Recommendations for health information technology

implementation in rural hospitals Yuan-Han Huang

Department of Industrial Engineering, The Pennsylvania State University, Erie, Pennsylvania, USA, and Anand K. Gramopadhye

Department of Industrial Engineering, Clemson University, Clemson, South Carolina, USA

Abstract Purpose – The purpose of this paper is to investigate violations against work standards associated with using a new health information technology (HIT) system. Relevant recommendations for implementing HIT in rural hospitals are provided and discussed to achieve meaningful use. Design/methodology/approach – An observational study is conducted to map medication administration process while using a HIT system in a rural hospital. Follow-up focus groups are held to determine and verify potential adverse factors related to using the HIT system while passing drugs to patients. Findings – A detailed task analysis demonstrated several violations, such as only relying on the barcode scanning system to match up with patient and drugs could potentially result in the medical staff forgetting to provide drug information verbally before administering drugs. There was also a lack of regulated and clear work procedure in using the new HIT system. In addition, the computer system controls and displays could not be adjusted so as to satisfy the users’ expectations. Nurses prepared medications and documentation in an environment that was prone to interruptions. Originality/value – Recommendations for implementing a HIT system in rural healthcare facilities can be categorized into five areas: people, tasks, tools, environment, and organization. Detailed remedial measures are provided for achieving continuous process improvements at resource-limited healthcare facilities in rural areas. Keywords Process improvement, Electronic health record, Health information technology, Medication administration process, Workflow Paper type Research paper

1. Introduction Health information technology (HIT) systems have been recognized as a solution for reducing medication errors and improving the quality of care in the healthcare field (Bates et al., 1998; Poon et al., 2006, 2010; Jaana et al., 2012; El-Kareh et al., 2013; Patterson, 2012). Since the late 1990s, HIT systems have been promoted in the healthcare sector not only because they are compatible with the commonly used clinical documentation system and the electronic health record (EHR) system (Khoury, 1997; Krall, 1995; Berg et al., 1998), but also because they include a computerized physician order entry (CPOE) system, a barcode scanning system, electronic medication administration records (eMAR, a formal computer-based record of the drugs administered to a patient), decision support tools, etc. (Wakefield et al., 2010; McCartney, 2006, 2011; Goldschmidt, 2005). The aforementioned systems cannot be considered separately if the US healthcare providers wish to achieve meaningful use of the EHR which was introduced by the US administration in a law known as the Health

International Journal of Health Care Quality Assurance Vol. 29 No. 4, 2016 pp. 454-474 © Emerald Group Publishing Limited 0952-6862 DOI 10.1108/IJHCQA-09-2015-0115

Received 22 September 2015 Revised 21 January 2016 18 February 2016 26 February 2016 Accepted 29 February 2016

The current issue and full text archive of this journal is available on Emerald Insight at: www.emeraldinsight.com/0952-6862.htm

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Information Technology for Economic and Clinical Health Act in 2009 (Blumenthal, 2010; Jha, 2010; Casey et al., 2013).

For monitoring the progress of implementing the “EHR” system (please note that the EHR system does not just describe the electronic clinical documentation system specifically, but more appropriately represents the whole package of HIT systems used to achieve quality of care), the Healthcare Information Management System Society (HIMSS) uses an eight-stage electronic medical record adoption model (EMRAM) to track the progress of EHR implementation in various categories of healthcare facilities (Garets and Davis, 2006; Hersh and Wright, 2008). The EMRAM model ranges from stage 0, which indicates a HIT system that cannot communicate between ancillary departments, to stage 7, which describes the establishment of a fully paperless clinical environment, data warehousing, and a mechanism for data exchange among facilities (HIMSS Analytics, 2014b).

Table I shows detailed EHR adoption model scores for nine categories of healthcare facilities, in which teaching hospitals have the highest adoption score of 5.18; the critical access hospitals and rural hospitals have the lowest scores, 3.60 and 3.59, respectively out of 7.00, (HIMSS Analytics, 2014a). In the USA, rural hospitals are the hospitals located at the rural areas, defined by US Census Bureau. Rural hospitals in the USA have relatively small amount of beds and physicians due to less population resides in the rural areas; but rural hospitals are usually defined by geographic location instead of size of the hospitals. In the USA, there are around 25 percent US population live in the rural areas, but only about 10 percent of physicians practice in these areas. Due to less medical practices in the rural areas, the rural healthcare facilities are relatively smaller than hospitals in the urban, and the rural hospitals are usually supported by the government (National Rural Health Association, 2015).

In addition, in the first quarter of 2014 the HIMSS EHR adoption model scores by number of bed sizes showed that hospitals with fewer than 100 beds have the lowest score, 3.65 out of 7.00. Hospitals with 501-600 beds have the highest adoption score of 5.21 (HIMSS Analytics, 2014a).

Although the government provides funding incentives and has clear expectations for the meaningful use and widespread adoption of HIT (Bahensky et al., 2008; Abramson et al., 2012), small-scale rural hospitals still lag behind other classes of healthcare facilities (Table I) (HIMSS Analytics, 2014a; Jaana et al., 2012; American Hospital Association, 2011; Yeager et al., 2010). This study mainly focusses on investigating the impact of using the new HIT system on the workflow in a rural hospital specifically on the medication administration process.

Hospital type category Mean Number

Academic/teaching hospitals 5.18 209 General medical/surgical hospitals 4.48 3,177 Urban hospitals 4.27 4,273 Integrated healthcare delivery systems (IDS) 4.18 3,624 Non-academic hospitals 4.08 5,240 Independent hospitals 4.00 1,807 Others 3.62 2,272 Critical access hospitals (CAH) 3.60 1,341 Rural hospitals 3.59 1,176 Source: HIMSS Analytics (2014a)

Table I. HIMSS EHR

adoption model scores by hospital

type in the first quarter, 2014

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2. Methods In this study, an observational analysis was used to map the workflow of the medication administration process while using the new HIT system in a rural hospital in the USA. The medication administration process was described by hierarchical task analysis (HTA) diagrams. Follow-up focus groups with the medical staff were held to review the medication administration process HTA diagram and explore violation against work standards associated with the HIT system. This study focusses on investigating the misconduct of work standards that are related to the HIT in the medication administration process. The process of medication administration is considered to be a series of complex tasks that involve multidisciplinary interactions between the medical staff, including physicians, pharmacists, and nurses (Fraind et al., 2002; Grigg et al., 2011; Sittig and Singh, 2010; Wetterneck et al., 2012). Most HIT systems (e.g. EHR, CPOE, or the barcode scanning system) are involved in the five main phases of the medication administration process: prescribing, documenting, transporting, administering, and monitoring (Agrawal, 2009; Agrawal and Glasser, 2009; Aspden et al., 2007). These HIT systems were developed primarily to prevent adverse events such as medication errors in drug ordering, transcription, dispensing, and administration (Lisby et al., 2005; Boockvar et al., 2010; Abramson et al., 2014).

2.1 Observational study settings and design After two months of implementing the new EHR, CPOC, and barcode scanning systems in a rural South Carolina hospital (which has 55 beds), an observational study was conducted to investigate the changes made to the workflow with regards to the medication administration process in the medical/surgical unit between May and August of 2012. In the facility being studied, the medical/surgical unit was typically staffed with one attending physician, three nurses, and one nursing assistant per eight hour shift. The lab and pharmacy staffs worked from 8:00 a.m. to 5:00 p.m., Monday-Friday.

Data collection took place only during the first shift (starting at 7:00 a.m.) due to the earlier shift not being able to collect detailed medication administration task information from the nurses, physicians, patients, and the patients’ families on the floor. Also, the relevant tasks for the lab and the pharmacy, such as ordering lab tests or restocking medications by the pharmacy technician, could only take place during the morning shift.

The study participants were recruited and informed about the study via announcements in their staff meetings. All participants voluntarily scheduled their observation times with the research team in advance. In this observational study, nurses were shadowed by trained research assistants while they administered drugs to patients during the first shift. The following information was documented in real time during the observations: time to perform a specific task; type and number of drugs for the patient; interruptions that occurred during the task; descriptions of the nursing task; and descriptions of the documentation task.

All of the observational data were verified by the research advisors to ensure the quality of the data. Verified observational data were transcribed into visualized HTA) diagrams for review by the focus groups. The HTA diagram has been demonstrated to be a comprehensive tool for describing activities and locating violations or deviations in a series of tasks (e.g. in the fields of healthcare or aviation maintenance) (Drury, 2008; Lane et al., 2006). The detailed methodology and application of HTA diagrams to medication administration processes can be found in Huang and Gramopadhye’s (2014) previous studies.

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2.2 Focus group settings and design The medication administration process was observed and mapped by an industrial engineering research team. However, none of the research team members had medical training to detect potential violations in the process. Thus, focus groups were used to identify the failures to follow of work standards relating to EHRs in the medication administration process when using an EHR system. Two focus group interviews involving medical staff were held at the hospital under study two weeks after the first phase of the observational study. The focus group participants were recruited via internal staff meetings and all of them volunteered to participate in the study.

A trained research assistant served as the moderator when conducting focus group interviews via a set of probe questions, while another research assistant transcribed the discussion verbatim during each focus group. The probe questions were designed to be based on the cluster of tasks from the HTA diagram (results of the observational study). Those probes were used to address potential issues in each medication administration task. The detailed focus group probe questions are shown in the following list:

(1) How do nurses access the medication administration records? (2) How does the new system change the way records are reviewed? (3) How does the new system communicate with the medication cart? (4) How does the new system communicate with the medication station?

(5) Does the new system impact the requirement of having a witness while preparing certain medications?

(6) How do nurses check out medical supplies using the new system?

(7) If supplies brought to the patient room are not used, how are they handled?

(8) How do nurses perform charting with the new system in the patient room?

(9) If the patient is not ready for medications (e.g. patient is sleeping), how does the nurse handle this with the new system?

The focus group study mainly concentrated on the medical staff’s concerns about how the new HIT system would impact the medication administration workflow. Consensus about misconducts in the medication administration process was reached through open discussion. During the focus group interviews, the moderator introduced each task in the order in which it is embedded in the medication administration process. The main responsibility of the moderator was to ensure that the participants had a shared understanding and agreement about the potential violations or deviations that took place when performing a particular task.

All the participants in the observational study and the focus groups were required to sign a consent form that specified that there were no adverse consequences for withdrawing from the study. No personally identifiable information about the medical staff or patients was recorded. All research data were kept confidential. All the study protocols were reviewed and approved by the Clemson University Institutional Review Board.

3. Results For this study, seven observational periods (based on the number of patients) were conducted during the morning medication administration rounds. Each observational period was approximately three hours. Observational data primarily included the nursing tasks performed while passing drugs to the patients. All the tasks were

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converted into a hierarchical structure and presented in an HTA diagram. Figure 1 shows the HTA diagram for administering medications when using the new HIT system.

In the two focus group sessions, there were five registered nurses (RNs) from the medical/surgical unit and three RNs from the critical care unit/emergency room. All of the participants were female. In the focus group interviews, the HTA diagram (Figure 1) was presented to all the participants, and consensus about potential violations or deviations during a clinical work standard relating to the new HIT system were generated from the discussion. There were 15 adverse factors that could deviate from the normative clinical workflow, potentially leading to medication errors (Adverse Factors a-o in Table II), and these adverse factors can be classified into six categories: barcode scanning tasks, computer interface or operating issues, unfamiliar procedures, omitted procedures, logistic issues, and miscellaneous others. Table II shows the 15 potential adverse factors divided by category.

3.1 Potential adverse factors in barcode scanning tasks In general, the barcode scanning system is used to verify the medication (type and dose) and patient identification while administering medication. However, since introducing the new barcode scanning system, it has been noted that nurses would just scan the patient’s barcode on the wristband rather than interacting with the patient in person (Adverse Factor a). Nurses should have a simple conversation with the patient (e.g. greeting them) not only to verify the patient’s name and date of birth, but also to evaluate the patient’s cognitive status.

In addition, the current study discovered that nurses often possess extra patient barcodes for convenience (Adverse Factor b). Nurses would scan the wristband before or after administering the drugs to the patient, but not at the time the medication was being given. The main reason for possessing a patient’s barcode is that the barcoded wristband can be smudged and hard to scan when the patient stays in the hospital too long without the wristband being replaced.

3.2 Computer interface or operating issues During the observations and the discussions in the focus groups, participants mentioned that the information in the EHR system is not easy to read. The size of the icons and fonts on the screen were too small to read and they could not be adjusted (Adverse Factor c). Sometimes, nurses would select the wrong function or not realize that they had made typos while charting in the system.

Another issue regarding computer operation was that the mouse speed is not adjustable. Thus, users would have problems tracking the movement of the mouse cursor (Adverse Factor d). A lack of appropriate feedback was another issue while operating the new HIT system (Adverse Factor e). For example, the new barcode scanning system makes a beeping sound as feedback, confirming that the barcode has been read by the system. However, the audio feedback cannot distinguish whether or not the correct patient/medication information was obtained.

3.3 Unfamiliar Procedures Before the new barcode scanning system was implemented, the nurses usually collected the barcode stickers from the package of medical supplies and then manually input the barcode information into the computer system for tracking the patient’s consumption of supplies. Although a new barcode scanning system for