Benchmark - User Testing Script

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CaseStudy.pdf

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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.

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 off 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 would need to work together to create a standardized oncology

solution for Universal Health.

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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

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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.

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.

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.

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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.