Experiences of Nursing Personnel Using PDAs in Home Health Care Services in Norwegian Municipalities Linda M. Hansen, RN, MSc1, Mariann Fossum, RN, MSc1,2, Olle Söderhamn RNT, PhD1, Ann Fruhling, PhD3 1
Centre for Care Research – Southern Norway, Department of Health and Nursing Science, Faculty of Health and Sport Sciences, University of Agder, Grimstad, Norway; 2 School of Health and Medical Sciences, Örebro University, Örebro, Sweden; 3School of Interdisciplinary Informatics, College of Information Science and Technology, University of Nebraska, Omaha, USA Abstract Although nursing personnel have used personal digital assistants (PDAs) to support home health care services for the past ten years, little is known about their experiences. This study was conducted to examine experiences of nursing personnel using a specialized home health care computer software application called Gerica. In addition, this research analyzed how well this application aligned with the workflow of the nursing personnel in their daily care of patients. The evaluation methods included user observations and learnability testing. Nursing personnel from two different municipalities were observed while performing real tasks in natural settings. This study shows that the nursing personnel were satisfied with the PDA user interface and the Gerica software; however, they identified areas for improvement. For example, the nursing personnel were concerned about trusting the reliability of the PDA in order to eliminate the need for handwritten documentation. Solutions to meet these shortcomings for nursing managers and vendors are discussed. Introduction Personal digital assistants (PDAs) have been proposed as suitable solutions for improving the accuracy, safety and quality of home health care services1, 2. Documentation in the Electronic Health Records (EHRs) is regulated by law and all nursing personnel in the home health care services in Norway are expected to document the planned and performed care of patients3. There are many factors that influence how an EHR is used and the usage often varies between groups of nursing personnel in health care systems, both in different municipalities and in interactions with hospitals and other health care institutions. Based on new reforms, the government expects to realize improved health care service for patients and lower total health care costs4. The software applications used in the EHRs in Norwegian health care settings vary and there are numerous challenges when exchanging information between systems. Gerica (www.tieto.no) is one software solution to meet these challenges and is the software application used on PDAs in the municipalities included in this study. Gerica is designed and developed to ensure all areas of documentation in the home health care services meet the ISO standard for information and documentation5, 6. Training nursing personnel when implementing EHRs often requires a great amount of economic and organizational resources7. One way to reduce the training costs is to improve the learnability of the new software application. For the purposes of this study, learnability is defined as how quickly a novice user can intuitively understand and use a system7. Research has shown that high learnability provides benefits to the organization and reduces costs7. To improve accuracy and safety in EHR documentation it is important to increase awareness of nursing personnel workflow, to identify security issues, and to eliminate handwritten paper notes and lists. These are important goals when using EHRs in the health care services4. Workflow could be defined as the order of tasks performed by various nursing personnel in order to complete a given procedure7. A decision made at other levels of the organization, or by software designers, may not only influence the overall workflow and habits of dealing with certain problems in patient care8, but also the specific actions of individual nursing personnel. Aim The aim of this study was to examine nursing personnel’s experiences with the PDA application software Gerica, which was designed to support documentation of home health care services. The study also evaluated how well the application aligned with the nursing personnel’s workflow in their daily care of patients.
1
Methods This study used an explorative design with mixed methods. Mixed methods were chosen to study nursing personnel using the PDA in order to obtain an in-depth understanding of how the application supported the nursing personnel’s workflow. Qualitative observations and a survey were combined to achieve a richer data collection and analysis9. Setting and participants The vendor supported the study with contact information for municipalities that had used the software application Gerica on PDAs for several years. The managers in the home health care districts in the two municipalities were informed about the aim of the study and were asked to recruit volunteers. Volunteers were given written and oral information about the study7,9 and asked to provide written consent to participate. It was required that the observations be conducted with nursing personnel who had real experience in using the application7. The nursing personnel who volunteered for the study had used the system for at least one year before the study was conducted. Observations were conducted with both registered nurses (RNs) and nursing aides (NAs), referred to collectively as nursing personnel in this study. These participants worked directly with caregiving in home health care services in two different municipalities in southern Norway. The RNs and NAs have similar responsibility regarding documentation, based on their professional qualification. The nursing personnel observed were between 29 and 66 years of age, most of them middle-aged. Seven had more than three years’ experience in computer use and one had more than two years’ experience. Six of the participants had more than three years’ experience in working with the Gerica application. The professional qualifications are as follows: three RNs, one had further education in psychiatry and one in cancer care; five NAs, one had further education in psychiatry. Observation Eight nursing personnel were observed by two researchers while performing real tasks in a real working environment, which is known to be one of the richest contexts for evaluating system learnability7, 9. The researchers used an observation form, developed for this study. The concepts in the observation form had been discussed to optimize the reliability. The nursing personnel were followed around their workplace throughout their entire day, both on home care visits and at the head office. It was extremely important that the researchers did not interfere or interact with the patients. Therefore, observations were carefully concentrated on watching the use of Gerica on the PDA. The home health care services in the municipalities were organized according to a primary nursing model, wherein each nursing personnel has a special responsibility for a group of patients, where these patients are those the nursing personnel visits on a regular basis. The nursing personnel use PDAs to support and organize their daily work, to remind them of important issues and to document the planned health care for the patients. The following activities were specifically observed: - How did they gather information at the start of the shift? - What did the display look like? - How did they communicate actions taken, or changes needed, back to the head office? - What did they document throughout the shifts? - How did they exchange information during shift changes? Field notes were taken during the observation to describe how the nursing personnel managed to retrieve information and pass information on when required. The researchers carefully noted the system’s ease of use and its usefulness in order to evaluate the learnability of the system. Furthermore, the researchers documented whether the nursing personnel made effective use of patient care options that were presented. Participants were asked whether they wanted something to be changed in the Gerica system to improve workflow7, 9. Survey Instrument Learnability was scored with a survey used earlier by Fruhling et al.10. The items were presented with a likert scale ranging from one to seven, where one indicated total disagreement and seven indicated total agreement. On all items, the participants could comment freely on what they liked or disliked about the system, and whether they would like anything to be changed. Analysis The data from the field notes was read thoroughly, clustered and organized into meaningful units for the analysis. During the analysis, the text was moved back and forth between the entire text and the various text segments identified as meaningful units11, 12. Table 1 shows examples of how the data was coded. Findings from the field notes were compiled from the participants’ answers to open-ended questions. These were further condensed into more meaningful units.
2
Table 1. Example of how data has been coded from field notes and open-ended questions in the survey. Meaningful unit
Condensed meaningful unit
Updates should be done at night, not during day-shifts or evenings when the PDAs are used most.
Dislike delay of work
When the device freezes
Cannot work as intended
The device often refers to settings whose purpose we do not understand
Disturbed by uninformative text
Code Poor system administration
Ethical considerations Norwegian Social Science Data Services gave permission to conduct the study: project number 27132. There was no conflict of interest between the authors or the stakeholder. Results Poor system administration was identified as a key problem based on open comments, field notes, and observations of the different kinds of problems which reduced the effectiveness of nursing personnel’s daily work. For example, nursing personnel explained that they were confused by uninformative text whose relevance to their daily work was unclear when using the PDA. Another problem identified was that the system did not match the workflow. According to the primary nursing model, when nursing personnel started a new shift, the first thing they looked for was ‘what’s new’ because they already knew their patients quite well. Some of the nursing personnel left the office immediately after the report and used the PDA to get the information needed to start their work with the patients. Many of the nursing personnel made comments both during the observation and in the open-ended questions about not being able to comment directly on interventions, while still at the patient’s home or directly after meeting with the patient, because they wanted to finish all the work related to the patient and avoid having to make notes about the same issue several times and in different locations in the application. Thus, this caused them to work less efficiently. When nursing personnel’s work caring for the patient is completed, the process is really not finished until everything has been properly documented 4. The system does not allow the nursing personnel to document everything at once, which is something they clearly wish to be improved. In addition, paper lists were used, in order to ensure that data was available even if the system, for some reason, ceased to work or where its use was inappropriate. Another issue identified was the need for a reminder function to be used for example when something is new or requires specific attention. Such a function would make the system easier to use and enable the nursing personnel to work more efficiently, in addition to enhancing the patients’ perception of safety. Being multifunctional, the PDA can be used for different purposes. For nursing personnel that are away from the office (home base), it is their main and only means of communicating with the application system Gerica, the head office, the physician and/or the patient’s relatives if they are not in the same building. If there is a need to look up information in the care plan on the PDA, the PDA cannot be used simultaneously as a phone. Thus, this causes problems when the nursing personnel need to refer to information during a phone conversation. Table 2 summarizes the results of the observations. The results are grouped into three categories: functional, organizational and technical. Comments included satisfaction with the nursing plan zoom function which provided a sense of security by eliminating the need to remember everything by oneself and the opportunity to take control in situations where the care plan had been changed. The results from the survey showed that questions concerning learnability were scored at a high level of satisfaction, with scores from five to seven.
3
Table 2. Results from observations of the nursing personnel using the PDA in a natural setting. FUNCTIONAL
ORGANIZATIONAL
TECHNICAL
Uses paper list with names of the patients in addition to the PDA
Reading procedures before leaving the office to be prepared for meeting with the patient
Different way of logging on and off the new and old PDA
Sends messages to the base about the time it takes to visit the patient Provides good overview when the PDA list is updated when a message is sent to base
Some of the nursing personnel gather information as they work through the patient list on the PDA
PDA skips to sleep mode; Gerica can be down for prolonged periods of time, and the work must be done
Mainly known patients
Challenging whenever updating of the care plan is necessary
An acute or core patient record is kept on paper at the patient’s to be sure to have information when needed
Transferring patients from other lists (because of illness, and absence among the employees)
To be sure it works, we have an additional handwritten list, just in case
Highlighting the Patient field can be done in two ways, by highlighting the field on the PDA or by changing the color (to blue)
End users are able to determine the time intervals based on estimation of the time actually spent
Need greater multi-functionality
The nursing plan can be zoomed, I dislike the fact that I am not able to bring up the medical prescriptions
Based on the primary nursing model, nursing personnel have more information about the patient than documented
Finding what you are looking for can easily get too complex.
Discussion This discussion will concentrate on the main findings from the observations presented above and in Table 2. One of the most important issues identified as a problem was system instability. This problem was identified based mostly on the written comments of the persons who had experience with the Gerica application. They stated that it was not unusual for the system to go down unexpectedly for more than two hours. Furthermore, they explained that the system was a valuable support tool when in use and a major frustration when it was not available due to technical network connectivity or system problems. Another shortcoming identified was the inability of the PDA to be used both as a phone and as a documentation tool. The need exists for a multifunctional PDA that can show picture-in-picture (P in P) while making a phone call. The expected result of this desired feature is the possible elimination of paper documentation, which is a security goal according to the Patients’ Rights Act in Norway4. PDA screen size varies and P in P requires a certain size to be readable. Some of the nursing personnel chose to use their own private mobile phone to make calls while using the PDA as, for example, an encyclopedia to gather whatever information the physician or the emergency team would need. The third concern about the system was not being able to comment immediately on interventions and thus, having to make notes on paper. When both using a PDA and making notes on paper, the nursing personnel add functionality to the system that is not already inherent in order to support their workflow. This can be both a matter of lack of trust in the system and a shortcoming in the system’s workflow support7. Many patients in the community health services are very sick and in need of long-term care. Many patients are totally or partially unable to communicate both verbally and cognitively13. This emphasizes the need for accurate and detailed reporting and care plans with a high degree of detail. Our observations show that nursing personnel use available resources to make notes, such as private notebooks with patient name lists, or they make reminder notes of what to write upon returning to base. This might be done to ensure the most accurate documentation of everything required or completed. Stressed by the thought that they might forget something important until they return to base, being able to create a reminder for oneself may solve part of the problem. A new feature that could increase the usefulness of Gerica is a reminder function. A reminder could be sent from the report written in Gerica to display automatically on the PDA, enabling people to add more information back at base or to simply copy and paste to the right location in the EHR. Reminders are common in calendar or payment systems and can be general or personal14. General reminders can be used to keep the system and the information up-to-date,
4
however, someone is required to decide on silencing them14. The fact that handwritten notes can get lost poses a serious problem due to laws regarding keeping personal information in non-secure files and notes4. In EHRs, personal reminders are necessary because of the need to know that someone has both acknowledged the reminder and taken care of the problem. Generally, many different people will need to respond to the reminder to ensure the problem has been addressed. When adding a reminder to the system it is important to be sure it is not simply adding more information to already overloaded minds7. In health care institutions there are often three or more shifts for each 24 hours. To ensure everyone having responsibility for the patient gets the right message, it is not sufficient for one person to have seen the message. If the next shift misses the information, then the reminder has failed. If there is a change in how medications should be administered, everyone responsible for this task would need to be notified. Different kinds of reminders should be created, some to remind of changes in medications, some to notify of acute illness or new procedures which might require other equipment than before. Others would alert to changes in the level of care, and time spent with the patient. These reminders could be shown as icons to fit the format of the PDA, but should be touchable, bringing you directly to the report in the EHR, and/or set up as interventions in the care plan to increase workflow and security. Although eight participants are a small sample9 much can still be learned from the observations. There are several different local setup possibilities for the Gerica application for municipalities when implementing the software. Our study included only two municipalities; further studies should involve users in different municipalities with different custom setups. Conclusions The study of the software application Gerica revealed some areas of concern. With respect to human computer interaction and Norwegian legal provisions and government regulations relating to home health care services4, this study showed that further development of a reminder function is needed to properly take care of the patients, update the documentation and keep care plans up-to-date on all levels. The observations provided detailed information on how personal reminders would help the nursing personnel stay up-to-date on the care plan for each patient. A greater number of participants would have helped provide a clearer picture of the learnability experienced by the nursing personnel. Acknowledgments Thanks to all the RNs participating in the study and to the vendor, TietoEnator, for suggesting municipalities to contact. References 1. Fletcher LA, Erickson DJ, Toomey TL, Wagenaar AC. Handheld computers: A feasible alternative to paper forms for field data collection. Eval Rev. 2003; 27: 165-178.2. 2. Yu P, de Courten M, Pan E, Galea G, Pryor J. The development and evaluation of a PDA-based method for public health surveillance data collection in developing countries. Int J Med Inf, 2009; 78: 532-542.3. 3. Norwegian Health Personnel Act. 2001 [cited 2010, 1 June]; available from: http://www.lovdata.no. 4. Helse- og omsorgsdepartementet [Norwegian Ministry of Health and Care Services], Samhandlingsreformen: rett behandling – på rett sted – til rett tid [The Coordination Reform]. St.meld.[Report to the Storting] l, vol. nr. 47; 2009, Oslo: Departementenes servicesenter, Informasjonsforvaltning. 149 s.5. 5. International Organization for Standardization, Information and documentation: records management, Part 1, General. 2001, Genève: ISO. VI.6. 6. International Organization for Standardization, Information and documentation: records management, Part 2, Guidelines. 2001, Geneve: ISO. VI.7. 7. Preece J, RogersY. Sharp H. 2007 Interaction design: beyond human computer interaction. printed: R.R.Donnelly/Crawfordsville, USA. 8. Harrison MI, Koppel R, Bar-Lev S. Unintented consequenses of information technologies in healt care - An interactive sosiotechnical analysis. JAm Med Inform Assoc. 2007;14:542 – 549. 9. Creswell, J.W. 2009 Research design, Qualitative, Quantitative and Mixed Methods Approaches, Third edition, Sage publications Inc. 10. Fruhling LSA. The influence of user interface usability on rural consumers’ trust of e-health services. IJEH, 2006; 2: 305-21. 11. Fog J, Kvale S. 1992: Artikler om interview [Articles on interviews] Centre for Qualitative Methodology Development, Department of Psychology, University of Aarhus, Denmark. 12. Graneheim UH, Lundmann B. Qualitative content analysis in nursing research:concepts, prosedures and measures to achive trustworthiness Nurse Education today. 2004;24: 105 – 112. 13. Selbaek G, Kirkevold O, Engedal K. The prevalence of psychiatric symptoms and behavioral disturbances and the use of psychotropic drugs in Norwegian nursing homes. Int J Geriatr Psychiatry, 2007; 22: 843. 14. Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ, 2005;330:765-8.
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Centre for Care Research – Southern Norway, Department of Health and Nursing Science, Faculty of Health and Sport Sciences, University of Agder, Grimstad, Norway; 2 School of Health and Medical Sciences, Örebro University, Örebro, Sweden; 3School of Interdisciplinary Informatics, College of Information Science and Technology, University of Nebraska, Omaha, USA Abstract Although nursing personnel have used personal digital assistants (PDAs) to support home health care services for the past ten years, little is known about their experiences. This study was conducted to examine experiences of nursing personnel using a specialized home health care computer software application called Gerica. In addition, this research analyzed how well this application aligned with the workflow of the nursing personnel in their daily care of patients. The evaluation methods included user observations and learnability testing. Nursing personnel from two different municipalities were observed while performing real tasks in natural settings. This study shows that the nursing personnel were satisfied with the PDA user interface and the Gerica software; however, they identified areas for improvement. For example, the nursing personnel were concerned about trusting the reliability of the PDA in order to eliminate the need for handwritten documentation. Solutions to meet these shortcomings for nursing managers and vendors are discussed. Introduction Personal digital assistants (PDAs) have been proposed as suitable solutions for improving the accuracy, safety and quality of home health care services1, 2. Documentation in the Electronic Health Records (EHRs) is regulated by law and all nursing personnel in the home health care services in Norway are expected to document the planned and performed care of patients3. There are many factors that influence how an EHR is used and the usage often varies between groups of nursing personnel in health care systems, both in different municipalities and in interactions with hospitals and other health care institutions. Based on new reforms, the government expects to realize improved health care service for patients and lower total health care costs4. The software applications used in the EHRs in Norwegian health care settings vary and there are numerous challenges when exchanging information between systems. Gerica (www.tieto.no) is one software solution to meet these challenges and is the software application used on PDAs in the municipalities included in this study. Gerica is designed and developed to ensure all areas of documentation in the home health care services meet the ISO standard for information and documentation5, 6. Training nursing personnel when implementing EHRs often requires a great amount of economic and organizational resources7. One way to reduce the training costs is to improve the learnability of the new software application. For the purposes of this study, learnability is defined as how quickly a novice user can intuitively understand and use a system7. Research has shown that high learnability provides benefits to the organization and reduces costs7. To improve accuracy and safety in EHR documentation it is important to increase awareness of nursing personnel workflow, to identify security issues, and to eliminate handwritten paper notes and lists. These are important goals when using EHRs in the health care services4. Workflow could be defined as the order of tasks performed by various nursing personnel in order to complete a given procedure7. A decision made at other levels of the organization, or by software designers, may not only influence the overall workflow and habits of dealing with certain problems in patient care8, but also the specific actions of individual nursing personnel. Aim The aim of this study was to examine nursing personnel’s experiences with the PDA application software Gerica, which was designed to support documentation of home health care services. The study also evaluated how well the application aligned with the nursing personnel’s workflow in their daily care of patients.
1
Methods This study used an explorative design with mixed methods. Mixed methods were chosen to study nursing personnel using the PDA in order to obtain an in-depth understanding of how the application supported the nursing personnel’s workflow. Qualitative observations and a survey were combined to achieve a richer data collection and analysis9. Setting and participants The vendor supported the study with contact information for municipalities that had used the software application Gerica on PDAs for several years. The managers in the home health care districts in the two municipalities were informed about the aim of the study and were asked to recruit volunteers. Volunteers were given written and oral information about the study7,9 and asked to provide written consent to participate. It was required that the observations be conducted with nursing personnel who had real experience in using the application7. The nursing personnel who volunteered for the study had used the system for at least one year before the study was conducted. Observations were conducted with both registered nurses (RNs) and nursing aides (NAs), referred to collectively as nursing personnel in this study. These participants worked directly with caregiving in home health care services in two different municipalities in southern Norway. The RNs and NAs have similar responsibility regarding documentation, based on their professional qualification. The nursing personnel observed were between 29 and 66 years of age, most of them middle-aged. Seven had more than three years’ experience in computer use and one had more than two years’ experience. Six of the participants had more than three years’ experience in working with the Gerica application. The professional qualifications are as follows: three RNs, one had further education in psychiatry and one in cancer care; five NAs, one had further education in psychiatry. Observation Eight nursing personnel were observed by two researchers while performing real tasks in a real working environment, which is known to be one of the richest contexts for evaluating system learnability7, 9. The researchers used an observation form, developed for this study. The concepts in the observation form had been discussed to optimize the reliability. The nursing personnel were followed around their workplace throughout their entire day, both on home care visits and at the head office. It was extremely important that the researchers did not interfere or interact with the patients. Therefore, observations were carefully concentrated on watching the use of Gerica on the PDA. The home health care services in the municipalities were organized according to a primary nursing model, wherein each nursing personnel has a special responsibility for a group of patients, where these patients are those the nursing personnel visits on a regular basis. The nursing personnel use PDAs to support and organize their daily work, to remind them of important issues and to document the planned health care for the patients. The following activities were specifically observed: - How did they gather information at the start of the shift? - What did the display look like? - How did they communicate actions taken, or changes needed, back to the head office? - What did they document throughout the shifts? - How did they exchange information during shift changes? Field notes were taken during the observation to describe how the nursing personnel managed to retrieve information and pass information on when required. The researchers carefully noted the system’s ease of use and its usefulness in order to evaluate the learnability of the system. Furthermore, the researchers documented whether the nursing personnel made effective use of patient care options that were presented. Participants were asked whether they wanted something to be changed in the Gerica system to improve workflow7, 9. Survey Instrument Learnability was scored with a survey used earlier by Fruhling et al.10. The items were presented with a likert scale ranging from one to seven, where one indicated total disagreement and seven indicated total agreement. On all items, the participants could comment freely on what they liked or disliked about the system, and whether they would like anything to be changed. Analysis The data from the field notes was read thoroughly, clustered and organized into meaningful units for the analysis. During the analysis, the text was moved back and forth between the entire text and the various text segments identified as meaningful units11, 12. Table 1 shows examples of how the data was coded. Findings from the field notes were compiled from the participants’ answers to open-ended questions. These were further condensed into more meaningful units.
2
Table 1. Example of how data has been coded from field notes and open-ended questions in the survey. Meaningful unit
Condensed meaningful unit
Updates should be done at night, not during day-shifts or evenings when the PDAs are used most.
Dislike delay of work
When the device freezes
Cannot work as intended
The device often refers to settings whose purpose we do not understand
Disturbed by uninformative text
Code Poor system administration
Ethical considerations Norwegian Social Science Data Services gave permission to conduct the study: project number 27132. There was no conflict of interest between the authors or the stakeholder. Results Poor system administration was identified as a key problem based on open comments, field notes, and observations of the different kinds of problems which reduced the effectiveness of nursing personnel’s daily work. For example, nursing personnel explained that they were confused by uninformative text whose relevance to their daily work was unclear when using the PDA. Another problem identified was that the system did not match the workflow. According to the primary nursing model, when nursing personnel started a new shift, the first thing they looked for was ‘what’s new’ because they already knew their patients quite well. Some of the nursing personnel left the office immediately after the report and used the PDA to get the information needed to start their work with the patients. Many of the nursing personnel made comments both during the observation and in the open-ended questions about not being able to comment directly on interventions, while still at the patient’s home or directly after meeting with the patient, because they wanted to finish all the work related to the patient and avoid having to make notes about the same issue several times and in different locations in the application. Thus, this caused them to work less efficiently. When nursing personnel’s work caring for the patient is completed, the process is really not finished until everything has been properly documented 4. The system does not allow the nursing personnel to document everything at once, which is something they clearly wish to be improved. In addition, paper lists were used, in order to ensure that data was available even if the system, for some reason, ceased to work or where its use was inappropriate. Another issue identified was the need for a reminder function to be used for example when something is new or requires specific attention. Such a function would make the system easier to use and enable the nursing personnel to work more efficiently, in addition to enhancing the patients’ perception of safety. Being multifunctional, the PDA can be used for different purposes. For nursing personnel that are away from the office (home base), it is their main and only means of communicating with the application system Gerica, the head office, the physician and/or the patient’s relatives if they are not in the same building. If there is a need to look up information in the care plan on the PDA, the PDA cannot be used simultaneously as a phone. Thus, this causes problems when the nursing personnel need to refer to information during a phone conversation. Table 2 summarizes the results of the observations. The results are grouped into three categories: functional, organizational and technical. Comments included satisfaction with the nursing plan zoom function which provided a sense of security by eliminating the need to remember everything by oneself and the opportunity to take control in situations where the care plan had been changed. The results from the survey showed that questions concerning learnability were scored at a high level of satisfaction, with scores from five to seven.
3
Table 2. Results from observations of the nursing personnel using the PDA in a natural setting. FUNCTIONAL
ORGANIZATIONAL
TECHNICAL
Uses paper list with names of the patients in addition to the PDA
Reading procedures before leaving the office to be prepared for meeting with the patient
Different way of logging on and off the new and old PDA
Sends messages to the base about the time it takes to visit the patient Provides good overview when the PDA list is updated when a message is sent to base
Some of the nursing personnel gather information as they work through the patient list on the PDA
PDA skips to sleep mode; Gerica can be down for prolonged periods of time, and the work must be done
Mainly known patients
Challenging whenever updating of the care plan is necessary
An acute or core patient record is kept on paper at the patient’s to be sure to have information when needed
Transferring patients from other lists (because of illness, and absence among the employees)
To be sure it works, we have an additional handwritten list, just in case
Highlighting the Patient field can be done in two ways, by highlighting the field on the PDA or by changing the color (to blue)
End users are able to determine the time intervals based on estimation of the time actually spent
Need greater multi-functionality
The nursing plan can be zoomed, I dislike the fact that I am not able to bring up the medical prescriptions
Based on the primary nursing model, nursing personnel have more information about the patient than documented
Finding what you are looking for can easily get too complex.
Discussion This discussion will concentrate on the main findings from the observations presented above and in Table 2. One of the most important issues identified as a problem was system instability. This problem was identified based mostly on the written comments of the persons who had experience with the Gerica application. They stated that it was not unusual for the system to go down unexpectedly for more than two hours. Furthermore, they explained that the system was a valuable support tool when in use and a major frustration when it was not available due to technical network connectivity or system problems. Another shortcoming identified was the inability of the PDA to be used both as a phone and as a documentation tool. The need exists for a multifunctional PDA that can show picture-in-picture (P in P) while making a phone call. The expected result of this desired feature is the possible elimination of paper documentation, which is a security goal according to the Patients’ Rights Act in Norway4. PDA screen size varies and P in P requires a certain size to be readable. Some of the nursing personnel chose to use their own private mobile phone to make calls while using the PDA as, for example, an encyclopedia to gather whatever information the physician or the emergency team would need. The third concern about the system was not being able to comment immediately on interventions and thus, having to make notes on paper. When both using a PDA and making notes on paper, the nursing personnel add functionality to the system that is not already inherent in order to support their workflow. This can be both a matter of lack of trust in the system and a shortcoming in the system’s workflow support7. Many patients in the community health services are very sick and in need of long-term care. Many patients are totally or partially unable to communicate both verbally and cognitively13. This emphasizes the need for accurate and detailed reporting and care plans with a high degree of detail. Our observations show that nursing personnel use available resources to make notes, such as private notebooks with patient name lists, or they make reminder notes of what to write upon returning to base. This might be done to ensure the most accurate documentation of everything required or completed. Stressed by the thought that they might forget something important until they return to base, being able to create a reminder for oneself may solve part of the problem. A new feature that could increase the usefulness of Gerica is a reminder function. A reminder could be sent from the report written in Gerica to display automatically on the PDA, enabling people to add more information back at base or to simply copy and paste to the right location in the EHR. Reminders are common in calendar or payment systems and can be general or personal14. General reminders can be used to keep the system and the information up-to-date,
4
however, someone is required to decide on silencing them14. The fact that handwritten notes can get lost poses a serious problem due to laws regarding keeping personal information in non-secure files and notes4. In EHRs, personal reminders are necessary because of the need to know that someone has both acknowledged the reminder and taken care of the problem. Generally, many different people will need to respond to the reminder to ensure the problem has been addressed. When adding a reminder to the system it is important to be sure it is not simply adding more information to already overloaded minds7. In health care institutions there are often three or more shifts for each 24 hours. To ensure everyone having responsibility for the patient gets the right message, it is not sufficient for one person to have seen the message. If the next shift misses the information, then the reminder has failed. If there is a change in how medications should be administered, everyone responsible for this task would need to be notified. Different kinds of reminders should be created, some to remind of changes in medications, some to notify of acute illness or new procedures which might require other equipment than before. Others would alert to changes in the level of care, and time spent with the patient. These reminders could be shown as icons to fit the format of the PDA, but should be touchable, bringing you directly to the report in the EHR, and/or set up as interventions in the care plan to increase workflow and security. Although eight participants are a small sample9 much can still be learned from the observations. There are several different local setup possibilities for the Gerica application for municipalities when implementing the software. Our study included only two municipalities; further studies should involve users in different municipalities with different custom setups. Conclusions The study of the software application Gerica revealed some areas of concern. With respect to human computer interaction and Norwegian legal provisions and government regulations relating to home health care services4, this study showed that further development of a reminder function is needed to properly take care of the patients, update the documentation and keep care plans up-to-date on all levels. The observations provided detailed information on how personal reminders would help the nursing personnel stay up-to-date on the care plan for each patient. A greater number of participants would have helped provide a clearer picture of the learnability experienced by the nursing personnel. Acknowledgments Thanks to all the RNs participating in the study and to the vendor, TietoEnator, for suggesting municipalities to contact. References 1. Fletcher LA, Erickson DJ, Toomey TL, Wagenaar AC. Handheld computers: A feasible alternative to paper forms for field data collection. Eval Rev. 2003; 27: 165-178.2. 2. Yu P, de Courten M, Pan E, Galea G, Pryor J. The development and evaluation of a PDA-based method for public health surveillance data collection in developing countries. Int J Med Inf, 2009; 78: 532-542.3. 3. Norwegian Health Personnel Act. 2001 [cited 2010, 1 June]; available from: http://www.lovdata.no. 4. Helse- og omsorgsdepartementet [Norwegian Ministry of Health and Care Services], Samhandlingsreformen: rett behandling – på rett sted – til rett tid [The Coordination Reform]. St.meld.[Report to the Storting] l, vol. nr. 47; 2009, Oslo: Departementenes servicesenter, Informasjonsforvaltning. 149 s.5. 5. International Organization for Standardization, Information and documentation: records management, Part 1, General. 2001, Genève: ISO. VI.6. 6. International Organization for Standardization, Information and documentation: records management, Part 2, Guidelines. 2001, Geneve: ISO. VI.7. 7. Preece J, RogersY. Sharp H. 2007 Interaction design: beyond human computer interaction. printed: R.R.Donnelly/Crawfordsville, USA. 8. Harrison MI, Koppel R, Bar-Lev S. Unintented consequenses of information technologies in healt care - An interactive sosiotechnical analysis. JAm Med Inform Assoc. 2007;14:542 – 549. 9. Creswell, J.W. 2009 Research design, Qualitative, Quantitative and Mixed Methods Approaches, Third edition, Sage publications Inc. 10. Fruhling LSA. The influence of user interface usability on rural consumers’ trust of e-health services. IJEH, 2006; 2: 305-21. 11. Fog J, Kvale S. 1992: Artikler om interview [Articles on interviews] Centre for Qualitative Methodology Development, Department of Psychology, University of Aarhus, Denmark. 12. Graneheim UH, Lundmann B. Qualitative content analysis in nursing research:concepts, prosedures and measures to achive trustworthiness Nurse Education today. 2004;24: 105 – 112. 13. Selbaek G, Kirkevold O, Engedal K. The prevalence of psychiatric symptoms and behavioral disturbances and the use of psychotropic drugs in Norwegian nursing homes. Int J Geriatr Psychiatry, 2007; 22: 843. 14. Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ, 2005;330:765-8.
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