Designing the Optimal EMR User Experience

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

2. 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

3. What devices? • Where to put them? • How to support patient-provider interaction? Image source: www.npr.org

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

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

6. 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

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 Image source http://cce-wakata.blogspot.fr/2014/03/

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

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.

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

11. When Human Factors are not considered

12. Using Human Factors to improve design No labels required

13. 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

14. 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

15. What is participatory design development?

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

17. Co-design how-to (brief) Warning! Can be time/resource intensive Can also be scaled up/down  • 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

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

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

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 Functions/Tasks Interaction Analysis Requirements

21. Findings from Observations & Task Analysis

22. EMR Hardware Options Sit/Stand Combo Arm with Work surface Sit/stand Flush wall-mounted Enclosure What about mobile? Shared Desktop PC workstation Large Flat screen wall mount (no data entry)

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

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.

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

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

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

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

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

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

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

32. Implemented solutions (e.g.)

33. ENT Procedure Room (Before)

34. ENT Procedure Rooms (After)

35. ENT Procedure Room (After)

36. Audiology Test Rooms (After)

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.

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)

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

40. Thank you Catherine Campbell ccampbell@cheo.on.ca Dr. W. James King king@cheo.on.ca

41. 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