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Huangetal-Recommendationsforhealthinformationtechnologyimplementationinruralhospitals.pdf
Recommendations for health information technology
implementation in rural hospitals Yuan-Han Huang
Department of Industrial Engineering, The Pennsylvania State University, Erie, Pennsylvania, USA, and Anand K. Gramopadhye
Department of Industrial Engineering, Clemson University, Clemson, South Carolina, USA
Abstract Purpose – The purpose of this paper is to investigate violations against work standards associated with using a new health information technology (HIT) system. Relevant recommendations for implementing HIT in rural hospitals are provided and discussed to achieve meaningful use. Design/methodology/approach – An observational study is conducted to map medication administration process while using a HIT system in a rural hospital. Follow-up focus groups are held to determine and verify potential adverse factors related to using the HIT system while passing drugs to patients. Findings – A detailed task analysis demonstrated several violations, such as only relying on the barcode scanning system to match up with patient and drugs could potentially result in the medical staff forgetting to provide drug information verbally before administering drugs. There was also a lack of regulated and clear work procedure in using the new HIT system. In addition, the computer system controls and displays could not be adjusted so as to satisfy the users’ expectations. Nurses prepared medications and documentation in an environment that was prone to interruptions. Originality/value – Recommendations for implementing a HIT system in rural healthcare facilities can be categorized into five areas: people, tasks, tools, environment, and organization. Detailed remedial measures are provided for achieving continuous process improvements at resource-limited healthcare facilities in rural areas. Keywords Process improvement, Electronic health record, Health information technology, Medication administration process, Workflow Paper type Research paper
1. Introduction Health information technology (HIT) systems have been recognized as a solution for reducing medication errors and improving the quality of care in the healthcare field (Bates et al., 1998; Poon et al., 2006, 2010; Jaana et al., 2012; El-Kareh et al., 2013; Patterson, 2012). Since the late 1990s, HIT systems have been promoted in the healthcare sector not only because they are compatible with the commonly used clinical documentation system and the electronic health record (EHR) system (Khoury, 1997; Krall, 1995; Berg et al., 1998), but also because they include a computerized physician order entry (CPOE) system, a barcode scanning system, electronic medication administration records (eMAR, a formal computer-based record of the drugs administered to a patient), decision support tools, etc. (Wakefield et al., 2010; McCartney, 2006, 2011; Goldschmidt, 2005). The aforementioned systems cannot be considered separately if the US healthcare providers wish to achieve meaningful use of the EHR which was introduced by the US administration in a law known as the Health
International Journal of Health Care Quality Assurance Vol. 29 No. 4, 2016 pp. 454-474 © Emerald Group Publishing Limited 0952-6862 DOI 10.1108/IJHCQA-09-2015-0115
Received 22 September 2015 Revised 21 January 2016 18 February 2016 26 February 2016 Accepted 29 February 2016
The current issue and full text archive of this journal is available on Emerald Insight at: www.emeraldinsight.com/0952-6862.htm
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Information Technology for Economic and Clinical Health Act in 2009 (Blumenthal, 2010; Jha, 2010; Casey et al., 2013).
For monitoring the progress of implementing the “EHR” system (please note that the EHR system does not just describe the electronic clinical documentation system specifically, but more appropriately represents the whole package of HIT systems used to achieve quality of care), the Healthcare Information Management System Society (HIMSS) uses an eight-stage electronic medical record adoption model (EMRAM) to track the progress of EHR implementation in various categories of healthcare facilities (Garets and Davis, 2006; Hersh and Wright, 2008). The EMRAM model ranges from stage 0, which indicates a HIT system that cannot communicate between ancillary departments, to stage 7, which describes the establishment of a fully paperless clinical environment, data warehousing, and a mechanism for data exchange among facilities (HIMSS Analytics, 2014b).
Table I shows detailed EHR adoption model scores for nine categories of healthcare facilities, in which teaching hospitals have the highest adoption score of 5.18; the critical access hospitals and rural hospitals have the lowest scores, 3.60 and 3.59, respectively out of 7.00, (HIMSS Analytics, 2014a). In the USA, rural hospitals are the hospitals located at the rural areas, defined by US Census Bureau. Rural hospitals in the USA have relatively small amount of beds and physicians due to less population resides in the rural areas; but rural hospitals are usually defined by geographic location instead of size of the hospitals. In the USA, there are around 25 percent US population live in the rural areas, but only about 10 percent of physicians practice in these areas. Due to less medical practices in the rural areas, the rural healthcare facilities are relatively smaller than hospitals in the urban, and the rural hospitals are usually supported by the government (National Rural Health Association, 2015).
In addition, in the first quarter of 2014 the HIMSS EHR adoption model scores by number of bed sizes showed that hospitals with fewer than 100 beds have the lowest score, 3.65 out of 7.00. Hospitals with 501-600 beds have the highest adoption score of 5.21 (HIMSS Analytics, 2014a).
Although the government provides funding incentives and has clear expectations for the meaningful use and widespread adoption of HIT (Bahensky et al., 2008; Abramson et al., 2012), small-scale rural hospitals still lag behind other classes of healthcare facilities (Table I) (HIMSS Analytics, 2014a; Jaana et al., 2012; American Hospital Association, 2011; Yeager et al., 2010). This study mainly focusses on investigating the impact of using the new HIT system on the workflow in a rural hospital specifically on the medication administration process.
Hospital type category Mean Number
Academic/teaching hospitals 5.18 209 General medical/surgical hospitals 4.48 3,177 Urban hospitals 4.27 4,273 Integrated healthcare delivery systems (IDS) 4.18 3,624 Non-academic hospitals 4.08 5,240 Independent hospitals 4.00 1,807 Others 3.62 2,272 Critical access hospitals (CAH) 3.60 1,341 Rural hospitals 3.59 1,176 Source: HIMSS Analytics (2014a)
Table I. HIMSS EHR
adoption model scores by hospital
type in the first quarter, 2014
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2. Methods In this study, an observational analysis was used to map the workflow of the medication administration process while using the new HIT system in a rural hospital in the USA. The medication administration process was described by hierarchical task analysis (HTA) diagrams. Follow-up focus groups with the medical staff were held to review the medication administration process HTA diagram and explore violation against work standards associated with the HIT system. This study focusses on investigating the misconduct of work standards that are related to the HIT in the medication administration process. The process of medication administration is considered to be a series of complex tasks that involve multidisciplinary interactions between the medical staff, including physicians, pharmacists, and nurses (Fraind et al., 2002; Grigg et al., 2011; Sittig and Singh, 2010; Wetterneck et al., 2012). Most HIT systems (e.g. EHR, CPOE, or the barcode scanning system) are involved in the five main phases of the medication administration process: prescribing, documenting, transporting, administering, and monitoring (Agrawal, 2009; Agrawal and Glasser, 2009; Aspden et al., 2007). These HIT systems were developed primarily to prevent adverse events such as medication errors in drug ordering, transcription, dispensing, and administration (Lisby et al., 2005; Boockvar et al., 2010; Abramson et al., 2014).
2.1 Observational study settings and design After two months of implementing the new EHR, CPOC, and barcode scanning systems in a rural South Carolina hospital (which has 55 beds), an observational study was conducted to investigate the changes made to the workflow with regards to the medication administration process in the medical/surgical unit between May and August of 2012. In the facility being studied, the medical/surgical unit was typically staffed with one attending physician, three nurses, and one nursing assistant per eight hour shift. The lab and pharmacy staffs worked from 8:00 a.m. to 5:00 p.m., Monday-Friday.
Data collection took place only during the first shift (starting at 7:00 a.m.) due to the earlier shift not being able to collect detailed medication administration task information from the nurses, physicians, patients, and the patients’ families on the floor. Also, the relevant tasks for the lab and the pharmacy, such as ordering lab tests or restocking medications by the pharmacy technician, could only take place during the morning shift.
The study participants were recruited and informed about the study via announcements in their staff meetings. All participants voluntarily scheduled their observation times with the research team in advance. In this observational study, nurses were shadowed by trained research assistants while they administered drugs to patients during the first shift. The following information was documented in real time during the observations: time to perform a specific task; type and number of drugs for the patient; interruptions that occurred during the task; descriptions of the nursing task; and descriptions of the documentation task.
All of the observational data were verified by the research advisors to ensure the quality of the data. Verified observational data were transcribed into visualized HTA) diagrams for review by the focus groups. The HTA diagram has been demonstrated to be a comprehensive tool for describing activities and locating violations or deviations in a series of tasks (e.g. in the fields of healthcare or aviation maintenance) (Drury, 2008; Lane et al., 2006). The detailed methodology and application of HTA diagrams to medication administration processes can be found in Huang and Gramopadhye’s (2014) previous studies.
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2.2 Focus group settings and design The medication administration process was observed and mapped by an industrial engineering research team. However, none of the research team members had medical training to detect potential violations in the process. Thus, focus groups were used to identify the failures to follow of work standards relating to EHRs in the medication administration process when using an EHR system. Two focus group interviews involving medical staff were held at the hospital under study two weeks after the first phase of the observational study. The focus group participants were recruited via internal staff meetings and all of them volunteered to participate in the study.
A trained research assistant served as the moderator when conducting focus group interviews via a set of probe questions, while another research assistant transcribed the discussion verbatim during each focus group. The probe questions were designed to be based on the cluster of tasks from the HTA diagram (results of the observational study). Those probes were used to address potential issues in each medication administration task. The detailed focus group probe questions are shown in the following list:
(1) How do nurses access the medication administration records? (2) How does the new system change the way records are reviewed? (3) How does the new system communicate with the medication cart? (4) How does the new system communicate with the medication station?
(5) Does the new system impact the requirement of having a witness while preparing certain medications?
(6) How do nurses check out medical supplies using the new system?
(7) If supplies brought to the patient room are not used, how are they handled?
(8) How do nurses perform charting with the new system in the patient room?
(9) If the patient is not ready for medications (e.g. patient is sleeping), how does the nurse handle this with the new system?
The focus group study mainly concentrated on the medical staff’s concerns about how the new HIT system would impact the medication administration workflow. Consensus about misconducts in the medication administration process was reached through open discussion. During the focus group interviews, the moderator introduced each task in the order in which it is embedded in the medication administration process. The main responsibility of the moderator was to ensure that the participants had a shared understanding and agreement about the potential violations or deviations that took place when performing a particular task.
All the participants in the observational study and the focus groups were required to sign a consent form that specified that there were no adverse consequences for withdrawing from the study. No personally identifiable information about the medical staff or patients was recorded. All research data were kept confidential. All the study protocols were reviewed and approved by the Clemson University Institutional Review Board.
3. Results For this study, seven observational periods (based on the number of patients) were conducted during the morning medication administration rounds. Each observational period was approximately three hours. Observational data primarily included the nursing tasks performed while passing drugs to the patients. All the tasks were
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converted into a hierarchical structure and presented in an HTA diagram. Figure 1 shows the HTA diagram for administering medications when using the new HIT system.
In the two focus group sessions, there were five registered nurses (RNs) from the medical/surgical unit and three RNs from the critical care unit/emergency room. All of the participants were female. In the focus group interviews, the HTA diagram (Figure 1) was presented to all the participants, and consensus about potential violations or deviations during a clinical work standard relating to the new HIT system were generated from the discussion. There were 15 adverse factors that could deviate from the normative clinical workflow, potentially leading to medication errors (Adverse Factors a-o in Table II), and these adverse factors can be classified into six categories: barcode scanning tasks, computer interface or operating issues, unfamiliar procedures, omitted procedures, logistic issues, and miscellaneous others. Table II shows the 15 potential adverse factors divided by category.
3.1 Potential adverse factors in barcode scanning tasks In general, the barcode scanning system is used to verify the medication (type and dose) and patient identification while administering medication. However, since introducing the new barcode scanning system, it has been noted that nurses would just scan the patient’s barcode on the wristband rather than interacting with the patient in person (Adverse Factor a). Nurses should have a simple conversation with the patient (e.g. greeting them) not only to verify the patient’s name and date of birth, but also to evaluate the patient’s cognitive status.
In addition, the current study discovered that nurses often possess extra patient barcodes for convenience (Adverse Factor b). Nurses would scan the wristband before or after administering the drugs to the patient, but not at the time the medication was being given. The main reason for possessing a patient’s barcode is that the barcoded wristband can be smudged and hard to scan when the patient stays in the hospital too long without the wristband being replaced.
3.2 Computer interface or operating issues During the observations and the discussions in the focus groups, participants mentioned that the information in the EHR system is not easy to read. The size of the icons and fonts on the screen were too small to read and they could not be adjusted (Adverse Factor c). Sometimes, nurses would select the wrong function or not realize that they had made typos while charting in the system.
Another issue regarding computer operation was that the mouse speed is not adjustable. Thus, users would have problems tracking the movement of the mouse cursor (Adverse Factor d). A lack of appropriate feedback was another issue while operating the new HIT system (Adverse Factor e). For example, the new barcode scanning system makes a beeping sound as feedback, confirming that the barcode has been read by the system. However, the audio feedback cannot distinguish whether or not the correct patient/medication information was obtained.
3.3 Unfamiliar Procedures Before the new barcode scanning system was implemented, the nurses usually collected the barcode stickers from the package of medical supplies and then manually input the barcode information into the computer system for tracking the patient’s consumption of supplies. Although a new barcode scanning system for
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checking out medical supplies was installed in the supply room, the nurses did not use it to check out the supplies (Adverse Factor f). Instead, they brought the supplies to the patient’s room and checked them out using the barcode scanning system attached to the medication cart. Yet, the system on the medication cart does not communicate with the medical supply inventory system. Participants in the focus groups also indicated that the procedure for checking out medical supplies from the supply room is confusing.
Another unfamiliar procedure with regard to the new system was also mentioned in the discussion. When a patient was not ready for their medications, the nurses did not know how to override the system to return unpassed and “checked out” drugs back into the storage system (Adverse Factor g). In fact, the participants were not sure that the system even allows them to put the unpassed drugs back into the medication cart/station. This issue could cause the unpassed medications to be stored in a risky manner.
3.4 Omitted procedures Sometimes, nurses omit critical procedures that could impact the patient’s safety. For example, nurses fail to return any remaining medication immediately after its preparation (Adverse Factor h). The exposure of the medications could affect the quality of the drug or result in it being accessed by unauthorized people. Additionally, the study also observed that nurses would temporarily leave the medication preparation site to seek tools, supplies, or help. However, some nurses did not lock the
Category Potential adverse factors
Barcode scanning tasks a. Scanning the patient’s identification barcode from the wristband without checking the patient’s cognitive status (e.g. without greeting the patient)
b. Possessing extra patient barcodes aside due to a failure to scan old or smudged barcoded wristbands
Computer interface or operating issues
c. Text and icons on the computer screen are too small to read d. The mouse cursor is moving too fast to follow e. The barcode scanning system failed to provide the appropriate feedback to identify the correct patient or medication information
Unfamiliar procedures f. Do not know how to check out supplies with the barcode scanning system
g. Do not know how to override the system to return unpassed drugs back into the system
Omitted procedures h. Failure to return remaining medication immediately i. Failure to lock the medication cart/station securely and leaving it alone with the patient
Logistic issues j. Failure to pass drugs on time (the pharmacy did not restock the inventory)
k. Cannot locate the correct place to fill inventory l. Medical supplies are out of stock (the system does not count the inventory accurately)
Others m. Ambiguity or a lack of work procedures n. Environmental lighting is insufficient to prepare the medication and
conduct the charting tasks o. Unnecessary idleness and interruptions while accessing drugs from the medication station
Table II. Potential adverse factors in the medication administration process with a new HIT system
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medication cart securely before leaving the preparation site (Adverse Factor i). It was found that semi-prepared medications had been left alone with a patient in the room.
3.5 Logistic problems Sometimes, drugs could not be administered to patients on time because the pharmacy did not restock the inventory (Adverse Factor j). In general, the pharmacy would send the next morning’s medications to the floor before 5:00 p.m. Physicians usually need to make their last orders before 3:00 p.m. using the CPOE system. However, if the physician put in the orders after 3:00 p.m., these will be delayed and processed the next morning at 8:00 a.m. Further, it takes time to verify, prepare, and deliver the medications from the pharmacy. Thus, some patients could miss their scheduled medications (usually starting at 9:00 a.m.). It was also common to see nurses call the pharmacy to track the status of a medication that was being prepared.
Incomplete supplies of medications would be sent to the floor while the medication administration process was taking place in the morning. When the nurses push the medication cart from room to room to pass drugs, the pharmacy technician would have difficulty locating the cart to fill the inventory (Adverse Factor k). This causes another delay in restocking the medical inventory.
Another logistical issue was caused by the barcode scanning system not working effectively for accurately counting the inventory of medical supplies. It was observed that medical supplies in the supply room would be out of stock without any notice (Adverse Factor l). Thus, the nurses spent a great deal of time accessing and searching for supplies from the warehouse.
3.6 Other adverse factor After implementing the new HIT system, the clinical workflow evolved and some new tasks were revealed. These new tasks usually lacked standard procedures for how to handle them (Adverse Factor m). Even floor managers and experienced nurses did not know how to correctly deal with certain tasks related to the new HIT system. An example of this is that when a patient is not ready for their medication, there is no clear procedure for telling the nurses how to check the unpassed medications back into the system (the medication station or cart). Additionally, no policy had been established to tell nurses when they should recheck a patient’s status to see if they are ready for drugs. Some nurses mentioned that the new EHR system would pop up with an alarm to remind them to recheck the patient’s status every ten minutes. Some of them preferred to recheck the patient after passing drugs to all the other patients.
Furthermore, the new EHR and barcode scanning systems are mounted on the medication cart. Nurses need to push the cart around the floor while passing medications. The nurses claimed that they felt eyestrain when charting tasks for long periods of time on the computer screen (Adverse Factor n). Indeed, the dim light sources in each patient’s room also impacted the medication preparation tasks (e.g. made it hard to measure medications precisely).
Interruptions and idleness were other issues that appeared while implementing the new HIT system in the hospital (Adverse Factor o) (Weigl et al., 2011, 2012). Some drugs are stored in the medication station in the hallway. The nurses usually needed to spend some time waiting in line to access the medications from the medication station. At the same time, the nurses in line would chat with the other nurse who was preparing the medications. Medication errors could be caused by these interruptions during the preparation of the medication (Westbrook et al., 2010).
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3.7 Reason’s Swiss cheese model and adverse factors However, not all potential adverse factors would cause medication errors by themselves. Based on Reason’s “Swiss Cheese Model” of system failure, one potential adverse factor represents a hole in a layer of Swiss cheese and systematic errors are usually caused by the aligned holes throughout all of the Swiss cheese slices (Reason, 1990, 2000). For example, for Adverse Factor i, the failure to securely lock the medication cart/station and leaving it alone with the patient does not indicate that Adverse Factor i must necessarily lead to any obvious error. The error is only apparent when the patient takes the exposed drugs without the care provider’s verification.
Furthermore, the root causes of the adverse factors should be analyzed in depth. It has been realized that some adverse factors have a cause-and-effect relationship with each other. For instance, the omitted procedure, Adverse Factor i (failure to lock the medication cart securely and leaving it alone with the patient) could be caused by the facility lacking clear standard procedures (Adverse Factor m) for securely storing the drugs. It could also be caused by unnecessary interruptions and in turn leads to the nurse leaving the medication preparation site without securely storing the drugs (Adverse Factor o).
Thus, the potential adverse factors related to using the HIT during medication administration processes cannot simply be considered individually. The root causes of some factors should be explored in depth and be related to a comprehensive investigation in other healthcare scenarios and settings.
4. Discussion This study is based on a series of detailed task analyses and focus group interviews that were used to demonstrate violations of work standards during the medication administration process while working with a new HIT system in a rural hospital. The results show that the potential adverse factors are interconnected and revealed the complexity of the clinical interactions among the medical staff, patients, technology, facility logistics, and the workflow. These findings suggest that the assessment of clinical tasks when using a new HIT system is necessary for adapting to the evolving workflow. These continuous process improvements to the clinical workflow should be introduced before, during, and after HIT system implementation (Carayon et al., 2014).
4.1 Potential adverse factor found in other healthcare settings Previous studies have reported rich findings with regarding to potential adverse factors that are related to using a new HIT system in other healthcare settings (e.g. teaching hospitals clinics, medical centers, etc.). Table III summarizes nine potential adverse factors (Adverse Factors p-x) related to HIT systems that were not discussed in this study so as to address potential hazards that could impact patient safety.
Previous studies (Table III) showed that medical staff could suffer from some unexpected IT issues when using the new HIT (Adverse Factors p-r), such as lost connectivity with the network and printers, or with troubleshooting hardware problems (Carayon et al., 2007; Koppel et al., 2008; Patterson et al., 2004). Global system issues were also mentioned in several previous studies. Those issues usually could not be solved by a single staff member, but would need coordination among departments. For example, not all barcoded drugs could be registered in the medication administration system in a timely manner (Adverse Factor s). Thus, the nurses and the pharmacy would need to effectively communicate regarding how to correctly document uncategorized drugs in the system (Bramble et al., 2013; Linsky and Simon, 2013).
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Similar issues would arise when the system did not recognize when a partial dose of a drug was administered (Adverse Factor t) (Grigg et al., 2011). The drug dose information in the inventory system would then be inconsistent with the physician’s order (Ranji et al., 2014). Even when the pharmacists, nurses, and physicians agreed to pass a partial dose of a drug to a patient, there would be difficulties in properly documenting the drug administration history into the system.
Some potential adverse factors related to the HIT could be categorized as training issues. These problems can be dealt with by proper training and practice. For example, proficient typing skills would decrease the amount of time spent on computer entry (Adverse Factor u) (Koppel et al., 2008; Unertl et al., 2009; Carayon et al., 2009). In addition, users who are familiar with HIT system operations and the interface would
Category Potential adverse factors in using HIT Studied settings
Troubleshooting skills
a. Staff experienced some IT technical problems (e.g. lost of network or printer connectivity)
Two teaching hospitals (Koppel et al., 2008) (470 and 929 beds)
b. Unexpected hardware downtime
Simulations in a laboratory (Patterson et al., 2004)
c. Computer screen needed alignment or had inadequate contrast
One teaching hospital (Carayon et al., 2007) (472 beds)
Global system issues
d. Medication identifying numbers (barcode numbers) had not yet been categorized in the system. Nurses needed to override the records manually when a particular drug was administered
Two teaching hospitals (Koppel et al., 2008) (470 and 929 beds) Simulations in a laboratory (Patterson et al., 2004) Pediatric Oncology Department in an academic medical center (Kim et al., 2006)
e. When a partial dose of drug was administered, the system did not recognize this. Instead, the system recorded a complete dose of the drug
Two teaching hospitals (Koppel et al., 2008) (470 and 929 beds)
Ability improvement issues
f. Dramatic increase in the amount of time spent on computer entry. This may slow the medication administration process during an emergency
Two teaching hospitals (Koppel et al., 2008) (470 and 929 beds) Fifteen chronic disease care clinics (Unertl et al., 2009) One family medicine residency clinic (Carayon et al., 2009)
g. Failure to document drugs or patient information correctly
One teaching hospital (Carayon et al., 2007) (472 beds)
h. Medical staff did not know how to retrieve the appropriate information when facing certain scenarios (e.g. how to respond to an allergy notification)
Two teaching hospitals (Koppel et al., 2008) (470 and 929 beds) Simulations in a laboratory (Patterson et al., 2004) Three chronic clinics (Unertl et al., 2009) One teaching hospital (Horsky et al., 2005)
Other i. New HIT impacted the patient- provider relationship because of fewer interactions with the patient or a difficulty focussing on patient communication
One academic medical center (Makoul et al., 2001) Four primary care offices (Ventres et al., 2006) One family clinics (Asan et al., 2014)
Table III. Potential adverse
factors in using HIT in different
healthcare settings
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make fewer mistakes when performing clinical documentation or retrieving information (Adverse Factors v and w) (Koppel et al., 2008; Patterson et al., 2004; Carayon et al., 2007, 2009; Unertl et al., 2009; Horsky et al., 2005).
It was also mentioned that the new HIT would impact the patient-provider relationship because of fewer face-to-face communications and less eye contact between the patient and their providers (Adverse Factor x) (Makoul et al., 2001; Ventres et al., 2006; Asan et al., 2014). Nurses would be too focussed on a computer screen, and as a result they would neglect to interact with patients while providing care.
4.2 Work system model To consolidate potential adverse factors that occur while working with the new HIT, the work system model was used to demonstrate the taxonomy of HIT implementation recommendations. The work system model was developed in 1989, and it is defined as individuals who usually perform tasks using certain tools or technologies in their physical working environments under organizational conditions (Carayon et al., 2006, 2007, 2009; Carayon and Smith, 2000; Smith and Carayon-Sainfort, 1989). Figure 2 shows the interrelationship among five elements in the work system model. In the current study, this work system model is adopted to further provide recommendations for rural hospitals when implementing a HIT system, as described in the following section.
4.3 Recommendations for rural hospitals In total, 15 recommendations that are divided into five categories are put forward, based on: the study results regarding to the failures to meet work standards (Adverse Factors a-o in Table II) in using HIT in a rural hospital; and potential adverse factors in using HIT found in other healthcare settings (Adverse Factors p-x in Table III). The recommendations for rural hospitals for HIT implementation are summarized in Table IV, and each recommendation is matched with the corresponding adverse factors. Most of the recommendations are related to each other because of the complexity of the workflow in the healthcare system. Thus, some recommendations should embed within another one, especially from an organizational aspect. In this section is a discussion of some major common issues in rural healthcare with 15 recommendations, which include topics relating to communication, interruptions, computer literacy, facility configurations, etc.
Technology Organization
Tasks Environment
People
Source: Carayon et al. (2006)
Figure 2. The framework of the work system model
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4.3.1 Communication and interruptions. Due to the implementation of the new HIT, some essential communication between patients and care providers could be neglected. For example, the current barcode scanning system supports part of the medication administration tasks by verifying a patient’s identification and drugs. The system ensures safety during the process while minimizing conversation between patients and their care providers. However, oral verification of drug information with the patient not only helps to establish a positive patient-provider relationship, but is also an important procedure for assessing the patient’s cognitive status through the greeting and other basic communicative interaction with patients. Therefore, Recommendation 1 suggests that the process of communicating with patients regarding medication information should be a non-neglected verification step for medication safety.
On the other hand, some communications could potentially cause interruptions in a healthcare setting. For example, unnecessary synchronous communication (e.g. face-to-face
Category Recommendations Corresponding adverse factors
People 1. Greeting the patient and giving elaborate drug information to the patient not only establishes a positive patient- provider relationship, but can also assess the patient’s physical and cognitive status at the same time
(a), (x)
2. Interruptions should be avoided during the preparation of medication
(o)
Tasks 3. Lock/store medications securely at all times (i) 4. Confirm the patient and medication information before passing drugs; do not just rely on the feedback from the HIT system alone
(a), (e), (x)
5. Return tools and remaining medications to fixed locations immediately after finishing the task
(h), (i), (o)
Tools 6. Change barcoded wristbands regularly to prevent invalid scanning
(b)
7. Provide staff with a computer operation troubleshooting manual (e.g. how to connect peripherals, adjust the computer screen, or setup the mouse sensitivity)
(c), (d), (f), (p), (r)
8. Exclude/distinguish confusing signals from the HIT system; information from the HIT system should be received so as to prevent errors
(e)
Environment 9. Provide sufficient lighting for preparing drugs or using the computer
(n), (v)
10. A quiet and private workspace is preferred so that medication preparation and documentation tasks will not be interrupted
(o)
Organization 11. Procedures and sequences of tasks should be established/ regulated clearly using proper standards
(a), (f), (k),( l), (m), (o), (s)
12. Enforce safety procedures regularly within the facility (a), (h), (i), (m) 13. Provide IT training and maintain the hardware regularly (c), (d), (f), (g), (l), (p),
(q), (v), (u), (w) 14. Communication among the staff, managers, IT support, and
system vendors should be freely available so as to solve global system issues
(e), (f), (g), (j), (s), (t), (u)
15. Collaborate with an outside 24 hour pharmacy to avoid logistical gaps
(j), (k)
Table IV. Recommendations
for HIT implementation
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and phone call) among care providers could result in interruptions during drug preparations and potentially lead to certain subsequent medication errors. It has been suggested that introducing some asynchronous communication modalities can help to reduce interruption in healthcare settings (Recommendation 2) (Huang and Garrett, 2012; Fairbanks et al., 2007). For instance, Bardram and Hansen (2004) suggested an asynchronous communication-based context-mediated social awareness model (e.g. send text message via the Awarephone), which allows providers to be aware of the current situation and avoid interrupting other staff. The context-mediated social awareness model mechanism (2004) supports decisions about when and how to appropriately contact staff and is aimed at minimizing interruptions to staff who are engaging in high-risk clinical tasks. However, entirely eliminating all of the interruptions among care providers is impossible due to of the fact that some interruptions in a healthcare setting could actually advance quality of care and achieve safer healthcare (Rivera-Rodriguez and Karsh, 2010) when proper communication modalities are adopted.
4.3.2 Computer literacy in rural healthcare settings. The shortage of health professionals in rural areas is critical, and the situation will become worse in the next 20 years due to aging care providers reaching retirement age (National Rural Health Association, 2012). The American Organization of Nurse Executives (2010) reported that nearly 40 percent of nurses in rural healthcare facilities are at least 50 years of age. Those aging care providers also tend to have inadequate computer literacy compared to their younger peers (Huang et al., 2012). Providing computer and IT training to care providers is one of the solutions that is regularly suggested so as to improve computer literacy, but this training could increase the financial burden, especially in resource- limited rural hospitals (Recommendation 13). Additionally, due to the shortage of health workforces in rural areas, supplemental part-time care providers are generally employed across different facilities. This alone increases the difficulties for part-time employees to become familiar with diverse HITs across multiple hospitals. Thus, providing computer operation manuals for basic HIT troubleshooting would be a feasible solution for those without adequate computer skills (Recommendation 7).
4.3.3 HIT design and IT support. Pursuing a transparent HIT system is the most realistic and practical solution to overcome the usability problems or other computer troubleshooting issues for care providers. However, rural healthcare facilities with limited resources usually are unable to acquire an optimal HIT system due to logistical, financial, and operational constraints. Therefore, it was observed that some HITs were not being utilized well with respect to current clinical practices in rural hospitals because the system was originally designed for a large-scale healthcare system. The HIT being used in rural healthcare facilities could not be easily reconciled human/ computer interaction design or to the necessary computer literacy. The HIT design for rural healthcare should be systematically reviewed to ensure that a detailed workflow can achieve quality of care. For example, it had been observed that not all HIT systems provide the authority or functions to allow staff to override any unexpected data, such as documenting partial doses of drug in the eMAR. Thus, Recommendation 14 suggests that communication among the staff, IT support, and HIT vendors is essential to maintain the flexibility of clinical documentation via an appropriately customized functional HIT system. Gathering feedback from users about the system operation would be another excellent way to understand how to better design a workflow- orientated HIT to support clinical tasks (Huang et al., 2012). In addition, IT support
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should be provided in a timely fashion within the facility so as to maintain a seamless clinical workflow.
4.3.4 Organizational regulated procedures, safety policies, and resilient work. Recommendations 11 and 12 suggest that establishing clear work procedures and enforcing safety regulations are the highest priorities for maintaining patient safety. In practice, care providers constantly assess situations and locate potential resources to prioritize their tasks when accommodating resilient clinical works in a dynamic healthcare work system (Nemeth et al., 2008; Jeffcott et al., 2009). Thus, implementing a series of rigidly regulated procedures and a safety culture within the facility need not imply that providers are failing to develop resilient strategies when dealing with unexpected and complex disturbances. By appealing to the organizational regulation and safety guidelines, it not only gives care providers a strong groundwork when practicing resilient clinical work, but can also improve situational awareness and responses in high-priority situations. For example, an unexpected event interrupts medication preparation, and the care provider must terminate the current task to provide assistance to others. In this scenario, the first response should not be to leave the current task to accommodate the immediate need. Instead, the care provider should store the drugs securely before taking any action. Therefore, with a resilient clinical practice, it not only reduces on-going temporary disturbances, but can also prevent any chaos from arising in the near future as well (Woods, 2006).
With a well-ground safety culture and regulated policies in place in healthcare facilities, resilience engineering concepts in the healthcare system would provide better performance for understanding situations occurring at any particular moment selecting correct responses, anticipating accurate projecting consequences, and gaining insights from concurrent medical practices (Fairbanks et al., 2014). Clear, simple, and high-level organizational policies would help to develop a continuous process improvement culture in a facility. The care delivery team should review the clinical practices regularly to ensure that the components in the work system well support the tasks in an effective, efficient, and safe manner.
4.4 Study limitations In the observational study, the participants’ practices could also be indirectly affected due to the researchers were shadowing nurses while performing the clinical activities; it is also known as the Hawthorne effect (Campbell et al., 1995). In this study, some strategies were applied to reduce the impact of the Hawthorne effect on the study results. For example, all the participants had been informed in advance that the study results will not be associated with any format of performance evaluations. Second, the research team did not collect any demographic information about the participants from either the observational study or the focus group. Thus, the results are only presented the systematic workflow information without recording participants’ age, gender, education, experience data, etc.
5. Conclusions Rural hospitals usually have fewer resources for obtaining an ideal HIT system that operates flawlessly within their preferred workflow (American Hospital Association, 2011; McCullough et al., 2011). Thus, it is important to introduce the concept of continuous process improvement into rural hospitals so as to clearly define a “context-appropriate” workflow and develop proper accommodations regarding the
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evolving clinical practice caused by implementing a new HIT (Huang and Gramopadhye, 2014). This study provides a roadmap for investigating potential adverse factors while using a new HIT in a rural hospital. In total, 15 recommendations for implementing HIT are provided to help facilities make the transition to a new HIT system. These recommendations can also be guidelines for any other facilities which are adopting a new HIT. The study methodology can also be applied to other clinical practices to investigate violations, deviations, or adverse factors affecting a clinical work standard.
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