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Table of Contents

Problem Statement

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• In the chaotic emergency care environment staff members must make snap judgement about patient treatment. Doctors, nurses and other members of the hospital staff need an efficient way to keep track of patients coming into and going out of the medical care units. They also need to keep track of patient medical status, interventions performed, and medications administered. To perform their role as caretakers effectively, they must also note which members of the staff are responsible for which patients. A common medium for information management in this fast-paced environment is a simple marker and white board, which doctors and nurses share to keep track of this large and complex network of information.
• While the whiteboard does score high on the efficiency and learnability scale, it is a dismally unsafe and prone to all kinds of error including lapses, mistakes, poor form, smudging, and other forms of human error. For an institution whose goal it is to provide care, the dismal safety score of the whiteboard merits a revamped user interface design.
• Several institutions employ existing medical information management platforms, but clinical staff often describe these tools as "cumbersome", "inefficient" and "annoying", and often prefer to use the white boards instead.

Example of the current platform

Figure 1:

User

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Analysis 

Flowchart

Flowchart 1:

Image Added

Target Users Classes and Their Goals

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• Goals
  • Track the procedures performed on patients for billing purposes
  • Contact family members
• Needs
  • Minimize hospital costs and maximize patient throughput  
  • Receive updates about patient status as quickly as possible
• Obstacles
  • Have difficulty understanding "Jargon" of the clinical staff, and layout of the information on the white boards
  • Are not informed of updates in status without rechecking the board, which is itself prone to latency issues.

Task Analysis ------------------------------------------------------------

5. Patients

Patients in the ICU are critical condition. Therefore we don't consider patients as forming a user class.

Task Analysis

There are essentially two types of tasks that users engage in as part of the patient information There are essentially two types of tasks that users engage in as part of the patient information management process. Here we will describe the two tasks with respect to the environment in which they are performed.

Common Constraints across Tasks

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• What can go wrong?
  • Everything that could have gone wrong during patient check-in is also a potential breaking point in this information-updating task. There is one more very significant and realistic threat of error introduced in this task, however: mistaken patient identification. It is very possible that a member of the hospital staff mistakenly updates the wrong patient's information.

Interviews ------------------------------------------------------------------

Interview 1: Doctor X

Interviews 

Interview 1: Doctor X

Dr. X is a young radiologist who often works in ICU. As he has very good IT skills (MIT CS level), we thought it would be a great idea to have his Dr. X is a young radiologist who often works in ICU. As he has very good IT skills (MIT CS level), we thought it would be a great idea to have his feedback on the current platform used for information management. He described his work in the ICU saying "Patients in ICU can stay for a few hours up to a few weeks. The goal of the hospital employees is basically first to keep patients alive, and second, if they succeed, to treat them." Dr X. then explained how the patient's data are handled by the hospital employees. "The medical information on each patient is currently stored in two different places: a file folder (paper) containing the main general information on the patient, such as the patient's medical history, physicians' observations, his age, etc. A whiteboard on which it is indicated which drugs the patient has received in the ICU, and at what time he/she received it. The whiteboard also contains key information on the patient that everybody should know, typically allergies and main diagnosis.

We asked him who used this information. He replied physicians, nurses as well as unlicensed assistive personnel need access to them. For example when unlicensed assistive personnel give a meal to a patient, they should know if the latter is allergic to it.We then inquired what key goals and needs he has which are not addressed by the current solution (file folder + whiteboard)

Key points

• Patients with intricate medical records are difficult to handle as the whiteboard only has enough space for a few major pieces of medical information. It's primary purpose now is to keep track of drug administration.
• The whiteboard makes it impossible to collect data for medical research.
• Physical papers can be lost/altered, and are inconvenient to move (in case the patient needs to be moved).
• Many measurements are done on the patient and displayed in real-time but then need to be manually written on the whiteboard, and never make it to the patient's file folder.
• Since information on the whiteboard aren't recorded in the patient's file folder, if one day another physician needs to give a drug to the patient that he had received during a previous ICU period, the physician will not know how the patient had reacted to it.
• When something's wrong and strange with the patient, it can be helpful to browse the detailed history (or for research purposes), but globally it doesn't happen often: 2-3 days after it's been measured it most likely won't ever be needed again.

Interview 2: Doctor Y

Dr Y. is a young ICU physician. As the ICU is a broad topic and in our interview we focused on how patient's information is handled. He described 5 different types of information containers (everything is contained on paper except the first one):

1. Administrative and general demographic information: everything non-medical, e.g. age/sex/address/...
2. Basic medical information: upon the patient's arrival to the ICU, a physician interviews the patient (provided that the patient is able to talk) and writes a medical summary of 1 or 2 pages containing anything that could be of interest to treat the patient. This synopsis follows a conventional format. It will be kept within the hospital, even after the patient has left.
3. Nurses notes: precise technical information such as drugs given (quantity/time) as well as key measurements on the patient such as blood pressure or ECG.
4. Nurse whiteboard: Another platform for recording data measurements (blood pressure/ECG/…), drugs, key events.
5. Assistive personnel whiteboard: Summary of the previous examinations of the patient in addition to the other 4 sources of information. There are some computer applications designed for specific types of information such as medical images, but those applications aren't interconnected. 

Key points

Dr Y. enumerated his most important needs for a medical information management system:

• Easy, rapid access to any information pertaining to the patient. 
• Reliability of the information, e.g. not having the wrong, or incomplete data on a patient (this seems obvious but it does cost many lives annually).
• Having one information container instead of the myriads of information sources he currently has to deal with. 

Interview 3: MIT paramedic

M. spent a year as an MIT paramedic, so she was responsible for patients from the time that 911 or Campus Police were called until the patient was officially transferred to a nurse at the hospital. She described the typical process for handling a patient and his/her information:

A paramedic dispatch begins with a one-line description of the case, sent over the radio from the 911 dispatch, such as "18 year-old male complaining of stomach ache in Next House." The paramedics respond to the dispatch with a priority number between 1 and 3 (1 being the most serious), which determines the level of urgency with which they travel in the ambulance. In practice, they would always respond with Priority 1, since without having seen the patient yet they can't be sure that there is not a life-threatening emergency. Once on the scene, the paramedics measure the vital statistics of the patient (BP, pulse, state of consciousness, etc.), make an on-site treatment is necessary, and then measure all the vital stats again. The stats and treatment are all recorded on paper carried by the paramedics. 

At this point, the paramedics will either transport the patient to MIT Medical or a local hospital, or the patient can decline to be transported and sign a waiver releasing the paramedics from responsibility. Assuming the paramedics decide to take the patient to the hospital, they will then transport them, again with a Priority number of 1, 2, or 3 (having now seen the patient, they can actually decide on the priority rather than just always choosing Priority 1). The paramedics communicate with Central Medical Emergency Direction (CMED), which coordinates between hospitals and paramedic, and they provide CMED with their priority number and another one-line summary of the patient's condition over the radio. 

At the hospital, the paramedics bring the patient and the notes they have recorded about times, statistics, and treatments to the primary triage nurse, and they once again give their one-line summary of the incident. This nurse has a mobile computer of some kind, and enters the information provided by the paramedics manually, if time allows. The paramedics then follow the patient to another room with another nurse, and they repeat their one-line description yet again to this nurse. At this point, they are no longer responsible for the patient's care. 

Finally, the paramedics fill out a full report of the incident. At MIT, this is done on a computerized system, in which the notes taken on paper by the paramedics are entered manually into a form. This form contains all of the relevant times (when the ambulance left, arrived, treated the patient, etc.) and statistics of the patient and any treatment given, and it is signed by all the paramedics who responded to the call. This record is sent to the hospital, MIT, and the ambulance service (in this case, MIT paramedic). 

Key points

M's primary concern with the way the patient information was handled was the many, many repetitions of a short, one-line summary of the incident, which they had to give to CMED and to nurse after nurse after nurse, which was often a waste of time. In addition, she felt that much of the nurses' time was wasted re-entering information already collected by the paramedics into the hospital's system. 
M. mentioned that she knew of at least one paramedic using a voice recorder for extremely urgent calls, in which there was no time for written notes, but that this created privacy issues since the recordings contained sensitive patient information. 

Takeaway

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Goals 

• The platform of patient information must maintain the safety of information transfer in ICUs.
• The platform must also be highly efficient to accommodate common ICU situations.
• The platform must be quick-to-learn and robust to allow for easy use by the various user classes who could be using it.
• The platform's underlying model should be information dense, but should present only the pieces of data most relevant to each user group.

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