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. © 2021. Grand Canyon University. All Rights Reserved. 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 2 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 Initial Contact With Patient Phone interview within 3 days Initial physician clinic visit All oncology patients Only oncology patients that have identified needs Paper form: See document: Nav Assessment 2018 Paper form: See document: Oncology North Patient Oversight Documentation 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. 3 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. 4 Oncology North: Navigator Intake Paper Form Oncology South: Oncology Navigator Intake Form Name: MRN: D.O.B.: ONCOLOGY NURSE NAVIGATION NEW PATIENT BARRIERS TO CARE and PSYCHOSOCIAL ASSESSMENT The Oncology Nurse Navigator (ONN) introduced self to the patient and gave a brief explanation of the nurse navigator role. Contact information was provided. The ONN obtained a verbal consent for navigation assessment and follow-up. Tell me about yourself: ▪ ▪ ▪ ▪ ▪ ▪ Who does your family consist of? What is your marital status? With whom do you live? What is your occupation? Are you in school? What do you enjoy doing in your spare time? Chief complaint: Tell me what you know about your diagnosis so far… (Use direct quotes when possible) Family History of Cancer: Smoking History: Exposure History: ACCESS TO CARE ASSESSMENT Was it difficult for you to schedule your first appointment at UACC? NO YES ▪ Tell me more about how the process was difficult for you… What is the name of your PCP? Who referred you to UACC? Lack of a PCP is a barrier to cancer care. YES ▪ Refer to MERCK Resource Navigators to help patient obtain a PCP NUTRITIONAL ASSESSMENT Is Nutritional Status a barrier to care? NO YES Malnutrition Screening Tool (MST): (If indicated) Weight loss: 1. Have you recently lost weight without trying? Yes or No? 0 = No 2 = I am not sure 2. If yes, how much have you lost? 1 = 2 to 13 lb. 2 = 14 to 23 lb. 3 = 24 to 33 lb. 4 = 34 lb. or more Appetite: 3. Have you been eating poorly because of decreased appetite? 0 = No 1 = Yes 4. MST Score (weight loss + appetite) Total score ______. Referral to Nutritionist should be made with a score of 2 or greater. LEARNING ASSESSMENT – Document in Cerner Do you have any Communication /Language barriers? NO YES ▪ In what language do you want to get your medical information? Any barriers to learning? NO YES ▪ Memory issues ▪ Dyslexia ▪ Impairment: hearing, eye site ▪ Cognitive Deficits ▪ Cultural Barrier ▪ Difficulty concentrating ▪ Emotional state ▪ Financial concerns ▪ Health Literacy ▪ Desire/Motivation Preferred Learning Style: Demonstration, Printed materials, Verbal explanation, Video, Internet PHYSICAL BARRIERS ASSESSMENT Do you have any challenges accomplishing your Activities of Daily Living? NO YES ▪ Do you have any problems with mobility (walking/getting around)? ▪ Do mobility challenges make it difficult for you to get out of the house for errands or appointments? ▪ Do you need any assistive devices? ▪ Self-care: bathing, dressing, cooking, etc. Do you have family care responsibilities that limit your ability to be away from home for several hours at a time? NO YES ▪ How many dependents (children, older adults) do you care for? Ages? ▪ Are you the primary caretaker? ▪ What support do you have for caring for your dependents? Do you expect to have difficulties obtaining transportation to your appointments? NO YES ▪ What is your primary mode of transportation? ▪ Is your transportation reliable? ▪ Do you expect there to be any transportation difficulties for your appointments? ▪ Is there someone who can drive you to your appointments if necessary? Is housing/lodging a barrier? NO YES ▪ Do you have safe place to live? ▪ If you come from out of town, do you need a place to stay while you are in Tucson? ▪ If you were to need radiation therapy every day for some weeks, would you need a place to stay close by? Would you say that your current financial situation including your insurance coverage will be a barrier to your receiving medical care for your cancer diagnosis? NO YES ▪ Do you have difficulty affording your current bills? ▪ Who provides the main source of income for your household? ▪ Do you have health insurance? Name? ▪ Are you worried about your health insurance being adequate to cover cancer-related services? If you were to need cancer treatment, would you anticipate there being any problems getting time off from work or school? NO YES ▪ Does your job allow for time off for being sick? ▪ FMLA? Other programs? ▪ Will you get a pay check if you cannot work? SOCIAL HABITS ASSESSMENT Let me ask you about social habits: Do you smoke? ▪ Never ▪ Quit; How many years ago? ▪ Yes; How many PPD? How many years? ▪ Are you interested in quitting? ▪ Do you know about ASHLine? 1-800-55-66-222 Are you in the habit of using recreational drugs or drinking alcohol? And if so, have you had any problems as a result? NO YES ▪ Have you ever been stopped for driving under the influence? ▪ Do you have difficulty keeping a schedule after drinking/using recreational drugs? PSYCHOSOCIAL BARRIERS ASSESSMENT Do you worry about having enough social support to help you during stressful times? NO YES ▪ Who can you rely on to help you at home or outside of your home? ▪ Is there someone that can attend appointments with you? Who? Do you have any religious and/or spiritual beliefs or cultural practices that may impact your health care decisions and that your health care team should be aware of? NO YES Would you say that you have difficulty trusting the medical system or medical providers? NO YES Learning that you have a cancer diagnosis can certainly be frightening. Do you anticipate that fear of cancer or its treatment might affect your willingness to get care? NO YES Have you ever been diagnosed with anxiety, depression or other mental health condition? NO YES ▪ What was the specific diagnosis? ▪ Are you currently under a doctor’s care? ▪ Do you take any medications? What are they? ▪ How long ago were you diagnosed? Would you say that you are having difficulty coping with your diagnosis at this time? NO YES ▪ ▪ How have you coped with stressors in the past? Would you find it helpful to speak to a counselor who can help with coping strategies? DISTRESS THERMOMETER: On a scale of 0-10, with 10 being “extreme”, how much distress have you been experiencing in the past week including today? ____ Is there anything else that you want to share with me that you think might make it difficult for you to get access to care or is a barrier for you? NO YES Distress Thermometer Score: ________________ Number of Barriers: _________________ Patient Acuity Score: _________________ NAVIGATION PLAN 1. Referrals: 2. Patient Education Plan: : At her initial visit, this patient will receive the ASCO Guide to Lung Cancer and an orientation packet containing the UACC Living with Cancer Guide book. If a decision to go to surgery is made, she will receive a surgical education packet. At subsequent visits, she will receive Krames or Chemocare Handouts on any systemic antineoplastic agents prescribed. 3. Navigation Follow-up Plan for Barrier Resolution (based on Acuity Score): Per the GREEN YELLOW ORANGE RED protocol, I will make future contact to reassess and offer further navigation as needed. 4. Hand-off: This note was routed to the Clinical Nurse Coordinator for Dr. who will take over care during the treatment phase. Barrier and Distress Resolution Protocol 1. GREEN (Normal) Within 5 business days of MD visit, ONN will call to assess understanding of the plan of care and reassess acuity. If patient remains at this acuity, no additional calls will be made unless new issues develop. If acuity increases, the number of FU calls will increase to that acuity level protocol. 2. YELLOW (Low) Within 5 business days of MD visit, ONN will call to assess understanding of the plan of care and reassess acuity. If patient remains at this acuity, at least one additional FU call will be made. If acuity increases, the number of FU calls will increase to that acuity level protocol. If acuity decreases, the number of FU calls will decrease to that acuity level protocol. 3. ORANGE (Medium) Within 5 business days of MD visit, ONN will call to assess understanding of the plan of care and reassess acuity. If patient remains at this acuity, at least two additional FU calls will be made. If acuity increases, the number of FU calls will increase to that acuity level protocol. If acuity decreases, the number of FU calls will decrease to that acuity level protocol. 4. RED (High) Within 5 business days of MD visit, ONN will call to assess understanding of the plan of care. If patient remains at this acuity, at least three additional FU calls will be made. If acuity decreases, the number of FU calls will decrease to that acuity level protocol. Course Code HCI-670 Class Code HCI-670-O500 Criteria Content Percentage 70.0% Identified Problems 10.0% Gaps 15.0% Opportunities 15.0% Developments to Clinical Workflow 15.0% Potential Solution 15.0% Organization and Effectiveness 20.0% Thesis Development and Purpose 7.0% Argument Logic and Construction 8.0% Mechanics of Writing (includes spelling, punctuation, grammar, language use) 5.0% Format 10.0% Paper Format (use of appropriate style for the major and assignment) 5.0% Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style) 5.0% Total Weightage 100% Assignment Title Needs Assessment Case Study 1: Unsatisfactory (0.00%) A description of the identified problem is not present. A description of the gaps resulting from the identified problem is not present. An explanation of the opportunities to expand or develop the capabilities of the EHR is not present. A description of the developments could be made to the clinical workflow setting is not present. A description of the potential solution to the identified EHR problem is not present. Paper lacks any discernible overall purpose or organizing claim. Statement of purpose is not justified by the conclusion. The conclusion does not support the claim made. Argument is incoherent and uses noncredible sources. Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is used. Template is not used appropriately or documentation format is rarely followed correctly. Sources are not documented. Total Points 75.0 2: Less Than Satisfactory (74.00%) A description of the identified problem is incomplete or incorrect. A description of the gaps resulting from the identified problem is incomplete or incorrect. An explanation of the opportunities to expand or develop the capabilities of the EHR is incomplete or incorrect. A description of the developments could be made to the clinical workflow setting is incomplete or incorrect. A description of the potential solution to the identified EHR problem is incomplete or incorrect. Thesis is insufficiently developed or vague. Purpose is not clear. Sufficient justification of claims is lacking. Argument lacks consistent unity. There are obvious flaws in the logic. Some sources have questionable credibility. Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register) or word choice are present. Sentence structure is correct but not varied. Appropriate template is used, but some elements are missing or mistaken. A lack of control with formatting is apparent. Documentation of sources is inconsistent or incorrect, as appropriate to assignment and style, with numerous formatting errors. 3: Satisfactory (79.00%) A description of the identified problem is included but lacks supporting details. A description of the gaps resulting from the identified problem is included but lacks supporting details. An explanation of the opportunities to expand or develop the capabilities of the EHR is included but lacks supporting details. A description of the developments could be made to the clinical workflow setting is included but lacks supporting details. A description of the potential solution to the identified EHR problem is included but lacks supporting details. Thesis is apparent and appropriate to purpose. Argument is orderly, but may have a few inconsistencies. The argument presents minimal justification of claims. Argument logically, but not thoroughly, supports the purpose. Sources used are credible. Introduction and conclusion bracket the thesis. Some mechanical errors or typos are present, but they are not overly distracting to the reader. Correct and varied sentence structure and audience-appropriate language are employed. Appropriate template is used. Formatting is correct, although some minor errors may be present. Sources are documented, as appropriate to assignment and style, although some formatting errors may be present. 4: Good (87.00%) A description of the identified problem is complete and includes supporting details. A description of the gaps resulting from the identified problem is complete and includes supporting details. An explanation of the opportunities to expand or develop the capabilities of the EHR is complete and includes supporting details. A description of the developments could be made to the clinical workflow setting is complete and includes supporting details. A description of the potential solution to the identified EHR problem is complete and includes supporting details. Thesis is clear and forecasts the development of the paper. Thesis is descriptive and reflective of the arguments and appropriate to the purpose. Argument shows logical progressions. Techniques of argumentation are evident. There is a smooth progression of claims from introduction to conclusion. Most sources are authoritative. Prose is largely free of mechanical errors, although a few may be present. The writer uses a variety of effective sentence structures and figures of speech. Appropriate template is fully used. There are virtually no errors in formatting style. Sources are documented, as appropriate to assignment and style, and format is mostly correct. 5: Excellent (100.00%) A description of the identified problem in the EHR is extremely thorough and includes substantial supporting details. A description of the gaps resulting from the identified problem is extremely thorough and includes substantial supporting details. An explanation of the opportunities to expand or develop the capabilities of the EHR is extremely thorough and includes substantial supporting details. A description of the developments could be made to the clinical workflow setting is extremely thorough and includes substantial supporting details. A description of the potential solution to the identified EHR problem is extremely thorough and includes substantial supporting details. Thesis is comprehensive and contains the essence of the paper. Thesis statement makes the purpose of the paper clear. Comments Clear and convincing argument that presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative. Writer is clearly in command of standard, written, academic English. All format elements are correct. Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error. Points Earned 
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