Macroergonomics to Understand Factors Impacting Patient Care During Electronic Health Record Downtime Ethan Larsen Dissertation submitted to the Faculty of the Virginia Polytechnic Institute and State University in partial fulfillment of the requirements for the degree of Doctor of Philosophy In Industrial and Systems Engineering Brian M. Kleiner, Chair Raj Ratwani, Co-Chair Eileen Van Aken Christian Wernz June 15th, 2018 Blacksburg, Virginia Keywords: Healthcare Safety, Macroergonomics, Macroergonomic Analysis and Design, Electronic Health Record, Downtime, Emergency Medicine, Clinical Laboratory Macroergonomics to Understand Factors Impacting Patient Care During Electronic Health Record Downtime Ethan Larsen ABSTRACT Through significant federal investment and incentives, Electronic Health Records have become ubiquitous in modern hospitals. Over the past decade, these computer support systems have provided healthcare operations with new safety nets, and efficiency increases, but also introduce new problems when they suddenly go offline. These downtime events are chaotic and dangerous for patients. With the safety systems clinicians have become accustomed to offline, patients are at risk from errors and delays. This work applies the Macroergonomic methodology to facilitate an exploratory study into the issues related to patient care during downtime events. This work uses data from existing sources within the hospital, such as the electronic health record itself. Data collection mechanisms included interviews, downtime paper reviews, and workplace observations. The triangulation of data collection mechanisms facilitated a thorough exploration of the issues of downtime. The Macroergonomic Analysis and Design (MEAD) methodology was used to guide the analysis of the data, and identify variances and shifts in responsibility due to downtime. The analysis of the data supports and informs developing potential intervention strategies to enable hospitals to better cope with downtime events. Within MEAD, the assembled data is used to inform the creation of a simulation model which was used to test the efficacy of the intervention strategies. The results of the simulation testing are used to determine the specific parameters of the intervention suggestions as they relate to the target hospitals. The primary contributions of this work are an exploratory study of electronic health record downtime and impacts to patient safety, and an adaptation of the Macroergonomic Analysis and Design methodology, employing multiple data collection methods and a high-fidelity simulation model. The methodology is intended to guide future research into the downtime issue, and the direct findings can inform the creation of better downtime contingency strategies for the target hospitals, and possibly to offer some generalizability for all hospitals. Macroergonomics to Understand Factors Impacting Patient Care During Electronic Health Record Downtime Ethan Larsen GENERAL AUDIENCE ABSTRACT Hospitals experience periodic outages of their computerized work support systems from a variety of causes. These outages can range from partial communication and or access restrictions to total shutdown of all computer systems. Hospitals operating during a computerized outage or downtime are potentially unable to access computerized records, procedures and conduct patient care activities which are facilitated by computerized systems. Hospitals are in need of a means to cope with the complications of downtime and the loss of computerized support systems without risking patient care. This dissertation assesses downtime preparedness and planning through the application of Macroergonomics which has incorporated discrete event simulation. The results provide a further understanding of downtime risks and deficiencies in current planning approaches. The study enhances the application of Macroergonomics and demonstrates the value of discrete event simulation as a tool to aid in Macroergonomic evaluations. Based on the Macroergonomic Analysis and Design method, downtime improvement strategies are developed and tested, demonstrating their potential efficacy over baseline. Through this dissertation, the deficiencies in current contingency plans are examined and exposed and further the application of Macroergonomics in healthcare. ACKNOWLEDGEMENTS Dr. Kleiner, thank you for your never-ending support, guidance, and mentorship through the years. Had we not spoken after ISE Symposium back at the beginning of my time at Virginia Tech, I never would have known the possibilities of healthcare research in ISE and gotten to the place I am now. Thank you for having me support your teaching of Theory of Org; being able to learn from your experiences and participate in the course have been some of my most informative and meaningful experiences here at VT. Dr. Ratwani, who would have guessed our conversation that started with “So what happens when the computer goes offline in the hospital?” and ended with “I’m not sure, why don’t you go find out.” was going to result in this dissertation. Thank you for always including me in your research center, training me to continue to make a difference in healthcare safety, and always encouraging me to keep looking for new opportunities. Dr. Van Aken, your ever positive and supportive attitude towards me and my work has helped me to continue through some very difficult stretches. Knowing that your door is always open for me to touch base and get your input has made many decisions easier and helped shape both this dissertation and my perspectives as a future researcher. Dr. Wernz, thank you for the opportunities you have afforded me in letting this dissertation support the larger project. The experiences in taking the level of leadership you gave me on a project of this size have given me experiences few of my peers can share. Thank you to the team at MedStar’s National Center for Human Factors for Healthcare. None of this would have been possible without the research assistants (Dan, Tracy, and Josh) who directly supported the observations, focus groups, and scanned the mountain of paper records for datasets. All of the research team, thank you for making time to speak with me and giving your expertise and guidance whenever I have needed it. A big thank you to the entire ISE department, for all your support over the years. Thank you to Rhonda Hawley, Sue Volkmar, Dot Cupp, Nicole Conner and Akiko Nakata for letting me stir up trouble with paperwork and contract difficulties, and always helping smooth things back out. Hannah and Greg both of you have supported me throughout my studies, being a sounding board and always made sure I kept working. Always available to bounce ideas, review presentations and provide extra insights, and at times when I most needed it, making sure I stayed in the program and finished this dissertation, none of this would have been possible without either of you. iv Thank you to Mom and Dad, you have always encouraged learning, exploration and education, your support has kept me going through the most difficult challenges and you both have inspired me to accomplish this and more. Zach, you may not have always understood what I was talking about, but you always listened and encouraged me to keep at it. Grandma you’ve always said I could do it, and now here it is, thank you all for your never-ending love and support. v TABLE OF CONTENTS Abstract ................................................................................................................................ ii General Audience Abstract ................................................................................................... iii Acknowledgements .............................................................................................................. iv List of Figures ........................................................................................................................ x List of Tables ........................................................................................................................xii 1. Introduction ...................................................................................................................... 1 1.1. Theoretical Perspective ...........................................................................................................3 1.2. Purpose and Scope of the Study ...............................................................................................3 1.3. Research Questions .................................................................................................................5 2. Literature Review .............................................................................................................. 7 2.1. Sociotechnical Work Systems Theory .......................................................................................7 2.2. Macroergonomics....................................................................................................................7 2.2.1. Macroergonomics in Healthcare ................................................................................................ 9 2.3. Simulation in Healthcare ....................................................................................................... 10 2.3.1. Discrete Event Simulation ........................................................................................................ 11 2.3.2. Systems Dynamics ...................................................................................................................