Lessons Learned From Listening
During one of my recent workshops, I was stunned by the nurses' reactions when I asked them what changes in their routine would make their lives easier. After an awkward silence--I thought I had inadvertently misspoken--one nurse replied, "Nobody really asks us that."
As designer/researchers at Mayo Clinic's Center for Innovation (CFI), we provide a forum and voice for collaboration and participatory creation. Being embedded designers affords incredible access to patients and providers. For one "deep-dive" activity, designers interviewed over 30 patients in the patient cafeteria. We can shadow providers to glimpse into their day-in-the-life. We are able to understand first-hand what happens during a patient examination. I will always remember one of my first patient exam observations when a physician told a ninety-seven-year-old woman that she had a polyp in her colon. I remember how her two granddaughters, who had accompanied her, reacted with the possibility of their grandmother having cancer. I remember how the grandmother used humor to mask her fear while asking a myriad of questions about the future, and how the physician gently touched her hand and said, "we'll cross that bridge when we get there."
Although rich and necessary information, user-centered research is not always welcomed or easy to corral in spite of being embedded in the institution. In wanting shiny new products and services, we move too quickly. This is a story about the lessons learned when we set aside our assumptions and slow down to listen and understand the needs of people.
CASE STUDY 1Looking Inward And Outward: Designing An EMR For Small Family Medicine Practices
The Center for Innovation was formed two years ago with the mission to transform the way health care is delivered. It is a multidisciplinary department of design researchers, project managers, administrators, physicians, business analysts, and quality, financial and IT consultants who work with both internal departments and external partners. Initiatives range from creating a culture of innovation within Mayo Clinic, to developing frameworks for future health and wellness services, to redesigning care team structures and prototyping new products.
When an external software company needed help in designing an electronic medical record (EMR) system for small family medicine practices, they approached the CFI. They had a prototype in progress and wanted our feedback. We proposed a brief pause in the production in order for us to understand the complexities of how an EMR would function, look, and feel.
As per the national government mandate that all family medicine practices must be on an electronic system by 2012, we had to create a system that complied with the functionality guidelines; however, we also wanted to design a system that complimented the practice. One of the main advantages to an electronic system is the ability to access and sort patient information. In the paper system, information is limited to whoever has the chart readily in-hand in the format at-hand. Another advantage to an EMR is the ability to communicate among the health "ecosystem" of pharmacies, laboratories, imaging facilities, and other providers, whereas the paper system required extra steps such as a phone call or fax for communication. Our concepts were about designing technology that enhanced what already works, not hinder it.
We were granted six weeks to conduct design research in order to identify the challenges and possibilities, anxiety and excitement, advantages and pitfalls of being on an electronic system. It was also important to understand the relationship and idiosyncrasies within small practices--defined as having less than ten practicing physicians--in order to provide context for an EMR system.
Our primary research activity was based on the firsthand experiences of three small practices in Iowa, Wisconsin, and Minnesota. These three sites represented different stages of adoption of an electronic record system. We referred to a site that was on a paper system as the Side Liners. The Transitionals had recently transitioned to an electronic system and the Crossovers was a site that had been on an electronic system for over a year.
At each site, we shadowed every member of the practice who would use an EMR, including physicians, nurses, medical secretaries, administrators, and the front desk and medical records staff. We conducted group interviews asking about work culture and customs. Additionally, we used a "relationship map" to structure our interviews with the nurse managers, asking what kinds of communication (physical or electronic) were used to accomplish day-to-day tasks. At the Side Liner site, we led brainstorms about the expectations and fears of an EMR. At the Transitional and Crossover sites, we discussed what was lost and gained from having transitioned from a paper to an electronic system.
Research revealed 99 observations around three themes: teamwork, workflow, and transition support. Within each theme we gained insights that informed design criteria as to how the EMR software should function.
Final deliverables included a presentation of the design process, insights, opportunities, user interface concepts, and final recommendations. Most importantly, our presentation made "converts" who came to believe in the importance of user-centered design research. This product is currently in production.
A Small Practice Is Like A Big Family
From working closely together, and for decades among some providers, people develop particular work habits that become accepted norms. Doctors and nurse teams are in sync to the point where, for example, it is understood that a Post-It note on a taller lotion bottle on a shelf indicates higher importance than a note on a shorter bottle.
In thinking about an EMR, we had to design for an environment where the workflow is implicit and learned over time. The ability to set up and customize the EMR within a practice to suit its own work habits was critical. For instance, customization for each clinic to define its own vocabulary was needed. Shared viewing of information also had to be available throughout the practice, rather than assigning different allowable page views to different work roles or individuals. We observed that in small practices immediate communication is physical and personal--it is easier and faster to write a Post-It note or walk down the hallway to ask someone a question. In turn, when electronic communication is used, the EMR must provide seamless and accessible communication among the staff and outside providers such as pharmacies and labs. This includes feedback mechanisms that create confidence that communication is indeed received and heard.
Small Practices Are High Volume And Fast Paced. Efficiency Means Everything.
Providers at small family practices see an average of thirty patients per day, roughly sixteen minutes per patient. Five to ten minutes is dedicated to rooming the patient while a nurse measures vital functions, updates patient information, and reviews health maintenance. The remaining six to eleven minutes is spent with the physician. Patients who visit for acute conditions need about ten to fifteen minutes with the physician. Clearly, efficiency means everything in this fast-paced environment.
At the Side Liner site, we noticed how a physician had set up his patient's paper chart so that it allowed him to quickly assess the patient and keep the workflow moving.
Inspired by this observation, our EMR concept incorporated an electronic clipboard feature to allow for a quick view of pertinent patient information. In mimicking how the doctor/nurse team functioned in a paper system, the initial concept imagined the nurse to prepare the clipboard in the EMR with critical information for the physician to readily view. User feedback suggested using the clipboard to manage chronic diseases such as diabetes and hypertension. In response, the EMR design included automated aggregation of certain patient information, thus reducing the prep time for the nurse.
A Small Practice With High Expectations.
Our research revealed an irony in the views of all three sites we visited in how they felt about paper versus electronic records system. The Sideliners had high expectations about what an EMR could do in terms of organization and paper pushing as they hoped "the EMR will reduce or eliminate that." However, at the Transtionals and Crossover sites, they expressed frustration about the EMR. The organization and access of information was actually easier in the paper system. They also felt distrust in the EMR. Providers were not confident that the information in the EMR was complete, accurate or up-to-date. As a result, they did double-work in both paper and electronic environment.
Our user interface concepts were based on the metaphor of a paper charting system. For example, the organizational structure of tabs and color-coding made for a "refreshing vision compared to other EMRs I have seen," one physician commented. Another quick view option we designed was for a longitudinal view of the patient. In addition to seeing a patient's episodic care, providers can enter into this view and see information about previous visits, medications, symptoms, etc., mapped over time.
Family Medicine Is 'Womb To Tomb' Care.
Providers and patients have an intimate and potentially life-long relationship with each other. Both parties need to be trained and prepared for a transition from a paper to electronic system in order to maintain this relationship. At the Sideliners site, providers were concerned that patients would leave the practice because they were not up-to-date or comfortable with using an EMR. Another potential consequence to improper training and preparation was that some physicians threatened to leave the practice.
Small practices do not have the support system that larger organizations have. "You can't just buy something. These are providers here. If you don't have a person to help transition, who gets you up and running?" asks a systems analyst who was on sabbatical.
At the Crossover site, we observed a problem with the equipment location of the computer. Some providers felt that having the computer in the room compromised their relationship with the patient because they were talking to the computer the rather than the person.
As part of the EMR software, we proposed a package including: support services in organizing the appropriate working teams together to account for equipment decisions, data transfer, staff training, and community preparation as technical glitches and long waits could be anticipated as the staff gets accustomed to the new system.
LESSON LEARNED: People Like Being Heard
After a presentation, one of our guests from the engineering department thanked us for giving him the opportunity to participate. I was shocked as I couldn't have imagined doing the project without the engineer's input. Our design research depends on collaboration, the voice, and perspective of others. If any gratitude was to be given, it was to him for his willingness to participate.
Caroline Lu is one of eight designer/researchers at Mayo Clinic's Center For Innovation in Rochester, Minnesota. Recognition to design partner, Leslie Ruckman, who worked on this highlighted project.