Pediatric Informatics: Computer Applications in Child Health (Health ...

8 Complexity in Healthcare Information Technology Systems 89
Conflicting interests (time spent with adjusting oxygen takes providers
away from other patients, and pushes 80-hour rule boundaries for residents,
coping)
Ambiguity (Unclear to users on which patients to implement the protocol)
The implementation failure of an apparently simple protocol to facilitate an evidence
based “practice change,” was unexpected by the implementers and revealed
a complicated “systems” problem. While the required workflow changes resulted
in a total “failure” of the Protocol in NICU B, NICU A produced fairly good process
compliance results that were improving monthly. In retrospect, the difference
between the success rates in the different NICUs is not unexpected. Had the
implementers done a Failure Mode and Effect Analysis (FMEA) (Chapters 9, 29),
many of the failures might have been discovered in advance. “Tribal knowledge”
of existing structures, work arounds, beliefs, obstacles, and conflicts can be highly
predictive of failures to be experienced later. Human factors analysis of HIT problems
often uses techniques emerging from ethnographic research. 16
Health care environments are under constant ethical, regulatory, and financial
pressure to improve performance, which paradoxically can have the unintended
consequence of materially decreasing system performance. NICU B’s redesign was
a response to new regulatory and oversight requirements by JCAHO (for formal
quality improvement initiatives), HIPAA (for privacy) and the AAP/ACOG (for
improved perinatal infrastructure quality standards). 17–19 Physical design changes
usually result in workflow adaptations. Change instituted to improve one performance
measure may result in negative effects on other performance measures. The
NICU B redesign specifically, and very successfully, addressed recommendations
for decreasing ambient noise, for modifying lighting environments geared to patient
needs, and for increasing parental involvement. 18–22 These changes affected the ability
of providers to monitor alarms effectively and to regulate oxygen saturations
more tightly.
8.2.3.1 Human Factors Engineering
“Human Factors Engineering” includes physical, sensory and psychological stressors,
body mechanics problems, fatigue, time pressure, workflow and physical
space design, computerized alarms, control systems (knobs, system status feedback
to users, cognitive design), shift work, heavy lifting, repetitive stress injuries
(Ergonomics) and human–computer interaction. Most Human Factors Engineering
(HFE) research has focused on avionics (pilots, planes’ controls and cockpit design,
and cockpit crew teamwork), military venues, corporate offices, transportation
situations, and nuclear power plants.
Very little HFE research is available for health care settings, 23 and even less for
intensive care unit environments. Research has focused on single devices, such as
physiologic monitors, anesthesia machines, gas connectors, and controls. However,
HFE lessons learned in avionics and military research may be applicable to hospitals.