HCI 670 Needs Assessment Case: Integrated Case Study


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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.

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 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 Oncology North
Initial Contact With Patient Phone interview within 3 days Initial physician clinic visit
Patient Oversight All oncology patients Only oncology patients that have identified needs
Documentation Paper form: See document: Nav Assessment 2018 Paper form: See document: 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.

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: Electronic forms shared by all types of navigators (e.g., ortho, pulmonary) 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.

Workflow Assessment

Cancer treatment is a complicated process that necessitates the whole oncology team to work together to guarantee practical, expeditious, and safe patient treatment in the two clinics. Thus, standardizing the Oncology North and Oncology South facilities’ workflows is crucial to minimize miscommunication and human errors and enhance treatment quality. In this regard, consistent documentation and clear procedural instructions are essential in attaining a standardized workflow (Halvorsen et al., 2019).

Current State of Workflow

The two oncology clinics lack a consistent documentation procedure. As a result, the workflow is constantly disrupted as the oncology navigator nurses have to develop creative workarounds, including accessing data that they may not typically utilize and continuously asking other staff for per-patient process instructions. Additionally, the current workflow affects the flexibility to customize treatments since no consistent documentation and procedures outline how key steps can be conducted. Therefore, streamlining the workflow can minimize ambiguity, redundancy and simplify the principle of shared responsibility.

Users and Opportunities

Identifying the users and their roles is a vital part of workflow improvement (Lowry et al., 2014). The future workflow involves three key users, the patient, the intake specialist, and the oncology navigator nurse. The intake specialist is responsible for documenting collected data, while the oncology navigator nurse is responsible for preparing a treatment plan based on emergency. Additionally, the new workflow creates new opportunities to reduce the patient waiting time. The intake specialist can pull the patient information from the EHR system after calling to secure an appointment. If it is a new patient, the intake specialist will create a new entry in the system, and the patient can fill in the electronic form remotely.

Optimization

With the patient information, the oncology navigator nurse can create a customized treatment plan based on the urgency. Sub-acute and acute patients can be scheduled in a timely manner due to their treatment’s urgency. For these patients, pre-treatment processes require to be offered proper time to be carried out before the pre-scheduled starting time to avert linac sessions’ rebooks (Vieira et al, 2019). On the other hand, regular patients with different treatment combinations can be scheduled right after the phone call. Consequently, even without visiting the clinic, a therapy plan can be developed to minimize the number of steps. The optimized workflow can be achieved with integrated information technology that simplifies the process (Beaumont et al., 2018).

Effects of the Future state workflow on Patient Care

The future state workflow will improve patient care by evading unnecessarily extended clinic waiting times. Waiting times result from patients visiting the clinic and securing an appointment based on an incomplete picture concerning their treatment and condition. The future workflow is adaptive to the patient since the therapy plan is developed based on urgency and up-to-date information. In this regard, high-risk patients are offered more priority.  At the same time, oncology navigator nurses will develop customized programs for moderate and low-risk patients that prevent them from becoming high risk.

Conclusion

Streamlining the workflow helps enhance overall patient care quality and department flow. By minimizing errors, omissions, and delays in the scheduling process, both oncology North and Oncology South can maximize resource utilization and improve patient satisfaction. Additionally, the workflow can assess patients’ risk profiles regularly and timely. Consequently, the future workflow frees the oncology navigator nurse from the stress and frustration produced by needless interruptions and inefficiencies. The nurses can also focus on developing an improvement plan and offering the best possible patient care.

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flowchart: decision: is patient new
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hci 670 needs assessment case: integrated case study

References

Beaumont, H., Iannessi, A., Klifa, C., & Patriti, S. (2018). 548P Can we improve the cost-effectiveness of oncology clinical trials workflow? A prospective RECIST 1.1 study. Annals of Oncology, 29(suppl_9), mdy433-001.

Halvorsen, P., Gupta, N., & Rong, Y. (2019). Clinical practice workflow in Radiation Oncology should be highly standardized. Journal of applied clinical medical physics20(4), 6.

Lowry, S. Z., Ramaiah, M., Patterson, E. S., Brick, D., Gurses, A. P., Ozok, A., Simmons, D., & Gibbons, M. C. (2014). Integrating Electronic Health Records into Clinical Workflow: An Application of Human Factors Modeling Methods to Ambulatory Care. Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care3(1), 170-177. https://doi.org/10.1177/2327857914031028

Vieira, B., Demirtas, D., Kamer, J. B., Hans, E. W., & Harten, W. v. (2019). Improving workflow control in radiotherapy using discrete-event simulation. BMC Medical Informatics and Decision Making.

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