EZ-ER GR1

Problem Statement ----------------------------------------------------

• In the chaotic emergency care environment, patients are being admitted haphazardly and 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 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, etc. 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 simply use the white boards instead.

User Analysis ------------------------------------------------------------

Target Users Classes

• Paramedics:
  • Perform on-site treatment and first response
  • Collect and record patient information
  • Need to inform the hospital of incoming patients and provide information on health condition
• Nurses:
  • Interact more personally with patients
  • Administer prescribed mediation
  • Keep record of patient health status
  • Asses situation and collect further patient information
  • Prepare patients for doctor
• Doctors:
  • Prescribe medication and treatment to patients
  • Provide more detailed (or accurate) diagnoses of patients' conditions
  • Provide oversight of operations
  • Tackle "harder" medical problems
• Other hospital staff: 
  • Track the procedures performed on patients for billing purposes
  • Contact family members

Target User Goals

• Doctors, Nurses, and Parademics:
  • Need to manage patient information cleanly, and safely without negatively impacting their operational efficiently
  • Want to Prioritize care to the most needy patients
  • Want to be able to easily access the content in the system
  • Would like to update patients status as quickly as possible
• Other hospital staff: 
  • Track the procedures performed on patients for billing purposes
  • Contacting family members
  • Minimize hospital costs and maximize patient throughput  
  • Would like to be updated about patient status as quickly as possible
• Paramedics:
  • Record and send information on patients to the hospital as early as possible to ensure that the caregivers are ready to receive and provide immediate treatment.

Target User Obstacles

• Doctors, Nurses, and Parademics:
  • Very little time or dedication to learning new interface designs.
  • Existing platform is highly error prone, and can be difficult to discern
  • Existing platform is cumbersome and information is not easily transmitted. This can lead to a latency issue where information is not updated frequently enough.   
•  Other hospital Staff:
  • 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.
• Paramedics:
  • No efficient way to communicate or send information collected in the ambulance to the hospital.
  • Must frequently repeat verbal descriptions of patient status and recount patient information to hospital staff.

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

Task 1: Checking Patients In

• Where is the task performed?
  • Patients are checked in the ER, usually by the EMTs or paramedics delivering the patient in coordination with a nurse or other hospital staff. Occasionally, when a patient's condition is less critical, check-in happens at a registration desk where further information is also collected about the patient.
• What is the environment like?
  • The environment is loud, crowded, and hectic. Patients, those accompanying the patients, doctors, nurses, EMTs/paramedics, and other hospital staff are all in the area (the ER, usually). Discussions between the patients, families, doctors, nurses, etc. create a noisy environment, and constant movement of hospital staff (including nurses and doctors) makes the environment a bustling one.
• What are the time or resource constraints?
  • There are both time and resource constraints. Due to the extremely time-sensitive nature of some ER cases, time is a very valuable resource which is treasured in an ER environment. Saving minutes could save lives, and so nurses, doctors, and other hospital staff try to make all interactions efficient.
  • In addition, unfortunately, most hospital ERs seem to be understaffed. That is, staffing is another limited resource: there are often fewer doctors, nurses, and other hospital staff than would be ideal, and so those professionals must split their time between the patients they are seeing.
  • Some hospitals have the added contraint of limited space. Many ERs have a relatively low limit on the number of patients they can hold (which could be a function of the point mentioned above: staffing), and thus have a limited number of beds in which patients can stay.  
• Who else is involved in the task?
  • As mentioned above, there are several classes of people involved in this process. In fact, each of our user classes described in the sections above plays a fairly distinct role in the task of checking patients in. Doctors are likely less involved in this particular task, but nurses, EMTs/paramedics, and other hospital staff certainly each play a large role in checking patients in.
• Why is the task being done?
  • Hospitals must keep detailed records of the patients for whom they are caring, and this record-keeping process starts with the patient check-in. The patient check-in process allows the hospital to know when patients have begun care, and allows the hospitals to collect one-time information from the patients (insurance information, contact information, etc.). 
• What does the user need to know or have before doing the task?
  • The users need to know where the patient is located, and what the status of the patient is. If the patient is conscious and able to answer questions, then this task can be reduced to a simple interview of the patient being checked in with medical details added. However, in the relatively common case of a patient who is unable to answer for him- or herself, the users must know about the patient's medical history as best they can, the current condition of the patient, and any other information that might help with diagnosis, triage, and treatment of the patient.
• How often is the task performed?
  • The task is performed on every patient entering the ER or ICU. For most hospitals, the rate of patients entering fluctuates greatly throughout the day, and our initial research and interviews have shown that it can be as low as 3-5 patients per hour during off-peak times, or as high as 30-60 patients per hour during peak times or during mass incidents.
• How is the task learned?
  • The task is usually learned through training and hands-on observation. New emergency nurses are often trained in a "live" ER or ICU, while doctors spend years of internships and residencies during which they also develop the necessary clerical techniques. Other hospital staff also receive training on patient check-in processes.
• What can go wrong?
  • Our research, observations, and interviews have shown that several things can go wrong during patient check-in. On occasion, some patients might "slip through the cracks" and not be checked in at all; this is a large problem when it occurs. Patients may also be checked-in with the wrong information accompanying their records, which can be especially problematic when the false information includes an incorrect medical history or medical status.

Task 2: Adjusting Patient Information

• Where is the task performed?
  • This task, like the one above, is performed primarily in the ER or ICU in question. Specifically, the task is most often performed alongside the patient, usually at or near his or her bed. On occasion, the patient's information might be adjusted from a remote room.
• What is the environment like?
  •  Given that this also occurs in the ER/ICU and that the area is in a relatively constant busy state, the description of the environment used in the task above is still applicable: the environment is loud, crowded, and hectic. Patients, those accompanying the patients, doctors, nurses, EMTs/paramedics, and other hospital staff are all in the area (the ER, usually). Discussions between the patients, families, doctors, nurses, etc. create a noisy environment, and constant movement of hospital staff (including nurses and doctors) makes the environment a bustling one.
• What are the time or resource constraints?
  •  
• Who else is involved in the task?
  •  
• Why is the task being done?
  •  
• What does the user need to know or have before doing the task?
  •  
• How often is the task performed?
  •  
• How is the task learned?
  •  
• What can go wrong?
  •  

Task 3: Checking Patients Out

• Where is the task performed?
  •  TODO
• What is the environment like?
  •  TODO
• What are the time or resource constraints?
  •  TODO
• Who else is involved in the task?
  •  TODO
• Why is the task being done?
  •  TODO
• What does the user need to know or have before doing the task?
  •  TODO
• How often is the task performed?
  •  TODO
• How is the task learned?
  •  TODO
• What can go wrong?
  •  TODO

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

Interview 1: Doctor 1

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 (A3) on which is indicated which drugs the patient has received in the ICU, and at what time he 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 goals and needs he has which are not addressed by the current solution (file folder + whiteboard). Here are the key points of his answer:

• Patients with intricate medical records are difficult to handle as the whiteboard only have enough space for if a few main medical information (as the whiteboard's primary purpose is to keep track of drug administration)
• it's impossible to collect data for medical research
• 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, displayed in real-time on-screen, but needs 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 previous ICU period, the physician will not know how the patient had reacted to it.
  Interesting remark on the last point: "For forensic purposes it could be interesting. But otherwise it's not useful very often. I guess maybe when something's wrong and strange with the patient it can be helpful to browse the detailed history (or for research purposes), but globally I don't think it happens often: 2-3 days after it's been measured most likely it won't ever be needed again. Otherwise, when a parameter needs to be monitored, again it's copied into the patient's file. All this is probably quite patient-dependent: probably the web interface should be able to adapt to different cases. Like, "pinning" a parameter of interest so that it's more visible for a specific patient (eg temperature for a patient with a severe infection vs blood pressure for one after myocardial infarction)"

Addendum after interview: "I thought about something: another interesting information to have on the whiteboard would be upcoming appointments: I'm thinking mainly about radiological exams: it can be interesting/useful to know that at hour X a radiologist (that's not actually a radiologist but a "manip radio" but I don't know the English term) is coming to do an X-ray to the patient, or that the patient will be moved to the scanner or something. I don't think patients move that much once installed in ICU, but still when they do it's good to have as much people as possible aware of it."

Key points

TODO

Interview 2: Doctor 2

Dr Y. is a young ICU physician. As ICU is a broad topic we focused on how patient's information is handled.

He described 5 different types of information containers (everything is on paper except the first one):

• administrative information (everything non-medical, e.g. age/sex/address/…)
• 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 write a medical summary of 1 or 2 pages containing anything could be interesting to treat the patient. This synopsis follows a conventional format. It will be kept within the service, even after the patient has left.
• the nurse folder, where nurses write down precise technical information such as given drugs (quantity/time) as well as key measures on the patient such as blood pressure or ECG.
• Nurse whiteboard: data measurements (blood pressure/ECG/…), drugs, key events
• Paramedic whiteboard: Sumary of the previous examinations of the patientIn addition to those five sources of information, they can be some computer applications designed for specific type of information such as medical images, but those applications aren't interconnected.Dr Y. then enumerated his most important needs:* easy, rapid access to any information pertaining to the patient* reliability of the information, e.g. not having the wrong file (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. We must be in mind that physicians/nurses/paramedics often have to react very quickly in the ICU. Also, it's not the job of physicians/nurses/paramedics to rewrite information in different folder. They should better use their time to help the patients.The goal is simple: saving the patient's life, while providing correct work conditions for the hospital's employees.

Key points

TODO

Interview 3: Emergency Medical Technician

M. spent a year as an MIT EMT (Emergency Medical Technician), 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 to me the typical process for handling a patient and his or her information:

An EMT 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 EMTs 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 EMTs 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 EMTs. 

At this point, the EMTs 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 EMTs from responsibility. Assuming the EMTs 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 EMTs communicate with Central Medical Emergency Direction (CMED), which coordinates between hospitals and EMS, 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 EMTs 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 EMTs manually, if time allows. The EMTs 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 EMTs 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 EMTs 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 EMTs who responded to the call. This record is sent to the hospital, MIT, and the ambulance service (in this case, MIT EMS). 

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 EMTs into the hospital's system. 
M. mentioned that she knew of at least one EMT 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 Goals --------------------------------------------------------------------

• Platform must improve the safety of information,be highly efficient, and easily learned by doctors and nurses.
• TODO