –Engage users in discussion/sketching solutions –Re-group for 15min group discussion at the end 23

24 Preliminary requirements and guiding principles… Before seeing patient –Providers need to know the patient is ready to be seen and where –Providers need the ability to review patient chart, results, nursing/provider notes, etc. 24

25 …Preliminary requirements and guiding principles… During patient visit –Provider should be able to review chart/ enter data while maintaining line of sight to the patient. –For hands-on encounters there is a need to facilitate quick entry of discrete data (e.g. ht, wt) and short notes for reference later –Display screen should be able to pan 50-90deg. to show or hide from patient/parent view (show to support explanation, hide to prevent misinterpretation) –Consider height-adjustable workstations for areas where data viewing/entry may be both quick and short as well long and detailed depending on workflow 25

26 …Preliminary requirements and guiding principles… In consultation with other providers –Shared workstations are required outside the patient room to support provider-provider (resident) consultation –Shared workstations should be located in an area of limited foot traffic to protect patient privacy –Screen savers and timeouts need to protect patient information while allowing providers to log in quickly –Workstations will be configured to support most common workflow in each space 26

27 …Preliminary requirements and guiding principles Closing the encounter –Before patient leaves orders need to be printed, signed and reviewed. Printers need to be in close proximity to facilitate this –After patient leaves the physician needs access to a workstation (in/out of exam room) to: finish documentation and close encounter, check schedule, review chart for up-coming patients 27

28 Potential solution for an exam room? 28 Existing setup Future concept?

29 …and then everyone started sketching, sharing, critiquing and building ideas 29

30 Step 2b: Interdisciplinary team meetings Similar outline and content to physician co-design session Objectives: –Validate identified requirements –Develop design solutions Advantages of interdisciplinary teams –Capacity to test solution ideas from multiple perspectives –Able to covered all clinic spaces and functions –More robust solutions 30

31 Outcomes Analysis across clinics and specialties revealed –Requirements associated with hospital-wide practices –Similarities by visit type (regardless of specialty) Office visit with exam Procedural Counseling/therapy Together the task analysis and co-design led to: –REUSABLE hardware and placement recommendations that support clinic requirements by visit type –Provided traceability for justification of hardware selection –Proactive identification of potential workflow issues and recommendations to prepare for them Solutions were developed and implemented 31

32 Implemented solutions (e.g.) 32

33 ENT Procedure Room (Before) 33

34 ENT Procedure Rooms (After) 34

35 ENT Procedure Room (After) 35

36 Audiology Test Rooms (After) 36

37 Lessons Learned Engaging users in requirements and design –facilitated collaboration between clinic users sharing the same space (e.g. different clinics using same space) –enhanced the understanding of complex workflows (e.g. Multi- provider appointments within and across clinics) Guiding principles led to equipment installations that supported end user workflow Requirements gathering and go live experience suggests that mobile devices may better support certain fast moving, dynamic workflows but the EMR interface must be designed with this in mind. 37

38 User Feedback Post-Go-Live Touch screens worked well for nursing workflows e.g. height/weight/vitals Shared workstations and hall-way touch points successfully allow providers to continue workflow/check shared schedule between patients When it comes to configuration of equipment, consistency is important so that users know what to expect no matter where they access the EMR (e.g. printing to the nearest printer) 38

39 User Feedback Post-Go-Live Where constraints prevented implementation of solutions that met all requirements, post-go-live, users report a gap  requirements are still there –Line of sight –Space constraints – existing facility design –System constraints Shared “heads-up” display Mobile friendly interface design Application of HF methods takes expertise and resources –Initial investment to developing guiding principles through study of varied clinic workflows is allowing us to apply and iterative across waves despite reduced resources 39

40 Thank you 40 Catherine Campbell Dr. W. James King

41 Suggested Reading & References Experience Based Co-Design Human Factors and Ergonomics Society (HFES) Symposium on Human Factors in Healthcare Vicente K. The human factor: revolutionizing the way people live with technology. Toronto: Knopf; 2003. World Health Organization. Human Factors in Patient Safety: Review of Topics and Tools. 2009 41

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