Chapter 3. Analysis and Design

Documenting current and future states is vital and can be diagrammed using:

"as is" and "to be" workflows

A process analysis report should include:

1. Analyst's name and organization 2. Dates of time on site 3. Individuals from whom information was gathered 4. Process inventory 5. Process variations and exceptions 6. Process diagrams 7. List of new system functionalities needed for the practice

What are the "Seven Key Process Aspects"?

1. Context 2. Process Steps 3. Data/Information Flow 4. Data/Information Content 5. Data/Information Transformation 6. Steps Sequence Control and Status 7. Roles Involved

Examples of office visit exceptions include:

1. Emergent reason to stop visit 2. A non-covered service needing a separate visit 3. The need to be seen by a different provider

Benefits of Workflow Analysis

1. Employees have better understanding of each other's roles and responsibilities 2. Employees will have a better understanding of the whole picture rather than just a piece of the puzzle 3. Future state workflows can reveal skill gaps amongst current staff which could require new job descriptions and retraining of current staff 4. Documenting workflows early in the process provides the opportunity to change inefficiencies even before implementation, thus, worksite can regain productivity faster 5. Lack of adequate documentation can result in a bungled health IT implementation, often requiring the workflows to be created in order to address problems 6. Less costly and time consuming to perform workflow analysis before implementation 7. Completing as is workflows can reveal the requirements needed for the new system to deploy successfully

What are the 6 principles of usability?

1. Learnability - defines how easy is it for users to accomplish basic tasks for the first time they encounter a health IT design 2. Efficiency - related to the quickness (after learning the basic use of the system) with which users can perform the tasks 3. Memorability - ease experienced by a user returning to a system or a product after a period of not using it. It is the measurement of how long it takes to reestablish proficiency 4. Error - is the measurement of everything related to errors made on the system: how often they made, and why are they made? How severe are the errors? Are they life threatening errors or just nuisance? How easily a user can recover from the errors is another dimension of usability quality 5. Satisfaction - is a measure of how pleasant the design, the product, or the system is to use 6. Utility - refers to the designs functionality. Does it do what the users need it to do? It matters little that something is easy to do if it is not what needs to be done. It is also no good if the system can hypothetically do what is intended, but users cant do it because the interface is too difficult for them. o Safety-critical environments require systems that avoid dissatisfaction and frustration in users.

Examples of office visit variations include:

1. Referral needed 2. Procedure needed 3. Diagnostic test needed

What are the steps in process analysis?

1. Start with PROCESS INVENTORY and PROCESS DIAGRAMS. These should provide a context diagram showing clinical functions and a flowchart for each process 2. For each process, list the process variations applicable to the clinic as well as exceptions that often occur. For example, for a patient visit, a common exception would be that a patient cancels or does not show up. 3) The last step in process analysis is to report findings. The findings from a process analysis would include major observations, a list of new system functionality necessary to support organizational functions, and opportunities for improvement (technology assisted or otherwise)

The occurrence of multiple variations is a signal to the analyst that:

1. The HIS must support multiple options 2. The HIS will likely need to show different screens or otherwise facilitate the process variants

According to the American Academy of Family Physicians (AAFP), family physician workflow can be broken down into two categories:

1. The flow of patients entering the office and having their needs met within the office environment. (MOVEMENT OF THE PHYSICAL PATIENT) 2. The flow of information within the office environment, whether the patient is physically present or not. This information includes clinical, social, and billing information. (MOVEMENT OF THE PATIENT DATA)

A processes consists of these important characteristics:

1. They happen in sequence order 2. They have steps, inputs and outputs 3. They happen over and over again

Physician champions can act as leaders within the community by: A. Sharing information about the benefits of EHRs B. Determining which EHR is best for the organization C. Deciding whether a new EHR is actually necessary

A. Sharing information about the benefits of EHRs

Physician and Nursing Champions

Act as leaders in promoting benefits of new system. They can act as liaisons between IT staff and can play a key role in planning for future enhancements and integration with an HIE or regional information organization (RHIO)

Informational

Actions that HUMANS or MACHINES perform Ex. Manipulating values and calculations

physical tasks

Actions that HUMANS or MACHINES perform Involves physical movement or physical energy to perform. Ex. Moving supplies from a loading dock into a supply room

Mental

Actions that the HUMAN Mind performs Ex. Reading and reasoning

What are two good methods for organizing and simplifying data?

Affinity Diagrams and Process Flow

When does the design phase start?

After the analysis phase

What did the HITECH Act seek to do in regards to EHRs?

Aimed to introduce more healthcare providers to adopt EHRs by offering incentive payments. The broad goals of the act are as follows:

ASQ is an acronym for what?

American Society for Quality

Float (sometimes referred to as slack)

Amount of time an activity can be delayed and not push back the early start of a successive activity

Effort

Amount of work or labor hours necessary to actually perform a scheduled activity

Process Exception

Are deviations from the optimal process which have the potential to kill the objective of the process.

Process Variations

Are processes that vary from the typical or normal workflow.

What is the role of the IT analyst?

Assisting in designing workflow that takes full advantage of features of a health IT system.

Which of the following are NOT steps in process analysis? A. Create process inventory B. Conduct process redesign C. Report analysis findings D. Identify EHR functionality

B. Conduct process redesign

Functional requirements describe: A. The electric power needs for a new EHR B. The capabilities of the system and what the user should be able to do with it. C. The necessary backup system D. Both A and B

B. The capabilities of the system and what the user should be able to do with it.

A user-centered approach is characterized by all of these elements except: A. Considers users' tasks and goals from inception through development B. Uses a linear life cycle model to clearly delineate tasks C. Is developed via an iterative design process

B. Uses a linear life cycle to clearly delineate tasks

Why would appointment scheduling be considered a process?

Because it has steps in a defined sequence: inputs (information about the appointment being scheduled) outputs (the appointment), and activity that happens repeatedly throughout the day.

Business Requirements include:

Business Goals, strategies, monetary considerations, budget constraints, regulatory and legal concerns, and high-level functional perspectives

What is the correct order of steps for process analysis? 1. Create process inventory 2. Report analysis findings 3. Identify variations and exceptions 4. Identify needed EHR functionality A. 1,2,3,4 B. 3,1,2,4 C. 1,3,4,2 D. 4,1,3,2

C. 1,3,4,2

In the requirements gathering process, naturalistic observation includes: A. Observing staff interactions to determine the best mix of personalities B. Developing process scenarios in the event of an EHR system failure C. Observing people at work in order to understand workflow and communication processes D. B and C

C. Observing people at work in order to understand workflow and communication processes

Scheduling tools

Computerized project management software applications that help the project manager develop the schedule and provide information to manage the project

What is the first step of process analysis?

Creating process inventory and diagrams

User requirements include:

Current and future workflows, policies and procedures, document and data trails, environmental concerns, and day to day operational perspectives

Health IT projects can be focused on: A. Selection of a new capability B. Enhancing existing systems C. Meeting reporting/analysis requests from the end-user community D. All of the above

D. All of the above

The project management plan involves a collaborative effort between: A. The project manager B. Team members C. Executive sponsors D. All of the above

D. All of the above

Choose the answer that best describes process inventory. A. Counting and tracking available stock B. Objectifying and measuring processes. C. Analyzing and improving stock processes. D. Identifying and recording processes.

D. Identifying and recording processes. After the processes for analysis has been identified, the analyst, working with people from the clinic creates diagrams of the processes. These graphical representations of the processes are used in the process analysis and redesign. We start with process inventory and diagrams because sometimes they are all that is needed, and they point to areas where different types of objective information may be needed.

System Requirements

Define desired characteristics of the system and properties that the system or product must have.

Business requirements

Describe and justify high-level business functionality that is needed.

Human Resource Management Plan

Describes how training requirements of team members will be accomplished and provides project organizational charts and position descriptions

User-Centered Design (UCD)

Design methodology in which studies, interviews and conducts empirical tests of users needs determine the characteristics of a design or computer application.

Activity relationships

Diagramming technique that illustrates the activity's logical relationship. Finish to start, and start-to-start, finish-to-finish, start-to-finish

A schedule management plan

Document that contains information on how the schedule will be developed and controlled, how the schedule process will be measured and what scheduling tool will be used.

Schedule

Documents when the project activities will be completed

User-centered approach

Early focus on users and tasks, empirical measurement, iterative design.

Process Analysis

Examines a process and identifies opportunities for improvement. It allows organizations to develop workflow requirements that take advantage of new application capabilities.

Prescription Process Variation or Exception? No Insurance

Exception

Variation or Exception Emergent reason to stop visit

Exception

Variation or exception? A non-covered service needing a separate visit

Exception

Interaction Design

Focuses on the role of the user in designing interactive products to optimize user interactions with a system to support and extend user activities in effective, useful and usable ways.

Provide some details of a user centered approach

Focuses on users and tasks very early in the design and conceptualization process Built on empirical measurements of users both prior to using the system and while using the system 1. Constant cycle of improvement Used to support humans in facilitating performance on a particular task The system needs to be shaped by an understanding of the capabilities, and limitations of the user Emphasizes that users are involved from the inception through cycles of iterative development All design considerations are influenced by user considerations

What are some future trends when it comes to usability in designing a new system?

Future - > Higher value placed on usability Systems will place higher importance on · Support efficient workflow in a hectic environment · Accommodates various ages · Ensuring adequate access to physical hardware in order to prevent competition for resources · Interoperability between multiple systems

System Requirements include:

Hardware, software, network, database, and other technical considerations

Provide a description of the process aspect "context"?

How a system or process interacts within the larger environment. Context diagrams show main components and the ways in which the system interacts with things outside the system, such as inputs and outputs.

Usability

How easily a user interacts with a product. Emphasizes USER EXPERIENCE.

User Requirements

Identify what is needed from the user's perspective. These can be things that the system or product must do.

Non-functional requirements

Include everything else, such as usability requirements that align with user characteristics security, compatibility with existing system architecture etc.

Why are paper charts considered a "batch and que" system?

Information is recorded on paper tends to accumulate and until it is entered into an electronic system in batches where as information recorded electronically at the POC (Point of Care) is entered directly into the system in real time.

What did American Recovery and Reinvestment Act of 2009 (ARRA) do?

Introduced requirements that vendors develop systems that meet standard certification criteria and that healthcare organizations purchase certified systems in order to receive additional reimbursement

"Big Bang" Approach

Involves bringing several applications live at one time and has shorter implementation time

Naturalistic Observation

Involves observing people at work in order to understand workflow and communication processes

Workarounds

Is a method of accomplishing a task when the usual or planned method either does not work or is unacceptable to the user

Requirement Analysis

Is a set of activities taken early in the design process and lists what the system must do (technical and non-technical), as well as define objectives for design and later testing.·

What is a "process"?

It is a set of interrelated work activities characterized by a set of specific inputs and value-added tasks that make up a procedure for a set of specific outputs.

What is the second step of process analysis?

List the process variations and exceptions applicable to the organization

Critical Path

Longest path of activities through the schedule network, it established the earliest date by which the project can be completed

Why is it important to use graphical representations in process analysis?

Often convey information more effectively that written or spoken words.

Process Maps are also called _____.

Process Diagrams

A laboratory report did not arrive in time for a patient visit, and the physician could not complete his diagnostic workflow. This is an example of:

Process exception because the workflow was unable to be completed

The "to-be" model consists of

Projected data collection, workflows, decision points, resources and responsibilities

What are the pros and cons of conducting interviews as part of eliciting requirements?

Pros: Allow a designer to explore issues in greater detail. Personal contact with user. Cons: Time consuming, involves scheduling, with people who have little free time

What are the pros and cons of focus groups as part of eliciting requirements?

Pros: Allow a designer to solicit multiple views and build consensus. Good for hearing thoughts on a process Cons: Not all voices heard, staff may fear to speak their true feelings or struggles, or not be given opportunity to express views. Less useful in eliciting serious evaluations about the efficacy or usability of a product

What are the benefits of requirements analysis?

Provide clarity in communication between users and development team, identify mismatches between user needs and designers understanding, time saving and cost saving Lack of clear requirements definitions lead to more costly changes down the road

What are some methods for eliciting requirements?

Questionaires Online Surveys Interviews Focus Groups Naturalistic Observation

What is the last step in process analysis?

Report findings

Clinical Process Maps

Represent how all of the tasks that support a particular healthcare process are achieved.

What are some core functions of a physician practice?

Scheduling and registration, documentation, prescription writing, billing, and referrals. Other functions vary on size and scope of practice such as laboratory testing, diagnostic testing.

Project schedule network diagrams

Schematic depiction of scheduled activities and dependencies which are logical relationships of activities. They model sequenced activities.

Affinity Diagrams

Sort and display ideas from multiple sources. They display a grouping of ideas and data.

When tasks must be completed in a certain order, they are broken down into _____.

Steps

Graphical representations use ____ to convey information

Symbols

"Staged Implementation"

System goes live gradually.

Conceptual models could include things like:

Task domain objects, their attributes and the operations that could be performed.

Design

The blueprint that specifies how the system will work. Focuses on the "HOW"

There are times when a physician does not have access to an EHR with computerized provider order entry (CPOE) capability and must phone in an order. In this example, the process variation is ___.

The handling of a phone order.

Provide a description of the process aspect "data/information transformation"?

The manipulations performed on data/information, such as calculating age from a patients date of birth and today's date; involves informational tasks or activities

Provide a description of the process aspect "step sequence control and status"?

The order in which data or things move through a process, and the logic that controls that flow

Provide a description of the process aspect "data/information flow"?

The path through which data and information travel in a process from the perspective of the data/information; involves informational tasks or activities

Provide a description of the process aspect "process steps"?

The physical or mental tasks or activities required to complete the process, usually from the perspective of the patient or healthcare professional

Provide a description of the process aspect "data/information content"?

The specific pieces of data/information required for process or informational steps or decisions

Procedure

The steps in a process and how these steps are to be performed for the process to fulfill a customer's requirements.

Tasks

They are the actions performed in the process, and can be classified as physical, informational, or mental.

Quality Management Plan

This document addresses project quality control, quality assurance, and continuous quality improvement

Gap Analysis

This type of analysis compares the conditions that currently exist within an organization with those that will exist after implementation of new system. The difference between the two sets of conditions is the "gap".

Applying the concept to information data flow, "the goal when implementing a health IT solution in the office is

To transition from a "batch and que" system to a system that exhibits continuous flow. ** The goal is to avoid a system in which information stops and waits for humans to move it along**

Duration

Total number of work periods, as in days or work weeks that are required to complete a scheduled activity

The benefit of creating "as is" workflows is that you are better able to determine how the implementation of a new system will result in new capabilities that will benefit both patients and staff. A. True B. False

True

Why/ When are "questionnaires" useful?

Useful in addressing very specific kinds of questions and they can reach many people.

Variation or Exception? Electronic prescriptions provided during the office visit

Variation

Variation or Exception? Paper prescriptions provided during the office visit.

Variation

Variation or Exception? The need to be seen by a different provider

Variation

When would the "as-is" model be used?

When analyzing your current system requirements, including the current procedures and processes.

Provide a description of the process aspect "roles involved"?

Who or what performs the process steps

Conceptual model

a verbal or graphical explanation for how a system works or is organized. Not the user interface.

If a user has to wait for access to a computer or too many people being logged into a system can cause longer than acceptable wait times. This is an example of a _____.

bottleneck

Designing a process requiring consecutive steps when steps could have been processed simultaneously can cause _____.

bottlenecks

______ are essentially traffic in a workflow/process

bottlenecks

Process Flow

depicts the overall flow of activities and the relationship between parts of a system and the individuals using it

Functional Requirements

describe the capabilities of the system and specify what the user should be able to do with the system.

Analogous techniques

determine the estimate by using resource duration estimate information from similar past projects

The "as-is" and "to-be" models should be compared to identify ___.

gaps

Process Map

is a visual representation of a process that shows boundaries (i.e. where the process begins and ends), steps taken in the process, and the sequence or order of the steps.

Workflow is a process it includes all of the following:

o Activities o Location o Roles o Choices and Decisions o Information needs

What were some broad goals of the HITECH Act?

o Improve quality, safety, efficiency and reduce health disparities o Engage patients and families in their healthcare o Improve care coordination o Improve population and public health o Ensure adequate privacy and security for personal health information

Process maps can represent three types of tasks:

physical, mental and informational

After the process inventory has been conducted and the initial diagrams made, the results of a process analysis should be compiled together into a ______.

process analysis report

Meaningful Use

the use of certified electronic health record technology to achieve health and efficiency goals, with a financial incentive from Medicare and Medicaid

What is the goal of process analysis?

to ensure that the organization has the best system for its needs and that the system meets requirements and enables the organization to achieve expected outcomes.

RFPs (Request for Proposal) and RFIs (Request for Information)

use a specific outline to tell prospective vendors what they need to know about a healthcare organization in order to provide useful information about their products

1. As-Is workflows help by:

§ Helps staff understand problems with current workflow § Staff can better see how new system will enhance current one § Team members can better understand how their roles will change and get the most out of their training on the new system · **Analyst should conduct as many interviews as possible - Collective Experience**

why and when should To-Be workflows be used?

§ May be utilized before and after implementation of new system § During - to ensure system is implemented in a way that supports the new workflow § After - To "tweak" the system and take advantage of tailoring capabilities provided by the system § Used in training - using staff and subject matter experts

RFP Outline

· Cover Letter · Introduction and selection process · Background Information, including organization size and specialty and current systems and hardware in place · Desired functionality · Vendor information including years in business, financial information, number of installed customers · Product description · Hardware and network components needed · Customer maintenance and support and warranties · Training available · Systems implementation plan · Proposed costs · Sample contract customer references for the application being considered

A Health IT Analyst Can Improve Processes By:

· Increasing efficiency · Decreasing delays, errors, and cost · Increasing quality and safety · Improving the work environment · Improving the ability to care for patients · Creating a better overall practice experience

A graphical representation helps in the following ways:

· Reveals where the sequence of tasks is crucial · Identifies bottlenecks or interruptions · Identifies opportunities (often the same as bottlenecks) · Creates solutions to relieve bottlenecks · Reanalyzes the new process · Makes efficiency improvements

Examples of sub-processes involved in a typical routine office visit are:

· Scheduling an appointment · Checking in/out · Receiving various forms of care · Processing insurance/payment

The steps for making an affinity diagram consist of:

· Write down individual ideas on a note card or post it · Look up ideas with similar themes · Group the ideas with similar themes together

An IT analyst must meet these requirements:

· basic understanding of data systems and clinical workflows · Be able to identify inefficiencies · Good communication skills

Why do we use symbols to convey information?

· make it easy to quickly share information with many audiences · efficient in presenting process components and flows