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

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

Nancy Staggers

About Us

• 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!

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

Agenda

• Introduction

• Project background and methods

• Results

– Nursing UX pain points

– Recommended solutions

• Conclusions and next steps

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 nursing-specific UX issues at the individual, organizational and national levels

http://www.himss.org/ValueSuite

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

Introduction & Background

Definition of Terms

Staggers, 2014

User Experience

A person's perceptions and responses

resulting from the use or anticipated use of

a product, system or service (ISO 9241-11)

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 9241-11)

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

http://www.nist.gov/itl/hit/upload/Guide_Final_Publication_Version.pdf

Introduction

Background

Staggers, Elias, Hunt, Makar, & Alexander, 2015

A Call To Action

Project Methods

Project Team Members

Nancy Staggers

Beth Elias

Jane Hunt Greg Alexander

Endorsements: HIMSS NI and AMIA NI

Ellen Makar

Methods

• Two phases

• Case studies, “story” submissions

• Interviews with experts

• Case studies/stories

• Requests to ANA, AMIA, HIMSS

• Interviews

• Snowball sampling of experts

• 30 - 45 min semi-structured interviews recorded

via Webex

• Two listeners, independent documentation of

findings via extensive notes

• Content analysis

Case Study/Story Submissions

• Handful of submissions despite wide requests

• Uneven cases

– A few on target

– A few not as clear

• Why?

– 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)

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

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

Project Results

Case Studies/Stories Sample of the Rich Data We Hoped For

- Theresa Brown (2015), The Shift, p. 117

Word Cloud (Expert Interview Results)

Major UX Pain Points/Issues

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

Health IT Design

“EHRs are not designed to support nurses’ professional

practice and work or the way they think and do work”

- Michelle Troseth

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

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

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

– Functions added at user requests but never pruned

– Describing mucous using 20 items

• Light green, medium green, dark green

“The data entry burden

is ridiculous.”

Stephanie Poe

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”

• Frames the whole shift

• Supports workflow, cognitive processing, tasks across patients

• Represents a “covert work system”

• Care transitions

– Between shifts, providers and units

– Across facilities, entities like long-term care

– More than just an issue of interoperability, lack of standards

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

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

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

Recommended Solutions

Recommended Solutions

• We need a new vision

• Voice of nursing

• Leadership and UX Ownership

• Design

• UX tools

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

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?

I

C

U

Patient

Health

IT

Nurse

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

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

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

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

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

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

Thank You, Participants!

• Pam Cipriano

• Rebecca Freeman

• Linda Harrington

• Michelle Troseth

• Lorraine Chapman

• Emily Patterson

• Marion Ball

• Lauren Zack

• Yan Xiao

• Marjorie Skubic

• Lindsey Steege

• Susan McBride

• Jane Carrington

• Marge Benham-Hutchins

• Mike Ludwig

• Marcy Stoots

• Robert Nieves

• Patti Abbott

• Teresa Brown

• Ann O’Brien

• Stephanie Poe

• Larry Wolf

• Ann Lyons

• Renee Alford

• Angela Ross

• Katherine Taylor-Pearson

• Constance Johnson

http://www.himss.org/ValueSuite

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

Ellen Makar

nancystaggers@sisna.com

Nancy Staggers

Questions & Contact Information

makarelv@gmail.com