By Kara Allen (@ergopropterdoc), Nova Barrios, Rebecca Szabo (@inquisitiveGyn) and Eve Purdy (@purdy_eve)
The alarm sounds in birth suite room 5. The maternity team rushes in to find a midwife caring for a woman with a post-partum haemorrhage (PPH). The team of midwives and doctors rapidly assess the woman and quickly decide that she needs to go to theatre for definitive management. Within two minutes they are in the emergency theatre. The woman needs blood, so the anaesthesiologist leaves the patient’s bedside and goes to the computer. She calls blood bank and starts trying to put in an order on the hospital’s new electronic health record (EHR). The anaesthesiologist can’t remember the precise sequence of steps….. The blood bank can’t issue the order until it’s completed. The anaesthesiologist keeps glancing at the patient and monitor while trying to input orders. “She’ll need a larger cannula,” she thinks while getting yet another error message before finally placing the order. When the blood finally arrives, two nurses must scan the bag and input the details into the computer before it can be hung and transfused for the patient. At the same time, the obstetrician can’t open the patient’s file until it is closed in birth suite. These delays are frustrating for all involved, can impact thinking and teamwork as well as leading to potential life-threatening delays for the woman needing urgent care.
The potential benefits of EHRs are inaccessible if poor usability makes work more challenging for clinicians and others involved in clinical care – like blood bank scientists and clerks as seen in the vignette above. Often “work as imagined” by EHR creators does not translate into “work as done” by teams caring for patients. This mismatch can be frustrating for teams and potentially dangerous for patients. Translational simulation focuses directly on improving patient care and healthcare systems through safety and performances issues and delivering simulation-based interventions to improve teamwork and systems. As such, translational simulation experts are well positioned to test and optimise usability of EHRs for patient safety, high-quality care, and health systems.
The integration of electronic health records (EHRs) into health organizations is both a challenge and an opportunity for those in translational simulation. We caution translational simulation teams against getting involved in the delivery of “EHR training”, “roll out education” or “competency assessment”. We do feel there are two domains where translational simulation can assist teams who are trying to integrate EHRs into their workflows – 1) contributing to EHR system design and 2) understanding and optimizing how the EHR impacts team function.
Translational Simulation for EHR Development
EHRs should work for teams. Teams shouldn’t work for EHRs.
The ideal time for translational simulation involvement is at the design phase of EHR development. Just as translational simulation is valuable in designing physical infrastructure, it also has a role to play in the design of IT infrastructure.
Unfortunately, to date, user-centred design has not always been a core tenet of EHR development. Healthcare teams and patients are now sometimes paying deeply for this oversight. Coronial findings have highlighted morbidity and mortality associated with poor usability and minimal end-user involvement in development. A systematic review from 2019 outlines some of the ways simulation might be involved at the design phase and highlights the need for increased awareness of the unintended impacts on sociotechnical and cultural interfaces. Hopefully as the industry evolves it will move towards routinely including end-users in EHR design from the development phase.
Translational simulation experts are well placed to help when that time comes. For example:
- this group used simulation to optimize their EHR interface for the reception of trauma patients (only after a disastrous initial implementation phase in the actual clinical care environment)
- this team who used simulation to intelligently design an EHR interface to reduce task load in critical care.
Translational simulation services could provide the perfect testing approach, in situ with real healthcare teams. This should become the industry standard for companies involved in the design and distribution of EHRs. Experts with complementary skill sets such as human factors, design thinking, and systems engineering would be invaluable in this process – providing further impetus for the translational simulation community to foster these skillsets in our ranks.
Translational Simulation for Team Integration – When EHRs don’t work for teams
The current landscape of EHR implementation globally is problematic. Instead of improving collaboration, unintended consequences show that EHR implementation may actually erode trust between teams and there have been no measurable improvements in 13/14 of the most important patient safety outcomes.
For teams looking after critically ill patients, the many issues related to implementation are particularly obvious. The implications of changing workflows to include EHRs in time dependent, complex scenarios is often underappreciated at the outset of implementation. The scenario above highlights some of the challenges faced in time-pressured and critical circumstances.
Simulation can be a tool to better explore the sociotechnical issues associated with EHR implementation. For example:
- One intensive care group used simulation to understand how the EHR interface impacted the care of patients with septic shock and worked with teams and informatics to overcome those challenges.
- This intensive care team used simulation to explore how the EHR impacted teamwork during rounds
- Our team, the Gandel Simulation Service, based in Melbourne Australia, has been exploring the impact of EHR during maternity emergencies using translational simulation testing. Although we were part of the large change management process at our organisation there have been ongoing issues with the EHR. This is unsurprising given the complexity of healthcare and known challenges of EHR integration. Through ongoing collaboration of the EHR team, simulation service, and leadership group we have used translational simulation for diagnostic and interventional purposes. We have found the EHR appears to add to both individual and team cognitive load and are taking steps to mitigate this impact on teams.
The EHR functions as a team member -a member with important information and the ability to perform critical tasks. For translational simulation to meaningfully explore how EHRs impact team function, teams must be faced with authentic tasks and ideally be able to work in the actual EHR environment – with all its functionality and limitations. Simulation and EHR teams should work together to develop risk mitigation strategies and processes to allow safe use of actual (not training) EHR environments when needed for translation simulation – just as the use of real clinical space is negotiated by translational simulation teams for necessary activities. Depending on situations being simulated, digital training environments may not offer high enough task fidelity for the teams to test and optimize integration.
EHR impact varies from team to team, and scenario to scenario. Its role in clinical care is likely to require constant negotiation, re-evaluation, and iterative improvement – as many roles in teams do. For EHR team integration to go well (or at least as well as it can) teams need to be vigilant about how it impacts teamwork and with what trade-offs and work arounds are acceptable. Translational simulation facilitators are well positioned to have such conversations.
So, back to the opening scenario. It was an in-situ simulation in the birth suite and operating theatre including maternity and perioperative services as well as involvement of the blood bank and EHR implementation group. The explicit goal of this simulation was to understand how the EHR impacts teamwork.
The debrief begins, led by the simulation team. Murmurings immediately start about the frustrations and delays caused by the “stupid computer”. After validating these reasonable emotions and committing to log the real risks identified, the simulation facilitator steers the conversation (given the rigid limitations of the current system) towards things that are within the team’s control.
They discuss a lopsided delegation of tasks to the anaesthesiologist who not only had to perform urgent hands-on patient tasks (cannulation, preparation for intubation) but who was also cognitively overloaded with the complicated task of ordering blood in the EHR. The team explored how, in their current structure and resources, they might have managed that imbalance more effectively – how the EHR changed the nature of their teamwork. They also explored what might have prevented the anaesthesiologist asking for more help. The team’s potential solutions include cognitive aids and team leadership as well as other solutions directly related to the EHR and back up paper solutions in dire emergencies. Though not a panacea, the team feels more prepared to mindfully incorporate the taskwork associated with the EHR when they next find themselves looking after a critically ill patient.
Ultimately, translational simulation should be incorporated along the spectrum of EHR ideation, design, implementation, team-integration and iterative evaluation and improvement.
What are your experiences with simulation for these purposes? What other possibilities do you see?
Picture Source: Flickr
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