Improving care for older Americans requires personalization, patient activation, aligning care provided to an individual's values and goals, and integrated team care (Reuben, 2007). Clinical dashboards may provide a means of reaching these goals for high quality and safe geriatric care. Clinical dashboards are defined as dynamic displays of timely and relevant information intended to inform decision making and safe and effective patient care (Dowding et al., 2015). Secondary use of real-time electronic health record (EHR) data can potentially improve the effectiveness of clinical dashboard displays. Recommendations by the National Research Council for the implementation of significant dashboard technologies include aggregating patient data into decision-centric displays, display of data that drives action, and a display that supports cognitive function (Stead & Lin, 2009).
To date, a limited number of studies have been completed that document the impact of clinical dashboards on patient care processes and outcomes. None of these studies focus on geriatric care. Dowding et al. (2015) conducted a review of quality and clinical dashboards and found that from 1996–2012 only 11 articles met their inclusion criteria (i.e., evaluation done within a health care organization and data reported). They found wide variability in the effectiveness of clinical dashboards. The few well-done studies published through 2012 suggest that actionable information displays at the point of decision making, such as screensavers, appear to be more effective than those that rely on clinicians to actively access dashboard content (Dowding et al., 2015). Dowding et al. (2015) concluded that more research is needed to identify optimal display methods and test the impact of clinical dashboards on decision making, workflow, and patient outcomes.
Using Dowding et al.'s (2015) inclusion and search criteria, the current authors found an increasing number of studies published since 2012 that demonstrate the benefits of secondary use of real-time EHR data to drive clinical dashboard displays; none of these studies, however, focus on the impact of clinical or quality dashboards in geriatric care. Tan, Hii, Chan, Sardual, and Mah (2013) displayed screensaver alerts on a clinical dashboard to notify nurses of stat orders, abnormal test results, and other pertinent issues in the context of their workflow. Two recently reported clinical dashboard projects used EHR and patient reported data to track patient and population level outcomes over time, including medication adherence (Dixon, Alzeer, Phillips, & Marrero, 2016) and quality of life (Azad et al., 2016). Other recently reported clinical dashboard projects used EHR data to improve provider prescribing practices (Anderson, Zlateva, Khatri, & Ciaburri, 2015; Redwood, Ngwenya, Hodson, Ferner, & Coleman, 2013) and close information gaps for physicians caring for patients in the emergency department (Swartz, Cimino, Fred, Green, & Vawdrey, 2014). The clinical dashboard projects published since 2012 consistently use EHR data to drive the information displayed and appear to improve workflow efficiency and facilitate delivery of quality care. They are, however, focused on providing quality metrics and scorecard data to care team members and do not deliver actionable data at the point of care (Cline, 2016; Fox, Walsh, & Schainnker, 2016; Stadler, Donlon, Siewert, Franken, & Lewis, 2016).
There is a dearth of clinical dashboard research on the use of clinical dashboards in hospital settings by patients, informal care partners, and paraprofessional members of the care team. Although gaps in information exist at the bedside for all team members (Caligtan, Carroll, Hurley, Gersh-Zaremski, & Dykes, 2012; Carroll, Dykes, & Hurley, 2010; Dykes et al., 2010), the current authors were unable to find published research evaluating clinical dashboards that target a range of hospital staff including non-professional members of the acute care hospital team. Based on qualitative research with patients, informal caregivers, and professional and paraprofessional providers (Caligtan et al., 2012; Ohashi et al., 2012), a personalized patient safety screensaver—a type of dashboard that provides actionable and tailored information at the point of care to align all care team members around the personalized safety plan—was created.
Previous research conducted by the current authors' team suggests that there is a core set of information needed by all care team members to engage in safe, effective, and efficient care (Caligtan et al., 2012; Dykes, Carroll, Hurley, Benoit, & Middleton, 2009; Ohashi et al., 2012). The majority of these requirements are particularly relevant to caring for geriatric patients. For example, it was found that when information related to the patient's fall prevention plan was available at the bedside and used by professional, paraprofessional, and patient members of the care team, patient falls decreased significantly and this approach was particularly effective with older patients (Dykes et al., 2010). Subsequently, the team has conducted a series of projects to explore the core set of information needed by all care team members to engage in safe, efficient, and evidence-based care (Caligtan et al., 2012; Dalal et al., 2016; Dykes et al., 2013; Ohashi et al., 2012). Through group and individual interviews with nurses and patients, it was found that an actionable safety plan screensaver must include information targeting the following themes: plan of care, patient education, communication of safety alerts, diet, and medications (Caligtan et al., 2012). In response, the authors developed an electronic Patient Risk Communication Board (ePRCB) that displayed a validated set of patient safety risk and intervention icons at the bedside (Ohashi et al., 2012). This preliminary prototype demonstrated promise in improving communication and the quality of patient care, but introduced workflow challenges when the EHR data needed to drive a customized display were unavailable and therefore required manual intervention. Over the past few years, the authors' health care system has adopted a comprehensive EHR. Through working with the EHR innovations team, numerous EHR data sources have been identified that can be reused to create a dynamic and personalized patient safety plan. For example, risk assessment data are routinely documented in the EHR by multidisciplinary team members and include fall and pressure ulcer risk assessments, ventilator bundles, and line infection prevention checklists (Dykes et al., 2013; Ohashi et al., 2012). Once documented, these data are typically stored in disparate sections of the EHR and not readily available to inform decision making at the point of care. Where there are configured data displays within the EHR system, paraprofessional and patient members of the team do not routinely have access (Dykes et al., 2009). Workarounds intended to provide key information at the bedside are common and include handwritten signs to alert team members of safety issues such as arm restrictions, nothing by mouth (NPO) status, and risk for aspiration. However, the manual nature of the workflow limits effectiveness. Compliance with updating signage is inconsistent; therefore, up-to-date safety plans are often unavailable. The screensaver aims to use technology to eliminate ineffective work processes through automation.
As part of an Agency for Healthcare Research and Quality (AHRQ)–funded Patient Safety Learning Lab Project, the authors' team used an iterative, participatory design approach (Dalal et al., 2009; Dykes et al., 2013; Dykes et al., 2014; Zuyev, Benoit, Chang, & Dykes, 2011) to further develop the ePRCB into a personalized safety plan screensaver (Figure). The goal was to provide tailored patient safety information at the bedside to engage all team members, including patients and their informal caregivers, in ensuring consistently safe, efficient, and evidence-based care. As noted by others, there are frequently unintended consequences associated with the introduction of health information technology into busy, acute care workflows (Bloomrosen et al., 2011). The Brigham and Women's Hospital (BWH) Patient Safety Learning Lab investigators are incorporating stakeholder perceptions of the potential impact of the screensaver on workflow, communication, and decision making into the design process to avoid unintended consequences after implementation. The personalized patient safety plan screensaver is fully integrated with the EHR and therefore automatically displays fall prevention, safety reminders, and patient needs icons at the bedside to provide education and clinical decision support at the point of care.
Electronic health record (EHR) personalized patient safety plan screensaver uses clinical documentation data from the Brigham and Women's Hospital (BWH) vendor-based EHR system and displays it as actionable icons on the patient's bedside personalized safety plan.
Reprinted with permission from BWH Center for Patient Safety, Research and Practice. Copyright © 2016 BWH Center for Patient Safety, Research and Practice.
To date, the personalized safety plan screensaver has been piloted on two oncology units (Phase 1) and is now live on three neurology units (Phase 2). The current article describes the Phase 1 evaluation to identify enhancements for the Phase 2 implementation, the Phase 2 evaluation, and the next steps for improvement in the iterative design process.
The purpose of this project was to identify end user perceptions of the Personalized Safety Plan Screensaver dashboard, identify strategies to overcome barriers to use, and iteratively improve the design and content. The specific aims of this study are to:
Describe nursing staff, patient, and informal caregiver perceptions of the personalized safety plan screensaver, including potential benefits, unintended consequences on decision making and workflow, and suggestions for improvement.
Identify barriers to use and strategies to overcome these barriers in future iterations of the personalized patient safety screensaver.
The study took place at BWH in Boston, Massachusetts, and was reviewed and approved by the Partners HealthCare Human Research Committee. Based on prior research, the authors developed and deployed the first iteration of the safety plan screensaver (Caligtan et al., 2012; Dykes et al., 2013; Dykes et al., 2010; Ohashi et al., 2012). An interview guide was developed after a review of the clinical dashboard literature. Interviews were conducted in two phases: on acute care oncology units (Phase 1) and acute neurology units (Phase 2). Nursing staff (i.e., nurses and nursing assistants), patients, and informal caregivers were interviewed to understand their distinct and shared perceptions of the personalized patient safety plan screensaver displayed at each bedside. All participants were 18 or older. Nurse and nurse assistant participants were regular members of the care team. All patients who were English-speaking, alert, oriented, and identified by their nurse as feeling well enough to participate were approached for the interviews. Informal caregivers were invited to participate at the discretion of the patient. All participants provided informed verbal consent. The semi-structured interview guide elicited perceptions of the degree to which the personalized patient safety plan is understood, the degree to which end users believe that the information is actionable and has or could influence behavior, the potential benefits, unintended consequences on decision making and workflow, and suggestions for enhancement. The interview guide questions are shown in the Table. Detailed field notes were taken during each interview. Investigators individually coded the interviews for themes and met regularly for debriefings to review field notes and identify themes through consensus. Data collection and analysis continued until theme saturation was achieved. In both phases, common themes across end users were translated into software requirements and prioritized for integration into the production versions of the personalized patient safety plan screensaver. Once identified, the barriers to use were mapped to a common framework (Cabana et al., 1999) and used to identify strategies to overcome each of the barriers.
Interview Guides for Patients and Informal Caregivers and Nurses and Nurse Assistants
In Phase 1, a total of 21 end users participated in interviews including nursing staff (eight nurses and two patient care assistants), six patients, and five informal caregivers. The nurses were mostly female (87.5%), ages 25 to 34 (50%), and White (87.5%). The nurse assistants were both female, one was 35 to 44 years of age and Hispanic, and the other was older than 65 and Black. Patients were mostly female (83.3%), one half were older than 65, one half did not have a college degree, and all were White, English-speaking, and most (83.3%) had an informal caregiver who participated in the interview (demographic data were not collected from informal caregivers in Phase 1). The interviews lasted approximately 15 minutes. Themes identified are included in Table A (available in the online version of this article). Barriers to use of the screensaver and strategies to overcome them and improve the design were developed after the interviews for the Phase 2 iteration of the screensaver and are included in Table B (available in the online version of this article).
Themes from Phase 1 and Phase 2 Interviews with End Users Related to the Personalized Patient Safety Care Plan Screensaver
Phase 1 and Phase 2 Barriers and Strategies to Overcome Use of the Personalized Patient Safety Plan Screensaver
Themes elicited by end users regarding the patient safety plan screensaver include appreciation of the clinical decision support provided, recognition of workflow efficiency, enthusiasm for the safety-centric content, recommendations for content and aesthetic improvements, questions about the audience scope, education suggestions, and the overall value of personalization.
In Phase 2, a total of 22 end users participated in interviews including nursing staff (eight nurses and six patient care assistants), six patients, and two informal caregivers. Nurses were all female, most were ages 25 to 36 (60%), and White (75%). Nurse assistants were all female, older than 35 (83%), and the majority were Black (67%). One half of the patients were female, most were older than 65 (63%), had a master's degree (67%), were White, and English-speaking. One informal caregiver was male and one was female, one was older than 65, both had master's degrees, and were White and English-speaking. Many of the Phase 2 interview themes paralleled the Phase 1 themes (Table A and Table B).
As patients 65 and older comprise <13% of the population but represent the majority (40%) of hospital stays (Mattison, 2016), the patient safety plan screensaver can disproportionately improve the safety and quality of geriatric care. Infections, falls, cognitive impairments, incontinence, sensory impairments, tethering devices (e.g., intravenous lines, catheters), and delirium are among the in-hospital geriatric syndromes that increase risk of adverse events (Cigolle, Langa, Kabeto, Tian, & Blaum, 2007). Awareness of the risks for these syndromes and a personalized approach to caring for older patients can decrease the risk of adverse events. The Personalized Safety Plan screensaver is tailored to address the common risk factors present in the older adult patient population, with icons specific to fall prevention, ulcer prevention, infection control, vision and hearing impairments, mobility status, and toileting.
The Meaningful Use Program (Centers for Medicare & Medicaid Services [CMS], 2017) requires that providers engage patients in their health care through technology. A key goal of meaningful use is to activate patients and make them full partners in their care by providing tools that increase access to health information and help consumers achieve ownership of their health care and wellness (CMS, 2017). This program is directed at all patients; therefore, efforts must be made to engage geriatric patients with health information technology tools and tailor information to the characteristics of this patient population. Simultaneously, there is a growing body of research on the use of clinical dashboards to improve quality and safety, but the need for research on a dashboard that provides real time, actionable data to patients, informal caregivers, and clinical team members at the point of care was identified. Both the icon content and intent of the personalized safety plan screensaver combine to align these two realities; it is a dashboard technology that broadens the scope of audience but includes content that is relevant to geriatric patients' care. The content of the screensaver is aimed at improving health outcomes and decreasing adverse events within the hospital. The screensaver is tailored to communicate risk factors that are common in older patients, and prevent decompensation by including mobility, assist, venous thromboembolism prevention, and ulcer prevention icons. The intent of the screensaver is to inform and engage all members of the care team with the personalized safety plan in real time.
There is limited research on patient, informal caregiver, and clinical team member perceptions of the usefulness, usability, and value of clinical dashboards in improving care for geriatric patients. To remedy these three issues, the current authors' team iteratively developed the personalized safety plan screensaver. End user requirements related to content, user interface, and display logic (Caligtan et al., 2012; Ohashi et al., 2012) were gathered. Bedside interviews with end users (i.e., nursing staff, patients, and informal caregivers) were conducted in two phases to learn their perceptions of the personalized safety plan screensaver and recommendations for enhancements. Overall, interviews were useful for identifying issues and concerns with stakeholders as part of the iterative development process. Despite enthusiasm for the screensaver, end users identified technical and workflow challenges (barriers to adoption and spread) that need to be addressed before wide scale implementation. These obstacles are similar to those identified by Cabana et al. (1999) as common in the adoption of new health care processes and practices: lack of awareness, familiarity, agreement, self-efficacy, and outcome expectancy, as well as inertia of previous practice and external barriers.
Although the screensavers were present on the monitor at each patient's bedside, a few patients, informal caregivers, nurses, and nurse assistants exhibited a lack of awareness of the personalized safety plan screensavers. The requirement that has emerged to remedy this is to train nurses and nurse assistants on the purpose and content of the screensaver, as well as to educate patients and families that it is also aimed to inform them of the safety plan. Nurses and nurse assistants described a lack of familiarity with the screensaver; it became clear through the interviews that providing clinical care team members with the logic and data sources that inform the icons would improve the familiarity with the screensaver and foster trust in its content. Most patients and informal caregivers who were 65 and older also relayed a lack of familiarity with the screensaver; they often recommended that staff explain the purpose of the personalized safety plan screensaver to overcome this barrier. Some nurses exhibited a lack of agreement with the content on the screensavers and wanted to remove generic icons, such as “wash hands”; the strategy to overcome this disagreement was to teach nurses that these icons provide information to patients and families, not just to members of the care team, and that patients were reassured to see a focus on infection control and hygiene. Nurse end users described a lack of self-efficacy because they already are so busy they predict they will not have time to stop and fully assess the screensaver before logging in to the computer. To overcome this perception, the authors will work to further minimize the cognitive load on the screensaver by prioritizing icon content.
Nurses in Phase 2 had more time to acclimate to the screensaver and voiced this concern less frequently. Phase 1 responses from nurses and nurse assistants included the theme of a lack of outcome expectancy; this was remedied in Phase 2 by collaborating with clinical staff to improve the icon content to make it as actionable and useful as possible. Overcoming the inertia of previous practice, a theme illustrated in the interviews when nursing staff described not using the screensaver because it was new to the workflow, will be overcome with time and training. Finally, external barriers were identified: the computer monitors are generally angled away from patients and understood by them to be only for the clinicians. Patients 65 and older most commonly understood the computer to be “none of their business,” and therefore assumed because they were not explicitly “invited to look at it” that the personalized information on the screensaver was not meant for them. These barriers will be overcome by training nursing staff to educate patients and families on the purpose and intended audience of the screensaver, as well as to turn the monitor toward the bed.
The themes elicited in these interviews were generally shared across end users; the differences, however, are most noticeable in their connection to each group of end user's role as a member of the care team. Overall, all end users recognized the value in communicating the personalized safety plan. Patients and informal caregivers placed complete faith in the information on the screensavers, not questioning whether the logic or documentation was accurate. Nurses, however, expressed doubt about the accuracy of some of the icons; generally, these concerns were assuaged by explaining the source of the data (which at times highlighted issues related to inaccurate or incomplete documentation). For example, nurses and patients both wanted to see an icon for whether a patient had an arm restriction for blood draws. This icon and the logic had already been developed, which would eliminate the inefficient practice of hanging signs to communicate this information. The authors' team trained the nursing staff on where to document this information in the EHR, thereby improving documentation and automating the safety plan display. Nurse assistants did not express any issues with the trustworthiness of the screensaver. Nurse assistants specifically liked seeing the patient's name, their diet icon, and their ambulatory aid icon. One nurse assistant detailed an instance in which a patient noticed the “wear compression boots as directed” icon, a venous thromboembolism prevention icon. The compression boots had not yet been delivered and the nurse assistant then made sure they were delivered and worn. This interaction highlights how patients can become more engaged in and aware of their care, which will then spur action by care team members. Nursing staff also provided feedback that the screensaver enhances their awareness of pertinent safety information. Nurse assistants' feedback centered on how helpful it is to have this information when assisting an unfamiliar patient, eliminating the time-consuming workflow of having to track down the nurse if they have not yet received report. Nurse assistants, like nurses, most frequently discussed workflow efficiency and the ways the screensaver provides clinical decision support, but their assessment of its use was much more task-oriented. This finding is unsurprising given their responsibilities as a part of the care team. Nurses discussed the screensaver's role as a communication tool and its broader implications for improving safety and quality metrics, which is also unsurprising given the significance of nursing quality metrics for each unit.
Nurses, nursing assistants, patients, and informal caregivers all found the user interface patient-friendly and the safety plan easy to interpret. All end users liked the use of icons and the icons themselves; however, across end users there were recommendations for improving the aesthetics of the screensaver to make it more eye-catching. Several geriatric patients recommended enlarging the size of the icons. All end users were enthusiastic that the information was personalized. Geriatric patients were particularly appreciative that the content centered on safety. Clinical and nonclinical end users believed that all icons should be actionable, but there were mixed views regarding elimination of generic icons (e.g., wash hands). Many clinical users found these reminders redundant, but some patients were relieved to see an emphasis on infection control and hygiene. In Phase 1, nursing staff expressed concerns related to patient privacy and HIPAA requirements (Freedman, Cantor, Merriman, & Edgerton, 2016), but these concerns were assuaged with increased familiarity with the scope of the screensaver content in Phase 2. Nurses also warned about causing undue worry and cognitive overload for all end users if too many icons were displayed. All stakeholders acknowledged environmental constraints, such as the orientation of the computer monitors, as barriers to patient and informal caregiver use of the screensaver. It became clear that team members needed to be trained to educate patients about their safety plan and encourage them to review their personalized safety plan screensaver on the bedside devices.
The novelty of a personalized safety plan screensaver as a clinical dashboard is that it provides actionable information for all care team members at the point of care. This technology drives action, provides clinical decision support, and improves workflow efficiency. The most common example of the screensaver providing clinical decision support cited by nurses was in situations when they were providing care for unfamiliar patients. Several nurses relayed how helpful it is to be able to quickly assess the fall prevention icons to learn how an unfamiliar patient toilets or ambulates, or the safety icons to see if an unfamiliar patient is on a restricted diet. Nurses and nurse assistants also provided feedback that the screensaver enhances their awareness of pertinent safety information. One nurse assistant said, “The information on the screensaver makes me more cautious,” in reference to responding to patient call bells; this type of feedback demonstrates how over time the personalized patient safety screensavers can improve outcomes and provide clinical decision support.
Although a personalized safety plan screensaver may not be appropriate for all patients and cognitive limitations need to be considered, the authors have found that in their setting, the concept is positively received by nursing staff, patients, and informal caregivers. Further research is needed to inform the development and design of personalized safety plan screensavers to meet the specific requirements of diverse patient populations. There are several limitations to the current study. It was conducted in a single hospital on oncology units and neurology units with a limited number of participants and may not be generalizable beyond those settings. However, the core requirements that were used to build the system were identified over many years in several hospitals with feedback from diverse clinician and patient populations (Caligtan et al., 2012; Carroll et al., 2010; Dykes et al., 2013; Dykes et al., 2009). The system is designed using standards and interoperates with a common EHR vendor system to facilitate broader adoption and use of the screensaver technology.
Personalization, alignment of care with a patient's goals and values, patient activation, and the successful implementation of a team model of care are all key factors in providing high-quality care to older adults. Accurate, accessible information is also required for professional, paraprofessional, patient, and informal caregiver team members to ensure collaboration on and personalization of safe patient-centered care. Meaningful use has led to widespread adoption of EHRs in hospital settings. However, work is needed to optimize display of data documented in these systems to decrease data fragmentation and improve workflow, decision making, and patient activation. The authors' team developed a personalized safety plan screensaver to display the core set of information needed by the care team, including patients and informal caregivers, to engage in safe, efficient, and effective care at the bedside. All end users, including geriatric patients, recognized the value provided by the personalized patient safety screensaver in safely and efficiently caring for unfamiliar patients. Through ongoing interviews with stakeholders, the authors have continued to identify strategies and improvements that will be used to optimize the next iteration of the personalized safety plan screensaver.
- Anderson, D., Zlateva, I., Khatri, K. & Ciaburri, N. (2015). Using health information technology to improve adherence to opioid prescribing guidelines in primary care. Clinical Journal of Pain, 31, 573–579. doi:10.1097/AJP.0000000000000177 [CrossRef]
- Azad, T.D., Kalani, M., Wolf, T., Kearney, A., Lee, Y., Flannery, L. & Ratliff, J.K. (2016). Building an electronic health record integrated quality of life outcomes registry for spine surgery. Journal of Neurosurgery: Spine, 24, 176–185. doi:10.3171/2015.3.SPINE141127 [CrossRef]
- Bloomrosen, M., Starren, J., Lorenzi, N.M., Ash, J.S., Patel, V.L. & Shortliffe, E.H. (2011). Anticipating and addressing the unintended consequences of health IT and policy: A report from the AMIA 2009 Health Policy Meeting. Journal of the American Medical Informatics Association, 18, 82–90. doi:10.1136/jamia.2010.007567 [CrossRef]
- Cabana, M.D., Rand, C.S., Powe, N.R., Wu, A.W., Wilson, M.H., Abboud, P.A. & Rubin, H.R. (1999). Why don't physicians follow clinical practice guidelines? A framework for improvement. Journal of the American Medical Association, 282, 1458–1465. doi:10.1001/jama.282.15.1458 [CrossRef]
- Caligtan, C.A., Carroll, D.L., Hurley, A.C., Gersh-Zaremski, R. & Dykes, P.C. (2012). Bedside information technology to support patient-centered care. International Journal of Medical Informatics, 81, 442–451. doi:10.1016/j.ijmedinf.2011.12.005 [CrossRef]
- Carroll, D.L., Dykes, P.C. & Hurley, A.C. (2010). Patients' perspectives of falling while in an acute care hospital and suggestions for prevention. Applied Nursing Research, 23, 238–241. doi:10.1016/j.apnr.2008.10.003 [CrossRef]
- Centers for Medicare & Medicaid Services. (2017). Electronic health records (EHR) incentive program. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/EHRIncentivePrograms/01_Overview.asp
- Cigolle, C.T., Langa, K.M., Kabeto, M.U., Tian, Z. & Blaum, C.S. (2007). Geriatric conditions and disability: The Health and Retirement Study. Annals of Internal Medicine, 147, 156–164. doi:10.7326/0003-4819-147-3-200708070-00004 [CrossRef]
- Cline, M.A. (2016). Increasing RN accountability in professional practice: Development of a pain reassessment documentation scorecard. Journal of Nursing Administration, 46, 128–131. doi:10.1097/NNA.0000000000000311 [CrossRef]
- Dalal, A.K., Dykes, P.C., Collins, S., Lehmann, L.S., Ohashi, K., Rozenblum, R. & Bates, D.W. (2016). A web-based, patient-centered toolkit to engage patients and caregivers in the acute care setting: A preliminary evaluation. Journal of the American Medical Informatics Association, 23, 80–87. doi:10.1093/jamia/ocv093 [CrossRef]
- Dixon, B.E., Alzeer, A.H., Phillips, E.O. & Marrero, D.G. (2016). Integration of provider, pharmacy, and patient-reported data to improve medication adherence for type 2 diabetes: A controlled before-after pilot study. JMIR Medical Informatics, 4, e4. doi:10.2196/medinform.4739 [CrossRef]
- Dowding, D., Randell, R., Gardner, P., Fitzpatrick, G., Dykes, P., Favela, J. & Currie, L. (2015). Dashboards for improving patient care: Review of the literature. International Journal of Medical Informatics, 84, 87–100. doi:10.1016/j.ijmedinf.2014.10.001 [CrossRef]
- Dykes, P.C., Carroll, D.L., Hurley, A.C., Benoit, A., Chang, F., Pozzar, R. & Caligtan, C.A. (2013). Building and testing a patient-centric electronic bedside communication center. Journal of Gerontological Nursing, 39(1), 15–19. doi:10.3928/00989134-20121204-03 [CrossRef]
- Dykes, P.C., Carroll, D.L., Hurley, A.C., Benoit, A. & Middleton, B. (2009). Why do patients in acute care hospitals fall? Can falls be prevented?Journal of Nursing Administration, 39, 299–304. doi:10.1097/NNA.0b013e3181a7788a [CrossRef]
- Dykes, P.C., Carroll, D.L., Hurley, A., Lipsitz, S., Benoit, A., Chang, F. & Middleton, B. (2010). Fall prevention in acute care hospitals: A randomized trial. Journal of the American Medical Association, 304, 1912–1918. doi:10.1001/jama.2010.1567 [CrossRef]
- Dykes, P.C., Stade, D., Chang, F., Dalal, A., Getty, G., Kandala, R. & Collins, S. (2014). Participatory design and development of a patient-centered toolkit to engage hospitalized patients and care partners in their plan of care. AMIA Annual Symposium Proceedings, 2014, 486–495.
- Fox, L.A., Walsh, K.E. & Schainnker, E.G. (2016). The creation of a pediatric hospital medicine dashboard: Performance assessment for improvement. Hospital Pediatrics, 6, 412–419. doi:10.1542/hpeds.2015-0222 [CrossRef]
- Freedman, R.S., Cantor, S.B., Merriman, K.W. & Edgerton, M.E. (2016). 2013 HIPAA changes provide opportunities and challenges for researchers: Perspectives from a cancer center. Clinical Cancer Research, 22, 533–539. doi:10.1158/1078-0432.CCR-15-2155 [CrossRef]
- Mattison, M. (2016, August17). Hospital management of older adults. Retrieved from http://www.uptodate.com/contents/hospital-management-of-older-adults
- Ohashi, K., Caligtan, C.A., Benoit, A.N., Breydo, E.M., Carroll, D.L., Keohane, C.A. & Dykes, P.C. (2012). An electronic patient risk communication board. International Congress in Nursing Informatics, 2012, 311.
- Redwood, S., Ngwenya, N.B., Hodson, J., Ferner, R.E. & Coleman, J.J. (2013). Effects of a computerized feedback intervention on safety performance by junior doctors: Results from a randomized mixed method study. BMC Medical Informatics and Decision Making, 13, 63. doi:10.1186/1472-6947-13-63 [CrossRef]
- Reuben, D. (2007). Better care for older people with chronic diseases: An emerging vision. Journal of the American Medical Association, 298, 2673–2674. doi:10.1001/jama.298.22.2673 [CrossRef]
- Stadler, J.G., Donlon, K., Siewert, J.D., Franken, T. & Lewis, N.E. (2016). Improving the efficiency and ease of healthcare analysis through use of data visualization dashboards. Big Data, 4, 129–135. doi:10.1089/big.2015.0059 [CrossRef]
- Stead, W. & Lin, H. (2009). Computational technology for effective health care: Immediate steps and strategic directions. Washington, DC: The National Academies Press.
- Swartz, J.L., Cimino, J.J., Fred, M.R., Green, R.A. & Vawdrey, D.K. (2014). Designing a clinical dashboard to fill information gaps in the emergency department. AMIA Annual Symposium Proceedings, 2014, 1098–1104.
- Tan, Y.M., Hii, J., Chan, K., Sardual, R. & Mah, B. (2013). An electronic dashboard to improve nursing care. Studies in Health Technology and Informatics, 192, 190–194.
- Zuyev, L., Benoit, A.N., Chang, F.Y. & Dykes, P.C. (2011). Tailored prevention of inpatient falls: Development and usability testing of the fall TIPS toolkit. Computers, Informatics, Nursing, 29(Suppl. 2), TC21–TC28. doi:10.1097/NCN.0b013e3181f9dbe9 [CrossRef]
Interview Guides for Patients and Informal Caregivers and Nurses and Nurse Assistants
|Patients and Informal Caregivers|
| Have you or your family noticed the screensaver on the computer?|
| Do you find the screensaver in your room helpful?|
| Do you believe your nurse or any care team member who walks into the room would find the safety plan beneficial?|
| What do you think of the content of the screensaver?|
| Has this screensaver taught you anything about your safety plan?|
|Nurses and Nurse Assistants|
| Have you noticed the screensaver on the computers in the patient rooms?|
| Can you summarize the patient's safety plan based on the information provided on the screensaver?|
| Is the patient safety plan information on the screensaver actionable?|
| Do you believe your patients or families would find the screensaver beneficial?|
| What do you think of the content of the screensaver?|
| Has this screensaver helped you in caring for your patients' safety?|
| What is your overall impression of the screensaver?|
Themes from Phase 1 and Phase 2 Interviews with End Users Related to the Personalized Patient Safety Care Plan Screensaver
|Themes||Phase 1||Phase 2|
|All End Users|
All stakeholders recognize value in personalizing and displaying patient's safety plan
Nurse assistants like immediately seeing the patient's first name
Nurse assistants unaware that screensaver information is meant to inform them
Patients view computers as care team's domain
Nurses and nurse assistants have inconsistent practice in involving patient and informal caregivers with screensaver
|Value of safety-centric content|
Patients and informal caregivers report comfort knowing safety is prioritized
Nurses and nurse assistants report increased caution and safety awareness due to presence of screensaver
|Content enhancement suggestions|
Addition of more icons and logic to display code status, contact precautions, and opioid safety reminders
Add a cognition icon (neurology-specific request) and a lift icon
Patient request for scheduling and visiting hours information
Patients, informal caregivers, nurses, and nurse assistants noted that screensaver is often turned away from patient's view
|Patients and Informal Caregivers|
Ignored computer monitor because presumed it was only for clinician use
Recommended that nurses should use the screensaver to educate patients about their personalized safety plan
Recommended that preliminary introduction and education of screensaver and the patient's personalized safety plan by nurse or nurse assistant would be helpful
Appreciate automation; screensavers perceived as a benefit because there is no additional work/data entry burden
Decreases workload by replacing manual process of hanging signs
Appreciate passive aspect of screen saver where no extra documentation is required for it to function properly
Improves speed and quality of care provided to unfamiliar patients
|Clinical decision support|
Believe the icons are actionable, but they are more helpful for someone who is not as familiar with the floor or a particular patient
Enjoy convenience regarding easy access to basic patient information, especially for unfamiliar patients (e.g., language barriers, diet orders)
Recognize icons as straightforward and actionable
Hesitant to completely trust information from screensaver
Requested clarification on which data elements are being pulled into screensaver
Highlights issues with integrity of nursing documentation because the bi-product is displayed at the bedside
|Culture and workflow change|
“It's hard to take it all in” when not pausing at a screensaver in workflow
Screensaver had not yet changed practice, but nurses envision its ability to generate positive change
Expressed the need to make an effort to further integrate screensaver use into their workflow (when caring for patients and using for education)
Expressed the need to familiarize themselves more with screensaver icons, data elements, and the logic that drives the icons
Use screensaver to quickly obtain information about keeping the patient safe (i.e., toileting, mobility status) without having to find a nurse to request patient-specific safety information
Assists them in getting to know the patient and with filling in information gaps, especially when nurses have yet to give a report on a particular patient
|Clinical decision support|
Screensaver guides decisions for when patients ask them for assistance as they begin their shift
The screensaver “makes me more cautious” and “informed” (i.e., when a patient asks for water but the screensaver diet icon indicates the patient is NPO [nothing by mouth])
|Audience scope||Unaware that screensaver was meant for nurse assistant use||Unaware (and impressed) that icons were driven by real time documentation by clinicians and displayed to provide information to all care team members|
Phase 1 and Phase 2 Barriers and Strategies to Overcome Use of the Personalized Patient Safety Plan Screensaver
|Barriers to Use of Screensaver||Software Requirements/Strategies to Overcome Barriers|
|Lack of awareness—Clinician is unaware of new guideline or evidence||Phase 1: Train nurse assistants that the screensaver is meant to provide them with clinical decision support.
Phase 2: Train nurses and nurse assistants to educate the patient and family on the purpose and content of the personalized safety plan.|
|Lack of familiarity—Clinician is unfamiliar with how to implement new guideline or evidence correctly||Phase 1: Train nurses that their documentation in the electronic health record drives the screensaver content. Seek end user feedback (i.e., on content of icons, aesthetic design) and leverage it to improve familiarity.
Phase 2: Provide nurses with comprehensive list of possible icons; improve documentation with education on data elements.|
|Lack of agreement—Clinician does not agree with new guideline or evidence||Phase 1: Incorporate suggested content changes (e.g., opioid management icon). Prioritize logic so that the most actionable, high priority icons are displayed, there-fore minimizing cognitive burden.
Phase 2: Reiterate that the screensaver is meant for all members of the care team, including patients and families.|
|Lack of self-efficacy—Clinician does not believe he/she can implement new guideline or evidence||Respond to concerns about time pressures with evidence that the screensaver improves workflow efficiency and provides clinical decision support at the bedside.|
|Lack of outcome expectancy—Clinician does not believe that the new guideline or evidence will positively impact outcomes||Involve nurses and nurse assistants in the development of the content so that it is perceived as actionable and worthwhile innovation. Example: Work with neurology nurses to tailor content to their patient population, such as an icon to communicate if a patient has left or right extremity weakness.|
|Inertia of previous practice—Clinician lacks motivation to depart from previous protocol and implement change||Incorporate the screensaver into training of new staff and competency assessments so as to integrate referencing the personalized safety plan screensaver into practice.|
|External barriers—Barriers that do not pertain to clinician knowledge or attitude: patient, guideline, and environmental factors||Train staff to angle the computer monitor toward patients so as to involve them in the safety plan.
Assuage concerns that some patients will not be cognitively intact and therefore cannot understand the safety plan by explaining that the screensaver is meant for all members of the care team to keep the patient safe.
Involve family/informal caregivers when patient is unable or unwilling to engage in safety plan.|