A recent article in Medical Economics, “The Promise of Next Generation EHRs” was an interesting read. It got me thinking, and there were a few parts of the article that left me uneasy, given the challenges in healthcare today.
First, the article cited reports that point to software as the primary administrative burden to physicians’ productivity. The article notes that inefficiencies in software lead to click fatigue and multitasking, which ultimately lead to mistakes.
Indeed, mistakes are very serious problems in healthcare. However, it’s not only physicians who suffer from inadequate software - nurses, clinicians and a host of administrative staff are spending most of their day using various software systems and applications.
Second, and perhaps more importantly, while stressing the need for flexibility and usability in information technology for healthcare orgs, the author specifically advocates that the best software is “designed by clinicians”. Ironically, this “designed by clinicians” paradigm is a major contributor to the dissatisfaction many users have with healthcare software products – including EHRs.
Of course, healthcare application vendors would be silly not to include significant input from current and former clinicians. Clinicians’ hands-on experience is invaluable to clinical in the form of environmental background, workflows, user scenarios, use cases, specific requirements and other types of content.
The much greater concern over healthcare institutions jumping onto the “designed by clinicians” bandwagon is that it quickly leads to the idea that software must be designed, not by just any clinicians, but by their own in-house team of clinicians.
Thus, when considering new software products, healthcare leaders are quick to ask the vendor, “Can we customize it?” (meaning a unique instance of a product, custom-developed for an organization) before they have seen much of the existing product. That question is where the real trouble begins. It is far from the end of the story, however.
Improving software in healthcare is a noble - and very necessary – goal. But when the rubber meets the road, software designed exclusively by clinicians leads to three major pain points that are already widespread in healthcare organizations.
The best software vendors use highly trained with a wide breadth of expertise in fields like information engineering, perceptive science, psychology, user interface (UI) and user experience (UX), for starters.
It takes all these skills and more to shape an optimal UX for a software product. Unfortunately, not every software developer is also gifted with design skills. Similarly, clinicians are untrained in the various disciplines of UX employed by a design expert during the product development process. As end-users, clinicians are often better at describing the problem rather then envisioning “clean slate” solutions that could drive the desired results.
In other words, both sides may be operating outside their area of expertise. Thus, having clinicians tell programmers what they want can lead to problems such as:
To avoid this scenario, I feel that the best outcomes result from software designed not by, but with clinicians at multiple points during the design, development and maintenance phases of the software lifecycle.
In recent years, custom development of healthcare management platforms has become ever more common. Vendors are eager to offer customization because they can charge more for the end product, while simply passing on the additional development costs directly to the customer. For some, in fact, it’s become a major part of their business model.
The more vendors provide custom development, the more customers ask for it, and so begins a vicious cycle. But the ugly truth is, while custom development or “customization” of healthcare IT products is lucrative for the manufacturer, it doesn’t necessarily benefit the customer. Much of customization work amounts to simple personal preferences which have no effect on patient care outcomes. Custom-developed products
One of the most important skills professional software designers have is the applied fundamental of design thinking. Design thinking uses a set of defined principles and constructs, combined with a very intentional process, to realize a desirable end product. Design thinking helps product designers fight the (very human) urge to “go with what you know”.
Most of us, when asked how a new system or product should look or work, will describe something very much like what we have used in the past – regardless of how well that product met our needs. People tend to lean on familiarity (often without even realizing it) which results in a “that’s the way we’ve always done it” attitude. It is this attitude that holds back much-needed progress in hospitals, clinics, and other healthcare organizations.
The unintended consequences of this perpetual cycle are:
After a few years and many thousands of dollars, too many healthcare organizations find themselves still encountering the same problems.
So what should healthcare organizations do? It will require a major attitude shift to get out of the rut that’s been dug over decades of stagnation and frustration at ineffective systems. Meaningful change requires buy-in, starting with management on down through all levels of the organization.
Here are some starting principles for effective change:
The takeaway here is that optimal product design “takes a village” – a multi-disciplinary team that includes, but is not controlled by, end users (clinicians, physicians, administrative staff).
ActionCue CI is built upon this principle. Our innovative solution was developed in partnership with clinicians, as well as highly trained UX/UI product designers, to address known problems in ways that go beyond what myopic visions of what so-called ”new” solutions can lead to. The dashboard is configurable to meet the unique needs of risk managers, clinicians, and healthcare executives while avoiding the pitfalls of full customization, resulting in a more cost-effective and intuitive product that end users love. By providing configurability without customization, ActionCue CI delivers an affordable solution that still meets specific users’ needs.
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As we work to continually evolve Prista’s ActionCue Clinical Intelligence (CI) application as the leading performance improvement workbench in the healthcare market, we often dig into the essence and science of improvement itself. The ActionCue application not only embodies well-designed and powerful information processing, but also demonstrates an awareness of the principles and psychological aspects of improvement methodologies.
Since the application is designed around these fundamentals and not overtly focused on the mechanics of any particular methodology, ActionCue’s design can support a variety of improvement mentalities. One approach to improvement frequently used in circles outside healthcare is the “Observe, Orient, Decide, Act” (OODA) cycle illustrated above. Ultimately, OODA is comparable in process and effectiveness to the “Plan, Do, Check, Act” (PDCA) cycle, but is nuanced in ways that may be applicable and valuable for healthcare .
As widely understood and utilized as the PDCA cycle is, many people subliminally think of the cycle and its steps as always in process across a variety of projects or topics, which can help support continuous improvement. While such cycles are intended to be continuous, the application of PDCA often begins with a plan developed by trained experts, to study certain functions or performance measures, or experiment with a technique, practice or protocol. Unfortunately, time and resource constraints in healthcare quality and safety efforts frequently dictate that as one improvement plan is undertaken, another gets retired.
OODA begins when someone—in some cases an improvement specialist, but often an executive—observes something that needs to be improved. This makes the process seem more immediately reactive than PDCA, which explains the popularity of OODA in the military and construction industry, where unexpected challenges arise requiring critical and immediate attention. Although it’s helpful for those initiating any process to denote a starting point,
Consider an executive with responsibilities stretched across the entire organization. One of the biggest challenges for management and executives is shifting mental focus as different departments or activities require his or her attention. While some members of the clinical team or supervisory staff may easily engage with and understand a certain sets of metrics, collection of related safety events or performance improvement project, those who have to do more frequent and significant context shifting can benefit from additional explanation and illustration, and will often ask for the “big picture.”
ActionCue CI’s Performance Standard Dashboard presents that big picture, with easy-to-follow links to additional presentations of related data, information and insight. These data hierarchies are designed to match the cognitive pathways of a healthcare leader, providing what we like to call the Fast Path to Insight™. Gaining insight is a crucial part of the “Orient” step in OODA, and when done well and quickly, leads to more effective “Decide” and “Act” steps. An understanding of the executive mindset and management process, functional integration, easy-to-use navigation, intelligent design, and a foundation of analytics, all play a part in providing effective insight.
The design focused on cognitive pathways and support for OODA orientation are not just valuable for executives. All users of ActionCue CI, in a variety of roles and with differing responsibilities, enjoy enhanced efficiency and productivity in their work, largely due to integrating daily into intuitive workflows. This is applicable whether a user is oriented to the OODA or PDCA mindset. All users collaborate and engage with necessary information more easily and when using ActionCue CI, and that is a big win.
If you’ve ever spent any time as patient in a hospital room, you can recall how your surroundings affected you—for better or for worse. The effects of hospital room design on patients can be profound, according to a New York Times report on specially-designed rooms at the University Medical Center of Princeton. These rooms included comfortable features such as:
The results were pretty amazing. Not only did patients report a stunning 99% satisfaction score, but they also asked for nearly a third less pain medication than patients in other rooms. Just as important are the potential safety benefits of a well-designed hospital room. Handholds in the right places can do much to prevent falls, for instance, while the use of non-shiny floor finishes can help individuals with glare-related vision problems. Even the choice of artwork style and subjects on the walls can make a direct impact on patients’ quality of experience.
Imagine how the right mix of safety event reporting and patient satisfaction information, as offered by ActionCue CI‘s integrated solutions, could help you optimize your own hospital rooms. You might find that certain room designs show a higher incidence of falls, leading you to change the flooring material, handhold placement and other features for the better. Even coming to an agreement on the nature of those changes becomes easier when you’re able to prepare easy-to-read staff reports for meetings. If certain medical mistakes seem to be occurring more frequently in specific rooms or areas, you can determine where you need to make adjustments. With ActionCue CI, all of these insights can be readily available. Contact us today for more information.
As the saying goes among software industry veterans, the cost burden of a highly customized product is applied to the customer “up-front and over-and-over, every day, inside and outside.”
Hospitals and other companies need to be somewhat aware of commercial software development economics, as it applies to buyers, since they are buying so much IT these days. A software product company does best when the high cost of developing the software is spread across many customers that use the same software as it is. Customization changes that. It requires each customer for which customization is done to bear the distinct and direct costs of that development that is uniquely done for them. There may be ways to economize the process, but it becomes substantial when much of the delivered software is customized. When the Total Cost of Ownership (TCO) for the software customer is considered, as it should be, customization costs becomes a big concern.
That is broken down as:
Up-front – The customer starts paying from contract-signing, before they can even access the product and long before they can really understand what will result from the process and assess its value.
Over-and-over – In that mode, customers usually think up and request additional changes from time to time. That then costs additional project dollars, and changes sometime become a continual process.
Every day – All enhancements that the company routinely makes to its base product must be specifically tailored to the unique version each customer is using. Looking at such effort for all of its customers and the additional overhead of tracking what software changes everyone has, this customization-focused approach, overall, is a more expense way to run the business of the software provider. That ongoing additional expense is reflected in all the pricing and fees the software company charges its customers.
Inside and outside – In addition to the costs paid to the software provider (outside), a significant customization effort requires that the hospital’s own (inside) employees – often some very busy key employees – are required to spend time documenting their needs. They must explain their work to the software companies analysts and review the output of various stages of the custom development lifecycle.
Some may suggest, and others believe, that major customization is the only way to obtain software that users in a variety of hospitals can effectively and enjoyably use in their particular environment, but that is simply not the case. Users don’t customize Microsoft Office applications like Word and Excel but are presented with many options to pick preferences and configuration settings, and provide localization data used by the application. Long term, users and the companies that buy applications come to understand that very particular choices that are applied in major customization efforts don’t really change the value of the use of the application in ways that could not have been done with truly good workflow and user experience design, by professionals, up front. And, overall, the idea that customization is some kind of norm has to be considered in a broader context. What other non-software products that healthcare providers, or the individuals who lead it, buy are customized ? Probably not many because of its being cost-prohibitive when the impact of custom development is considered against what can be achieved with readily available options and configurability.
The long-term, strategic and most insidious cost of customization is the bad habit that it enables among management. Faced with a truly innovative product, which necessarily represents change, leaders and staff in hospitals can, and do, customize their new products back to the familiar appearance, sequences, artifacts (forms,reports, etc.) and activities that they have used for decades, nullifying expertly-designed process innovation. Because that which is familiar is relatively comfortable. Can anyone calculate the total cost of healthcare’s infamous resistance to change ?
The approaches outlined below have earned for our ActionCue® Clinical Intelligence product very high user satisfaction scores, many spontaneous statements of praise and 100% customer retention from its inception. Cost conservation is addressed at every part of the application and our operation. So, it doesn’t mean that we don’t listen to customer input or modify the product for it. We simply are prudent in making changes that truly make the product more valuable and the customer experience more rewarding.
Becker’s Healthcare reports statistics on a significant rise in influenza and pneumonia deaths, focusing on flu-related death in 10 states: Alabama, Georgia, Kansas, Louisiana, Minnesota, Missouri, New Jersey, Oklahoma, South Carolina and Tennessee.
With such outcomes, the tracking of clinical staff immunizations, according to guidelines, becomes critical to impact the outcomes as well as for compliance reasons. As with many standards, being compliant needs at least as much focus by healthcare management as reporting compliance. How well is your healthcare delivery organization doing at its part in containing influenza, pneumonia and other diseases through vaccination efforts ?
Our research shows that the most successful vaccination programs have good operational tracking that:
ActionCue Clinical Information has built-in forms for CDC/NHSN-defined data requirements and a built-in report with both detailed data and immediate indication of immunization program effectiveness.
Form for easy entry of disposition data
ActionCue CI saves clinical managers 20-30% of their work time while delivering more insightful, actionable information across the entire Quality, Patient Safety and Performance Improvement effort. Over 90% of organizations using the ActionCue application are compliant with vaccination requirements and compliance is just that clear.