Case Study On User-Related Problems Identified In The EHR
Case Study On User-Related Problems Identified In The EHR
User-Related Problems Identified in the EHR
The operation of two Oncology programs by Universal Health; Oncology North and Oncology South, has raised a number of issues based on the fact that the EHRs are different and are sourced from different vendors. This presents a challenge to the users of the two systems, for users not well acquainted with the two, may be unable to effectively use them and this may compromise their work Case Study On User-Related Problems Identified In The EHR.
A look into the two EHR systems, Oncology North and Oncology South, reveals two user-related problems. The first issue is with data entry. Clinicians and patients using the two EHR systems are required to input data in different formats. This, according to Joukes et al. (2019), presents risks to users as they have to recall and replicate some of the entries but using different formats. Dayama et al. (2022) has written that in health care settings, users need a clean and consistent system. The justification for this is that they are able to consistently communicate through the system, master its operations and provide quality care for patients.
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The second issue with the two EHR systems at Universal Health is that users are required to constantly learn how the system works. This is often done at the expense of their clinical work and could lead to reduced attention to their patients. Joukes et al. (2019) argue that when an EHR system is put in place, the objective is to improve clinical workflow. In view of this, the Universal Health case is different as users are constantly required to learn the new system and, if sustained, this would heavily compromise clinical workflow. It is possible that by having two unintegrated systems in place, nurses working in the organization will be psychologically impacted due to the limitations being created by the two competing systems on their performance Case Study On User-Related Problems Identified In The EHR.
Opportunities to Expand EHR Capabilities
There are plans by Universal Health to ultimately integrate Oncology North and Oncology South EHR systems into one. Doing this will be beneficial to the entire organization and more so to the clinicians who rely on the system for workflow. Drawing from this, there are two opportunities that could help expand the capabilities of EHR. Firstly, the organization needs to focus on creating a user-centered EHR system. According to Dayama et al. (2022) an EHR has the potential to place barriers on operations and optimal care. With this in mind, the developers need to liaise with clinical practitioners especially nurses and physicians in order to consider their views, opinions, and challenges with the existing EHR system. Secondly, the development of a new EHR should put in mind that the core objective is to enhance clinical workflow. What this means is that Universal Health should consider ways of fully merging the two systems or integrating them in ways that clinicians using the two can be able to share information and enter data flawlessly. Although Colicchio et al. (2019) mention that integrating systems is time-consuming and cumbersome, the long-run benefits are immense.
In fact, Dayama et al. (2022) have warned that a major cause of failures in merged healthcare organizations in the United States is the inability to merge competing EHR systems causing risky bottlenecks to performance. The suggested remedy to address this issue is to contract a vendor that is reputable for creating EHR systems for large and complex organizations. In addition to this, the contracted EHR vendor should dedicate sufficient time and resources to train the clinicians who will be using the system on a day-to-day basis. Further to this, the organization should make arrangements with the vendor to offer ongoing support until a time when the IT department and the practitioners are well acquainted with the system.
Recommend Developments
A recommended change that could be made to the clinical workflow setting is optimizing the alerts that the EHR. Effective performance of clinical workflow emanates from an EHR system that adds value by being assistive and not disruptive. Drawing from this, the suggested EHR system should be designed to have the necessary data categories and inputs and also an optimum number of alerts. The justification for this is to cause minimal disruptions to clinical workflow while at the same time offering emergency alerts in a timely and effective way. Joukes et al. (2019) have warned that when an EHR system has too many alerts and demands, the chances of overwhelming clinical users and in effect causing them to miss out on crucial alerts is high. A second recommendation is the provision of training on EHR and informatics in general. Contemporary nurse practitioners need to have knowledge of how nursing informatics works and refresher courses and training come in handy especially when new systems are installed.
In view of the multitude of challenges that Universal Health clinical practitioners are faced with because of the existence of two EHR, a user-focused solution that would help address the problem is having in place a reporting program. In an IT system where informatics plays a central role in clinical operations, allowing users to report issues when they identify them goes a long way in addressing them and ultimately improving them over time. Nurses and patients should have a way of sharing their views and reporting glitches or challenges with the system. Alongside this, the EHR should allow for clinical users to share information with their colleagues such as screenshots. The rationale for this is to promote increased communication and liaisons in resolving problems when they emerge Case Study On User-Related Problems Identified In The EHR.
The purpose of this assignment is to identify and analyze the needs of an EHR in a clinical setting in order to determine a potential solution to an EHR problem.
Read “Integrated Case Study,” “Oncology North: Navigator Intake Paper Form,” and “Oncology South: Oncology Navigator Intake Form,” located in the Class Resources, prior to beginning this assignment and use the information in the resource to write a 750-1,000-word paper that provides answers to the following questions:
What are the user-related problems identified in the EHR?
What are the gaps resulting from the identified problems?
What are some opportunities to expand or develop the capabilities of the EHR?
Recommend developments that could be made to the clinical workflow setting?
Create a potential user-focused solution to the identified EHR problem?
References
Colicchio, T. K., Borbolla, D., Colicchio, V. D., Scammon, D. L., Del Fiol, G., Facelli, J. C., … & Narus, S. P. (2019). Looking behind the curtain: identifying factors contributing to changes on care outcomes during a large commercial EHR implementation. eGEMs, 7(1). https://doi.org/10.5334/egems.269
Dayama, N., Pradhan, R., Davlyatov, G., & Weech-Maldonado, R. (2022). EHR Implementation and Financial Performance: The Case of Under-Resourced (High Medicaid) Nursing Homes. https://doi.org/10.21203/rs.3.rs-1281662/v1
Joukes, E., de Keizer, N. F., de Bruijne, M. C., Abu-Hanna, A., & Cornet, R. (2019). Impact of electronic versus paper-based recording before EHR implementation on health care professionals’ perceptions of EHR use, data quality, and data reuse. Applied clinical informatics, 10(02), 199-209. https://doi.org/10.1055/s-0039-1681054
Integrated Case Study
Overview:
Throughout this course, you will use this case study to demonstrate knowledge of the following course content:
- Clinical decision support
- Assessing user needs
- Analyzing and documenting workflow
- Designing and customizing fields, forms, and templates
- User testing
- Evaluation metrics
- Designing user documentation and training
In a series of assignments, you will use this case study to integrate user interface design (including usability/human factor principles) into a design document, analyze and develop workflows, evaluate users’ needs (including their involvement in user testing), develop evaluation metrics, and design end-user training materials.
The case study, which will be used throughout the course, will focus on various components of the course topics. It focuses specifically on the unique needs of oncology patients and the health care needs of oncology navigators and prior authorization/financial coordinators Case Study On User-Related Problems Identified In The EHR.
The Case:
Universal Health is a large not-for-profit health care system with 12 hospitals in three states and two large oncology programs in Arizona. One of the oncology programs is affiliated with Academic Hospital and the other with a larger national oncology health care system. Although both oncology locations are part of Universal Health, there are significant differences in how each of the locations operates due to a recent merger/acquisition of the Academic Hospital oncology program (Oncology South) and the affiliation of the other oncology program (Oncology North) with a national oncology health care system. To compound these operational issues, Oncology North had been part of Universal Health for 8 years, so its Electronic Health Record (EHR) was Chrystal, which was the EHR platform for Universal Health and became the model used to convert Oncology South from its EHR to align with the rest of the organization. Management of oncology patients is quite complex and there was significant concern from Oncology South about the EHR conversion, as well as changes that would affect its operating model. Previously, both oncology programs worked relatively independently with IT to create custom solutions, but now they will need to work together to create a standardized oncology solution for Universal Health.
If a merger/acquisition of a large academic hospital and its oncology program was not complex enough, adding the conversion of an EHR certainly made the situation more difficult. Also compounding the issue, Oncology North—although it had been on the EHR Chrystal for almost 8 years—had significant issues with the current build and felt that there were several gaps related to functionality for oncology clinicians to service its unique population. Since Universal Health was in the process of converting the EHR at Academic Hospital and Oncology program, the EHR vendor, Chrystal, was actively involving its alignment specialists to assist in the conversion. One of the key first steps of the Chrystal alignment specialists was to do a gap analysis and prioritization of EHR functionality for oncology as well as throughout Universal Health.
The gap analysis done by Chrystal found that the oncology build for Universal Health overall did not align to its recommendation for oncology specialties in several areas within the EHR. As a result, a focused team (including a project manager, nursing informatics, Universal Health IT resources, Chrystal oncology alignment specialists, and Chrystal oncology IT experts) was created to systematically address the recommendations from the Chrystal oncology gap analysis. Although there were recommendations globally related to Universal Health’s overall EHR build, there were some specific recommendations related to the build of the oncology platform within Chrystal. Some of the initial focus was related to concerns related to prior authorization/financial gaps and the functionally/workflow of all the oncology providers/clinicians, but also the oncology navigators who really did not have any oncology functionality within Chrystal.
Servicing an oncology population is a significant part of the patient demographics of any large health care organization. Oncology patients have unique needs due to the frequency of their visits and the length of their treatments and follow-up, which can last a lifetime. A cancer diagnosis is life changing and can cause great emotional, physical, and financial stress. Oncology navigators exist to assess and assist patients and their families during their cancer treatment and hopefully into remission/survivorship. Unfortunately, cancer treatment can be costly, and dealing with insurance companies for prior authorization is an unfortunate reality in the current health care system. For health care providers, there is great financial responsibility in providing cancer treatment, so obtaining authorization from insurance companies and ensuring that patients are aware of their own financial responsibility are essential for both the patient and the organization.
After a patient receives a cancer diagnosis, the next step is usually a referral to an oncology specialist/program like Oncology North or Oncology South. That referral can come from a patient calling an oncology specialist/program directly or from the diagnosing physician contacting an oncology specialist/program. Oncology South and Oncology North both have dedicated intake referral specialists who work directly with patients, families, and referring physicians to get patients scheduled with an oncology specialist based on their diagnosis. Before the patient sees the oncology specialist for the first time, many documents need to be sent to the prior authorization team for review to ensure that the appropriate prior authorization is obtained from the insurance company, as well as making sure that the patient will be seen by the most appropriate oncology specialist for the specifically diagnosed cancer. These documents vary from pathology reports, diagnostic results, and referring physician notes that can be sent to the prior authorization specialist at different times for different patients. It is essential to have a standard workflow and expectation of standard documentation in a certain place in the EHR, so that everyone involved in the initial authorization and clinical care knows what steps have been taken and what actions are pending. While these financial steps are occurring behind the scenes and are important details that need to be secured before a patient’s first appointment, it is worth noting that at this juncture patients have just received some of the worst news in their life and they just want to get treatment as soon as possible.
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Oncology navigators are nurses that specialize in assisting patients navigate their cancer journey from diagnosis through treatment and into survivorship. After the first contact with the oncology intake specialists, oncology navigators are the next foundational step in the patient’s journey towards treatment and recovery. After the initial documentation is completed by the intake specialist who provides some basic information, including name of person calling, contact information, referral sources, provider information, and diagnosis information, such as type of cancer. Based upon the type of cancer on the intake documentation, an oncology navigator who specializes in that cancer type is notified of the new patient and contacts the patient to initiate a custom navigation plan based upon assessment of needs. The oncology navigator role is an extremely important part of the oncology team. However, oncology navigators were identified as being significantly underdeveloped within Universal Health EHR based upon Chrystal’s gap analysis, so there needed to be focused attention on this group within the organization.
As a result, a dedicated team needed to be formed to include individuals from nursing informatics from Universal Health, Chrystal oncology alignment and IT specialists, Chrystal IT staff, and oncology navigators from both Oncology North and Oncology South. This team would be responsible documenting workflow, assessing end-user needs, and submitting a final design recommendation (including training materials) to the Universal Health IT build team. The completion deadline for the design document is 8 weeks Case Study On User-Related Problems Identified In The EHR.
Assessing current state and understanding end-user needs must be one of the first goals of this dedicated team. Two days were dedicated for onsite observations of oncology navigators at Oncology South and Oncology North, during which it was discovered from the observations that even though the oncology navigators at both locations performed the same role, they had some significant differences that needed to be overcome to be able to collaborate and create a single oncology navigator solution. The grid below outlines some of the differences.
| Operations Differences | Oncology South | Oncology North |
| Initial Contact With Patient | Phone interview within 3 days | Initial physician clinic visit |
| Patient Oversight | All oncology patients | Only oncology patients that have identified needs |
| Documentation | Paper form: See document: Nav Assessment 2018 | Paper form: See document: Oncology North |
Although each location has operational differences, they also have several similarities in how they used some of the tools in the EHR, as well as their need for data and the ability to track/trend the outcomes of their patients. One key request was to make it easier for all oncology clinicians to be able to see their documentation within Chrystal. These foundational similarities aligned to what Chrystal oncology specialists had implemented at other institutions, having already created an Oncology Navigator Recommended Design Document that could be used at Universal Health. The table below provides some similarities between Oncology North and Oncology South.
| Operations Similarities | Oncology North and Oncology South |
| Position | Navigator/Coordinator RN |
| Data Request | Wanted discrete data for reports |
| Electronic Documentation | Used same two electronic methods to chart:
1. Electronic forms shared by all types of navigators (e.g., ortho, pulmonary) 2. Free-text note also shared by same navigators above |
| Electronic Documentation | Wanted it to be easier to find specific oncology navigator documentation |
Health care is all about data. In addition to using EHR for recording documentation, it is used to extract data to evaluate outcomes. Data in the EHR can come from discrete data from ICD10/ICD9 used by providers/coders, SNOMED, IMO codes used clinicians, but also directly from forms and flowsheets from discrete data fields. Understanding the unique data requirements of the oncology navigators, as well the initial prior authorization team, is foundational to creating the appropriate discrete fields or using existing data fields like ICD10 to help sort and organize data Case Study On User-Related Problems Identified In The EHR.