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