Transcript 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.

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
Conflicts of interest
None to declare
Acknowledgements
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
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• What devices?
• Where to put them?
• How to support patient-provider interaction?
Image source: www.npr.org
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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
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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
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Regional trauma center
Level III NICU
Medical Staff >450 physicians
Medical Trainees
Nursing Staff
Allied Health
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Implementing an integrated EMR at CHEO
Phase 1: Ambulatory, Lab, Registration, Billing
Phase 2: Emergency, Pharmacy, Inpatient
Wave 1 Ambulatory Clinics
Pediatric Medicine
Rheumatology
Infectious Diseases
Genetics
Ear, Nose & Throat
Audiology
Physiotherapy
Phase 3: Anesthesia, Surgery, Oncology
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Scope and Challenges
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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
Image source http://cce-wakata.blogspot.fr/2014/03/
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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
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What is Human Factors?
• The study of human
behaviour, capabilities
and limitations as they
relate to the work
environment
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Physical (Ergonomics)
Cognitive
Organizational
Cultural
• Applies to the design and
evaluation of safer and
more effective tools,
machines, systems, tasks,
jobs and environments.
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A Human Factors Framework
Performance
Human Factors
Environmental Factors
Source: A Human Factors Framework from Parush et al. 2011
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When Human Factors are not considered
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Using Human Factors to improve design
No labels required
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Using Human Factors to improve design
Cardiopulmonary
bypass machine
Before
After
Baylor Healthcare System, Image source: http://www.hfes.org/web/DetailNews.aspx?ID=298
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HF Methods & Tools Applied at CHEO
• 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
 Today’s Case Study
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What is participatory design development?
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Participatory / Co-design
• Engages end users early in the design process
• Can be used to
– Develop common understanding of requirements in multidisciplinary 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
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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
Warning!
Can be time/resource intensive
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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
Can also be scaled up/down 
– 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
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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
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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
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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
Functions/Tasks
Functions
7. Initial
assessment
Tasks
Interaction Analysis
Users
a. Nurse conducts
Nurse,
assessment, fills out
Patient/Family
chief complaint and past
medical history section of
the assessment form
b. Nurse places chart in
Nurse
the chart holder outside
the room to cue the
resident that Jim is ready
to be seen
Location
Artifacts/Equip
Procedure
room
Otolaryngology
assessment
form
Procedure
room
Patient chart,
chart holder
Requirements
Interaction
Type PRERequirements
EMR
H-H, H-A
Ability to
document
assessment
results real-time
H-A
Visual cue of
patient ready to
be seen
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Findings from Observations & Task Analysis
Requirement Category
Patient Information
Description
Elicit, 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
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EMR Hardware Options
Sit/Stand Combo Arm
with Work surface
Requirements
Patient Information
Line of Sight
Privacy
Sit/stand Flush wallmounted Enclosure
What about mobile?
Shared Desktop PC
workstation
Clinic Coordination
Shared Awareness
Large Flat screen wall
mount (no data entry)
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Step 2a: Physician Co-Design Sessions
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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
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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.
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…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
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…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
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…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
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Potential solution for an exam room?
Existing setup
Future concept?
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…and then everyone started sketching,
sharing, critiquing and building ideas
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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
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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
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Implemented solutions (e.g.)
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ENT Procedure Room (Before)
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ENT Procedure Rooms (After)
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ENT Procedure Room (After)
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Audiology Test Rooms (After)
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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. Multiprovider 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.
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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)
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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
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Thank you
Catherine Campbell [email protected]
Dr. W. James King [email protected]
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Suggested Reading & References
• Experience Based Co-Design
http://www.kingsfund.org.uk/projects/ebcd
• Human Factors and Ergonomics Society (HFES) Symposium on
Human Factors in Healthcare www.hfes.org
• 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
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