Identifying Solutions for Nurses Health IT Pain Points March 1, 2016 at 2:30 PM

Transcription

1 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

2 About Us Nancy Staggers 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 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!

3 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

4 Agenda Introduction Project background and methods Results Nursing UX pain points Recommended solutions Conclusions and next steps

5 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 nursingspecific UX issues at the individual, organizational and national levels

6 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

7 Introduction & Background

8 Definition of Terms User Experience A person's perceptions and responses resulting from the use or anticipated use of a product, system or service (ISO ) Staggers, 2014

9 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 ) User Centered Design (UCD): Process to build improved human performance into a system or device

10 Introduction

11 Background A Call To Action Staggers, Elias, Hunt, Makar, & Alexander, 2015

12 Project Methods

13 Project Team Members Nancy Staggers Greg Alexander Jane Hunt Beth Elias Ellen Makar Endorsements: HIMSS NI and AMIA NI

14 Methods Two phases Case studies, story submissions Interviews with experts Case studies/stories Requests to ANA, AMIA, HIMSS Interviews Snowball sampling of experts min semi-structured interviews recorded via Webex Two listeners, independent documentation of findings via extensive notes Content analysis

15 Case Study/Story Submissions Handful of submissions despite wide requests Uneven cases Why? A few on target A few not as clear 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)

16 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

17 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

18 Project Results

19 Case Studies/Stories Sample of the Rich Data We Hoped For - Theresa Brown (2015), The Shift, p. 117

20 Word Cloud (Expert Interview Results)

21 Major UX Pain Points/Issues

22 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

23 Health IT Design EHRs are not designed to support nurses professional practice and work or the way they think and do work - Michelle Troseth

24 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

25 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

26 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 The data entry burden is ridiculous. Stephanie Poe Functions added at user requests but never pruned Describing mucous using 20 items Light green, medium green, dark green

27 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 Care transitions Frames the whole shift Supports workflow, cognitive processing, tasks across patients Represents a covert work system Between shifts, providers and units Across facilities, entities like long-term care More than just an issue of interoperability, lack of standards

28 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

29 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

30 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

31 Recommended Solutions

32 Recommended Solutions We need a new vision Voice of nursing Leadership and UX Ownership Design UX tools

33 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

34 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? Patient Health IT Nurse I C U

35 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

36 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

37 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

38 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

39 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

40 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

41 Thank You, Participants! Pam Cipriano Marjorie Skubic Rebecca Freeman Lindsey Steege Linda Harrington Susan McBride Michelle Troseth Jane Carrington Marge Benham- Lorraine Chapman Hutchins Emily Patterson Mike Ludwig Marion Ball Marcy Stoots Lauren Zack Robert Nieves Yan Xiao Patti Abbott Teresa Brown Ann O Brien Stephanie Poe Larry Wolf Ann Lyons Renee Alford Angela Ross Katherine Taylor- Pearson Constance Johnson

42 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

43 Questions & Contact Information Nancy Staggers Ellen Makar