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 from its EHR to align with the rest of the organization. Management of oncology patients is quite complex and there was significant concern from Oncology South about the EHR conversion, as well as changes that would affect its operating model. Previously, both oncology programs worked relatively independently with IT to create custom solutions, but now they will need to work together to create a standardized oncology solution for Universal Health. If a merger/acquisition of a large academic hospital and its oncology program was not complex enough, adding the conversion of an EHR certainly made the situation more difficult. Also compounding the issue, Oncology North—although it had been on the EHR Chrystal for almost 8 years—had significant issues with the current build and felt that there were several gaps related to functionality for oncology clinicians to service its unique population. Since Universal Health was in the process of converting the EHR at Academic Hospital and Oncology program, the EHR vendor, Chrystal, was actively involving its alignment specialists to assist in the conversion. One of the key first steps of the Chrystal alignment specialists was to do a gap analysis and prioritization of EHR functionality for oncology as well as throughout Universal Health. The gap analysis done by Chrystal found that the oncology build for Universal Health overall did not align to its recommendation for oncology specialties in several areas within the EHR. As a result, a focused team (including a project manager, nursing informatics, Universal Health IT resources, Chrystal oncology alignment specialists, and Chrystal oncology IT experts) was created to systematically address the recommendations from the Chrystal oncology gap analysis. Although there were recommendations globally related to Universal Health’s overall EHR build, there were some specific recommendations related to the build of the oncology platform within Chrystal. Some of the initial focus was related to concerns related to prior authorization/financial gaps and the functionally/workflow of all the oncology providers/clinicians, but also the oncology navigators who really did not have any oncology functionality within Chrystal. Servicing an oncology population is a significant part of the patient demographics of any large health care organization. Oncology patients have unique needs due to the frequency of their visits and the length of their treatments and follow-up, which can last a lifetime. A cancer diagnosis is life changing and can cause great emotional, physical, and financial stress. Oncology navigators exist to assess and assist patients and their families during their cancer treatment and hopefully into remission/survivorship. Unfortunately, cancer treatment can be costly, and dealing with insurance companies for prior authorization is an unfortunate reality in the current health care system. For health care providers, there is great financial responsibility in providing cancer treatment, so obtaining authorization from insurance companies and ensuring that patients are aware of their own financial responsibility are essential for both the patient and the organization. After a patient receives a cancer diagnosis, the next step is usually a referral to an oncology specialist/program like Oncology North or Oncology South. That referral can come from a patient calling an oncology specialist/program directly or from the diagnosing physician contacting an oncology specialist/program. Oncology South and Oncology North both have dedicated intake referral specialists who work directly with patients, families, and referring physicians to get patients scheduled with an oncology specialist based on their diagnosis. Before the patient sees the oncology specialist for the first time, many documents need to be sent to the prior authorization team for review to ensure that the appropriate prior authorization is obtained from the insurance company, as well as making sure that the patient will be seen by the most appropriate oncology specialist for the specifically diagnosed cancer. These documents vary from pathology reports, diagnostic results, and referring physician notes that can be sent to the prior authorization specialist at different times for different patients. It is essential to have a standard workflow and expectation of standard documentation in a certain place in the EHR, so that everyone involved in the initial authorization and clinical care knows what steps have been taken and what actions are pending. While these financial steps are occurring behind the scenes 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 Running head: BENCHMARK - USER TESTING SCRIPT Benchmark - User Testing Script 1 BENCHMARK - USER TESTING SCRIPT 2 Benchmark - User Testing Script This paper employs user testing to examine the factors necessary for effective utilization of the future state workflow designed to solve the current Oncology North and Oncology South issues. Although the future state workflow provides the potential to modify the manner healthcare is delivered and structured in Oncology North, and Oncology South, the implementation's success relies heavily on how well the workflow supports patients and clinicians in performing their tasks. In this regard, determining the essential participants is a crucial part of user testing. Since the changes in the system's functionality that future workflow seeks to offer is geared towards incorporating Oncology Navigator Nurses' (ONN) role, the evaluators will choose two or more ONNs from Oncology North and Oncology South clinics. Participants will also encompass the intake specialists who have had many years of experience with the current Crystal EHR. Elements to Test User testing aims to analyze whether the workflow offers a practical and valuable way to collect, process, and store data successfully using the Patient Intake Navigation Form (Hebda, Hunter & Czar, 2019). Therefore, the test elements will involve the intake form's ability to capture patient information, streamlining authorization, and develop treatment plans. The future state workflow's usefulness will be determined by identifying whether the intake form contains all the oncology clinical tasks' domain functions. Learnability is also a crucial element that involves determining how fast the participants can comprehend the interface to carry out the intake functions (Corrao, Robinson, Swiernik, & Arash Naeim, 2010). Testing efficiency will determine the speed at which the participants can accomplish an objective or attain a task (Hebda et al., 2019). BENCHMARK - USER TESTING SCRIPT 3 Steps Performed for Testing After establishing the objectives, user acceptance testing is carried out to validate that the system capabilities correspond to the set end users' requirements (Rizvi et al., 2017). Based on the functionality requirements, creating a test case for every feature is crucial. The test cases will encompass series of steps and their anticipated outcomes. Afterward, the participants will be required to examine the interface and fill in the Patient Intake Navigation Form. The feedback acquired will determine whether the users' needs are met and whether the modified system is ready for use. Integration testing will involve examining how the Patient Intake Navigation Form functions within the other Crystal EHR components. Enhancement testing takes place last, and the participants play a crucial role in this stage by determining the effects of the changes and how the design team can enhance the supporting systems. Rules Involved The first step to user testing is creating goals (Hebda et al., 2019). Outlining the objectives beforehand ensures that the evaluators utilize the appropriate techniques, and the participants stay focused. A test script is also necessary to highlight what the participant aims to test. Additionally, the procedure's success requires adhering to the test script as much as possible to ensure consistency and minimize bias in the outcomes. Before carrying out the user testing, the evaluators need to know what is being measured, how they will measure it, and how they will report the outcomes. Standard metrics that evaluators can use to analyze the user testing involve the task's success rate and the time spent on every task. Expected Outcome User testing is expected to reveal many of the assumptions and biases in the interface design (Lewis, 2006). Furthermore, the testing will aid in determining the Patient Intake BENCHMARK - USER TESTING SCRIPT 4 Navigation Form's error tolerance. In this regard, error tolerance entails the system's capability to assist users evade and recover from errors. User testing is also expected to identify the issues using the anticipated execution times and realize the specific areas that the participants may be spending much time on with the patient intake navigation form's application. Action Plan for Failed Testing The testing process cannot be void of errors. As a result, every set of scenarios and separate test scripts should be developed and examined based on the test plan. Furthermore, every discrepancy or issue from the anticipated results should be noted and analyzed. Errors noticed may be an outcome of an invalid system setup that the implementation team can rectify. Thus, learning by examining and rectifying errors is an exceptional technique for acquiring full competency. Any issues noticed in the failed testing that are not easily rectifiable should be analyzed and discussed with the Crystal EHR IT team. Conclusion Interface design experts frequently carry out user testing to determine improvement areas for redesign efforts and analyze how well the end-users can perform various tasks within the designed interface. Additionally, the workflow's usefulness is determined by combining its visual appearance, functionality, and features. Therefore, the Patient Intake Navigation Form must be customized to fit its user's context and consider the user's characteristics. Nevertheless, the healthcare environment introduces an ethical challenge that may not be available in other user tests since it is crucial to balance clinician participants' usability and patient safety considerations. BENCHMARK - USER TESTING SCRIPT 5 References Corrao, N. J., Robinson, A. G., Swiernik, M. A., & Arash Naeim. (2010). Importance of Testing for Usability When Selecting and Implementing an Electronic Health or Medical Record System. J Oncol Pract, 120-124. Hebda, T., Hunter, K., & Czar, P. (2019). Handbook of informatics for nurses and healthcare professionals (6th ed.). New York, NY: Pearson. ISBN-13: 9780134711010 Lewis, J. R. (2006). Usability Testing. Handbook of Human Factors and Ergonomics, 1275 1316. Rizvi, R. F., Marquard, J. L., Hultman, G. M., Adam, T. J., Harder, K. A., & Melton, G. B. (2017). Usability Evaluation of Electronic Health Record System around Clinical Notes Usage–An Ethnographic Study. Appl Clin Inform, 1095–1105. BENCHMARK - USER TESTING SCRIPT 6
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