Healthcare Focus: Let End Users Help Design Business Systems

With the UK NHS under pressure to justify expenditure and the national economy stretched tight, there is no more room for error or delay in its National Programme for IT (NPfIT). An electronic medical record (EMR) system for the NHS Ñ or for any healthcare system - requires the flexibility to gather and visualize data, while supporting tasks within many different medical settings and physician specialties. Moreover, systems must accommodate the hectic pace of real clinical settings and the diverse ways medical staff work with patients, record data, delegate tasks and review results. Other sectors of the business community have been receptive to the new ways technology can transform data into usable information. However, the healthcare industry remains fixated on traditional ways of displaying data.

By bringing qualified designers to the development process, effective EMR systems can be developed. The design process provides business with an opportunity to explore alternatives, and invent and refine concepts in order to first figure out exactly what they need, and then define a form that meets that need most effectively. 

For example, for decades a pen-and-pencil, paper-based record tracked the patient's treatment and served as the main conduit of communication among a team of caregivers during the patient's hospital stay. Within the patient record, is the nursing flow sheet, where nurses record their observations and measurements of the patient's state and record interventions and assessments, organized according to time and date. No one else providing care to the patient writes on this page.

Computerizations of the nursing flow sheet usually have a nurse leading the product design process by translating the paper-based world to on-screen requirements for data display and system functionality - a computerization of the current world. Whenever there is a question as to the correctness of modelling the new world according to such a strict translation of the old, nerves become raw and concerns of user adoption and acceptance drown out any challenges to this approach: "Nurses understand the flow sheet, so that's what we need to deliver."

Dr F. Philip Robin is a practicing lawyer who also is a physician with a long and successful record of winning medical-malpractice suits. According to Dr Robin, the very design of the patient chart is at the root of his successful record of litigation. He could point to almost any patient chart and identify where communication broke down and how the patient's treatment had run amuck. He pointed to the flow sheet as a primary culprit. 

Dr Robin describes the structure of the patient chart as a collection of separate and distinct narratives. What we understand about the patient's care will depend upon what narrative we choose to follow and when. Physicians create and monitor a narrative that is separate from those of the nurses, the radiologists, and the laboratory technicians. One hospital administrator who is also a physician explained his concern that nursing notes are never actually read by others during the patient's treatment. Clearly, designing another computerized flow sheet will hardly improve this situation.

Experts have been telling the technology industry for years that better outcomes will result when end users participate in the design of business systems. For the most part, this has happened through standard techniques such as surveys, questionnaires, focus groups and working sessions that ask users to describe what they do and how they believe things should work. Unfortunately, these inputs are too often taken as gospel and used to define a set of design criteria that are not the best guidelines for constructing a system. These audiences are just too close to existing tools and methods and do not have the skills to design a software system, even when that system's sole purpose is to support their work.

If people can't tell you what they need, how can you find out? They can show you. When done well, the design process provides the opportunity for innovation that can invigorate a business. The results can bring satisfaction to all concerned.