SISTEM INFORMASI KESEHATAN MELALUI METODE PROTOTYPING

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Tugas

Nursing informatik

Development of health information systems

Cicilia anita

0910321001

Program studi ilmu keperawatan

Fakultas kedokteran

Universitas andalas

2010

SISTEM INFORMASI KESEHATAN MELALUI METODE PROTOTYPING SEBAGAI SOLUSI DALAM MENINGKATKAN MUTU PELAYANAN KEPERAWATAN DI RUMAH SAKIT

Abstract

Sistem informasi pada dasarnya merupakan kumpulan sumber daya pengolah data yang mengelola data menjadi bentuk yang lebih berguna dalam rangka kegiatan manajemen asuhan keperawatan. Karya tulis ilmiah ini menguraikan mengenai protatyping dan aspek-aspek penting yang mempengaruhi para pengelola dalam pendekatan sistem informasi manajemen asuhan keperawatan khususnya pendokumentasian asuhan keperawatan dengan menggunakan sistem komputerisasi. Desain tampilan layar atau prototipe yang dihasilkan sesuai dengan kebutuhan pengguna. Hasil kajian didapatkan Aplikasi program dapat diakses oleh komputer yang ada disetiap unit rawat karena setiap komputer yang ada pada bagian tersebut sudah terintegrasi dengan adanya sistem jaringan lokal dan internet. Menyusun SIM Asuhan Keperawatan harus melibatkan manajemen Rumah Sakit sebagai penyedia dana dan pengambil kebijakan, user (perawat) sebagai pengguna, System Analis sebagai perancang SIM Asuhan Keperawatan dan Programer Komputer sebagai penyusun pemrograman SIM Asuhan Keperawatan. Implementasi SIM Asuhan Keperawatan menggunakan metode Parallel Approach yaitu menjalankan 2 system secara bersamaan sampai system system manual dapat dilepas semuanya.

Kata Kunci : Sistem Informasi manajemen, Prototyping, Pelayanan keperawatan

A.   Latar Belakang

Sistem informasi pada dasarnya merupakan kumpulan sumber daya pengolah data yang mengelola data menjadi bentuk yang lebih berguna dalam rangka kegiatan manajemen asuhan keperawatan. Prototyping merupakan metodologi pengembangan software yang menitik beratkan pada pendekatan aspek desain, fungsi dan user-interface. Developer dan user bertemu dan melakukan komunikasi dan menentukan tujuan umum, kebutuhan yang diketahui dan gambaran bagian-bagian yang akan dibutuhkan.

Di Indonesia pada era keterbukaan ini, masyarakat telah mempunyai kebebasan dalam mengemukaan pendapatnya, sehingga bila pelayanan yang diberikan khususnya pelayanan kesehatan tidak bermutu dan memuaskan masyarakat mempunyai hak menuntut pada pemberi pelayanan kesehatan. Namun kondisi keterbukaan pada masyarakat sepertinya belum didukung oleh kesiapan pelayanan kesehatan, salah satunya dalam memenuhi ketersediaan dokumentasi yang lengkap dipelayanan kesehatan khususnya rumah sakit. Perkembangan tehnologi informasi dan komunikasi dewasa ini di Indonesia belum secara luas dimanfaatkan dengan baik umumnya pelayanan di rumah sakit khususnya pelayanan keperawatan.

Kebutuhan masyarakat akan kesehatan semakin meningkat,memicu rumah sakit- rumah sakit yang ada untuk meningkatkan fasilitas kesehatan yang melakukan perbaikan terhadap manajemen pelayanan kepada pasien yang terkait dengan pendokumentasian asuhan keperawatan secara komputerisasi.

Dokumentasi keperawatan adalah bagian yang penting dari dokumentasi klinis. Namun pada realitanya dilapangan, asuhan keperawatan yang dilakukan masih bersifat manual dan konvensional, belum disertai dengan sistem /perangkat tekhnologi yang memadai. Contohnya dalam hal pendokumentasian asuhan keperawatan masih manual, sehingga perawat mempunyai potensi yang besar terhadap proses terjadinya kelalaian dalam praktek. Dengan adanya kemajuan teknologi informasi dan komunikasi, maka sangat dimungkinkan bagi perawat untuk memiliki sistem pendokumentasian asuhan yang lebih canggih dengan memanfaatkan perkembangan tehnologi informasi. Pendokumentasian keperawatan dengan menggunakan komputer diharapkan akan membantu meningkatkan dokumentasi keperawatan yang berkwalitas.

Mutu pelayanan keperawatan yang ada di rumah sakit tergantung kepada kecepatan, kemudahan dan ketepatan dalam melakukan tindakan keperawatan yang berarti serta pelayanan keperawatan tergantung kepada efisiensi dan efektifitas struktur yang ada dalam keseluruhan sistem rumah sakit. Pelayanan rumah sakit terbagi dua pelayanan medis dan pelayanan non medis. Sebagai contoh dalam pelayanan non medis seperti proses penerimaan,proses pembayaran, sampai proses administrasi yang terkait dengan klien yang dirawat adapun pelayanan medis terdiri dari pemberian obat, pemberian makan, asuhan keperawatan diagnosa medis dan lain-lain yang merupakan bentuk pelayanan yang tidak kalah pentingnya.

Pendokumentasian Keperawatan merupakan hal penting yang dapat menunjang pelaksanaan mutu asuhan keperawatan. (Kozier,E. 1990). Selain itu dokumentasi keperawatan merupakan bukti akontabilitas tentang apa yang telah dilakukan oleh seorang perawat kepada klien nya. Dengan adanya pendokumentasian yang benar maka bukti secara profesional dan legal dapat dipertanggung jawabkan. Masalah yang sering muncul dan dihadapi di Indonesia dalam pelaksanaan asuhan keperawatan adalah banyak perawat yang belum melakukan pelayanan keperawatan sesuai standar asuhan keperawatan. Pelaksanaan asuhan keperawatan juga tidak disertai pendokumentasian yang lengkap. (hariyati, RT, 1999).

Berdasarkan uraian pada latar belakang tersebut diatas,maka perlu dikembangkan cara pengelolaan data, agar mendapat informasi yang lebih cepat dan kepada pengguna sesuai dengan kebuutuhannya. Dan dapat membantu dalam proses pengolahan data yang lebih baik.

B.   Kajian Literatur

1.   Manajemen informasi

Manajemen sumber daya informasi rumah sakit merupakan salah satu keunggulan kompetitif suatu rumah sakit, jika dikelolah dengan baik. Manajemen sumber daya informasi (Information Resources Management- IMR) adalah aktivitas yang dijalankan oleh manajer pada semua tingkatan dalam perusahaan dengan tujuan mengidentifikasi, memperoleh, dan mengelolah sumber daya informasi dan diperlukan untuk memenuhi kebutuhan pemakai.

Sumber daya informasi mencakup :(Mcleod, 1995)

a.      Perangkat keras komputer

b.      Perangkat lunak komputer

c.       Para spesialis informasi : Analisis sistem, Pengelolah database, spesialis jaringan, programmer, operator

d.      Pemakai sebagai pihak pemakai sistem

e.      Fasilitas

f.        Database

g.      Informasi

2.   Prototyping

Prototyping sistem informasi adalah suatu tehnik yang sangat berguna untuk mengembangkan informasi tertentu mengenai syarat-syarat informasi pengguna secara cepat.

Jenis-jenis informasi yang dicari saat melakukan prototyping (Kendal, 2003)

a.      Reaksi awal dari pengguna : saat analis sistem menampilkan sebuah prototipe sistem informasi, maka analis akan tertarik dengan reaksi pengguna dan pihak manajemen terhadap prototipe.

b.      Saran-saran dari pengguna : Analis juga tertarik dengan saran-saran pengguna dan pihak manajemen perbaikan terhadap prototipe yang ditampilkan

c.       Inovasi : merupakan bagian dari informasi yang dicari oleh analis sistem. Inovasi adalah kemampuan-kemampuan sistem baru yang tidak dianggap berhubungan dengan waktu saat pengguna mulai berinteraksi dengan protoyipe.

d.      Rencana revisi : membantu mengidentifikasikan prioritas apa yang akan diprototipekan

3.   Langkah-langkah pengembangan prototipe (Kendal,2003)

a.      Mengidentifikasi Kebutuhan pemakai : mewawancarai untuk mendapatkan gagasan dari apa yang diinginkan oleh pemakai.

b.      Pengembangan prototipe : bekerjasama dengan spesialis informasi lain, menggunakan satu atau lebih pendekatan prototyping untuk mengembangkan sebuah prototipe. Contoh dari alat prototyping adalah Integrated application generator adalah sistem prangkat lunak yang mampu menghasilkan sebuah tampilan yangdiinginkan dalam suatu sistem baru sperti menu, laporan, layar, database dsb dan prototyping toolkits adalah mencakup sistem-sistem perangkat lunak terpisah yang mampu menghasilkan tampilan sistem yang diinginkan.

c.       Menentukan apakah prototipe dapat diterima memberi kesempatan kepada mereka untuk membiasakan mereka dengan sistem

d.      Menggunakan prototipe menjadi sistem operasional

e.      Mengkode sistem operasional

f.        Menguji sistem operasional, progremer munguji sistem

g.      Menentukan jika sistem operasional dapat diterima.

4.   Garis Besar Pengembangan Prototyping

Ada 4 garis besar yang harus diamati untuk mengintegrasikan prototyping dalam pemenuhan kebutuhan dalam fase SDLC, yaitu: a. Bekerja dengan modul yang dapat diatur b. Membangun prototype dengan cepat c. Memodifikasi prototype dalam iterasi suksesif d. Menekankan interface (tampilan) pemakai

5.   Pengertian dokumentasi keperawatan

Potter (2005) mendefenisikan dokumentasi sebagai segala sesuatu yang tercetak atau tertulis yang dapat diandalkan sebagai catatan tentang bukti bagi individu yang berwenang . Dokumentasi keperawatan juga merupakan salah satu bentuk upaya membina dan mempertahankan akontabilitas perawat dan keperawatan (Webster New World Dictionary dalam Marelli (1996). Pelaksanaan dokumentasi proses keperawatan juga sebagai salah satu alat ukur untuk mengetahui, memantau dan menyimpulkan suatu pelayanan asuhan keperawatan yang diselenggarakan di rumah sakit (Fisbach, 1991).

6.   Tujuan dokumentasi keperawatan

Dokumentasi keperawatan yang lengkap adalah prasyarat dalam melaksanakan perawatan yang baik dan untuk efesiensi dari kerjasama dan komunikasi antar profesi kesehatan dalam pelayanan kesehatan professional. Dokumentasi keperawatan yang lengkap dan akurat akan memudahkan disiplin ilmu lain untuk menggunakan informasi di dalamnya.

7.   Dokumentasi Keperawatan Berbasis Computer.

Computerized nursing documentation adalah suatu modul keperawatan yang dikombinasikan dengan sistem komputer rumah sakit ke staf perawat.Dengan sistem yang terkomputerisasi ini perawat dapat melakukan akses ke laboratorium, radiologi, fisioterapi, dan disiplin yang lain, seperti ahli gizi, fisioterapi, dan disiplin ilmu lain seperti ahli gizi, fisioterapis, occupational therapies.

Pemikiran tentang dokumentasi keperawatan yang terkomputerisasi di buat dalam rangka memudahkan dan mempercepat pendokumentasian asuhan keperawatan yang dibuat. Dengan sistem ini perawat lebih dapat menghemat waktu dan perawat akan lebih sering berada di samping klien .

8.   Manfaat Dokumentasi keperawatan yang terkomputerisasi

Suatu studi diselenggarakan di University medical center Heidelberg selama 18 bulan . Hasil dari studi menunjukkan adanya suatu peningkatan yang penting tentang kwantitas dan kwalitas dokumentasi . Aspek positif meliputi kelengkapan dari dokumentasi keperawatan , aspek yang formal dan peningkatan kwalitas hubungan antar perawat. Aspek yang negatif adalah berkaitan dengan contens dari rencana keperawatan (Cornelia,et all ,2007).

9.   Format pendokumentasian

Aziz Alimul (2001) mengemukakan ada lima bentuk format yang lazim gunakan:

a.      Format naratif

Merupakan format yang dipakai untuk mencatat perkembangan klien dari hari ke hari dalam bentuk narasi.

b.      Format Soapier

Format ini dapat digunakan pada catatan medic yang berorientasi pada masalah (problem oriented medical record) yang mencerminkan masalah yang di identifikasi oleh semua anggota tim perawat.

c.       Format soapier terdiri dari:

S = Data Subjektif

O = Data Objektif

A = Pengkajian (Assesment)

P = Perencanaan

I = Intervensi

E = Evaluasi

R = Revisi

d.      Format fokus/DAR

e.      Format DAE

f.        Catatan perkembangan ringkas

10. Bentuk format catatan perawat (Nursing Note) antara lain :

a.      CP 1 A : dimana data yang telah dikaji melalui format pengkajian data subjektif (DS) dan data objektif (DO) yang dikenal sebagai data focus.

b.      CP 1 B : adalah format yang digunakan perawat untuk membuat analisa data dan mengidentifikasi etiologi dan masalah klien.

c.       CP 2 : adalah format catatan perawatan yang berisikan masalah/ diagnose keperwatan, tanggal ditemukan masalah dan teratasinya masalah klien

d.      CP 3 : adalah format catatan perawat yang berisi tentang rencana keperawatan yang terdiri dari; hari dan tanggal/jam, diagnose keperawatan disertai data penunjang, tujuan yang akan dicapai, rencana tindakan dan rasionalisme.

e.      CP 4 : adalah format catatan perawat yang berisi tentang tindakan perawat dan hasil yang diperoleh.

f.        CP 5 : adalah format catatan perawat yang berisi tentang catatan perkembangan klien yang terdiri dari hari, tanggal, nomor diagnose, jam/waktu, data SOAP (Subjektif, Objektif, Assessment, Planning).

g.      CP 6 : adalah format catatan perawat yang berisi tentang resume akhir atau ringkasan klien pulang.

11. Desain sistem

a.      Klien datang dilakukan pengkajian oleh perawat

b.      Data pengkajian sebagai dasar untuk menentukan diagnosa keperawatan

c.       Perawat memasukkan data pengkajian dikomputer

d.      Komputer mencari data pengkajian didatabase jika ketemu maka keluar data diagnose keperawatan jikatidak tetemu maka perawat harus memasukkan data diagnosa keperawatan lewat tambahan data

e.      Setelah diagnosa keperawatan dimunculkan oleh komputer perawat mengisi data rencana asuhan keperawatan yang akan diberikan kepada klien

f.        Inplementasi rencana asuhan keperawatan diberikan kepada klien

g.      Hasil dari inplementasi dimasukkan kedalam komputer dan kemudian dilakukan evaluasi untuk melakukan tindak lanjut asuhan keperawatan yang akan diberikan kepada klien.

h.      Jika dalam evaluasi pasien belum sembuh maka dilakukan pengkajian lanjutan kepada pasien

i.        Jika hasil evaluasi klien sembuh maka klien diperbolehkan pulang setelah melakukan penyelesaian administrasi

C.   Kesimpulan

1.      Dengan adanya sistem informasi pengelolaan data pasien yang terkomputerisasi, maka pengelolaan data menjadi informasi akan lebih cepat dibandingkan dengan cara manual.

2.      Informasi pasien, ruang rawat dan kegiatan pada setiap pasien yang dirawat khususnya masalah pendokumentasian asuhan keperawatan dapat memenuhi kebutuhan pengguna.

3.      Desain tampilan layar atau prototipe yang dihasilkan sesuai dengan kebutuhan pengguna.

4.      Aplikasi program dapat diakses oleh komputer yang ada disetiap unit rawat karena setiap komputer yang ada pada bagian tersebut sudah terintegrasi dengan adanya sistem jaringan lokal dan intranet.

5.      Pendokumentasian Keperawatan merupakan hal penting yang dapat menunjang pelaksanaan mutu asuhan keperawatan.

6.      Metode pendokumentasian asuhan keperawatan saatnya mulai berpindah dari sistem manual, bergeser kearah komputerisasi. Metode pendokumentasian tersebut dengan menggunakan Sistem Informasi Manajemen Asuhan Keperawatan berbasis komputer.

7.      Menyusun SIM Asuhan Keperawatan harus melibatkan manajemen Rumah Sakit sebagai penyedia dana dan pengambil kebijakan, user (perawat) sebagai pengguna, System Analis sebagai perancang SIM Asuhan Keperawatan dan Programer Komputer sebagai penyusun pemrograman SIM Asuhan Keperawatan.

8.      Implementasi SIM Asuhan Keperawatan menggunakan metode Parallel Approach yaitu menjalankan 2 system secara bersamaan sampai system system manual dapat dilepas semuanya.

9.      Perkembangan Rumah sakit Anutapura Palu yang sedemikian pesatnya sudah saatnya mulai menggunakan SIM Asuhan Keperawatan berbasis computer sebagai pemecahan masalah pendokumentasian Asuhan Keperawatan.

D.   Daftar Pustaka

Anis Fuad,(2007), Belajar Informatika Keperawatan di RSUD Banyumas, Diambil dari http://www.dinkesjatim.go.id pada tanggal 5 Otober 2010

Bambang Hariyanto,(2004), Rekayasa sistem berorientasi Objek, Informatika, bandung

Fitria Nita,(2009), Perlukah ada sistem informasi manajemen asuhan keperawatan, diambil darihttp://www.fkep.unpad.ac.id/keperawatan/sistem-informasi-manajemen-asuhan-keperawatan.html pada tanggal 6 oktobe 2010

Ikhwan Arief, Dicky Fatrias, (2008), Jurnal Ilmiah pengembangan sistem informasi pengelolaan data pasien menggunakan pendekatan prototyping, diambil dari http://endriputro.files.wordpress.com/2010/03/prototyping.jpg, Dosen Jurusan Tehnik Industri fakultas Tehnik Universitas andalas, diakses tanggal 3 oktober 2010.

Jamea A Menke dkk, (2001), Computerized clinical documentation system in the pediatric intersive care unit, diambil dari http://www.biomedcentral.com pada tanggal 3 oktober 2010

Jogiyanto, H.M, (1999), Analisis dan desain sistem informasi pendekatan terstruktur teori dan aplikasi bisnis, Edisi kedua, Yogyakarta

Jurnal, (2003), Prototype Information Sistem, Oregon Wastershed Enhancement board.

Kendall, Kenneth,E dan Julie E, Kendall,(2003), Analisis dan perancangan sistem, Edisi bahasa Indonesia, PT Prenhallindo, Jakarta

Sabargu Boy, (2003), Sistem Informasi Manajemen Rumah sakit, Editor Berkat, Tim Konsorsium,Cetakan 1, Yogyakarta

Seminar nasional aplikasi tehnologi informasi, (2006), Kajian teoretis pendekatan prototyping dan relevansinya terhadap pengembangan sistem informasi, Yogyakarta

Sri Haryati Tutik,(2007) Sistem Informasi Keperawatan Berbasis computer Sebagai Salah satu Solusi Meningkatkan Profesionalisme Perawat, Diambil dari http://www.poltekestniau.ac.id/node/30 Diakses tanggal 3 oktober 2010

Witarto, (2004), Pemahaman sistem Informasi, Informatika, bandung

(SUMBER: Fatmawati, Andi. 2010. “Sistem Informasi Kesehatan Melalui Metode Prototyping Sebagai Solusi Dalam Meningkatkan Mutu Pelayanan Keperawatan Di Rumah Sakit”. http://www.fik.ui.ac.id/pkko.pdf diakses tanggal 14 November 2010)

DESIGNING PUBLIC WEB INFORMATION

SYSTEMS WITH QUALITY IN MIND

PUBLIC REPORTING OF HOSPITAL PERFORMANCE DATA

David Birnbaum, M. Jeanne Cummings and Kara M. Guyton

Healthcare Associated Infections Program,

Washington State Department of Health, Olympia, Washington, USA

James W. Schlotter

Washington State Department of Health, Olympia, Washington, USA, and

Andre´ Kushniruk

School of Health Information Science, University of Victoria,

Victoria, Canada

Abstract

Purpose – This paper aims to describe evolution of a new public information web site, through

evaluation-refinement prototyping cycles.

Design/methodology/approach – An expanding range of participants is being engaged in formal evaluations as the site design evolves. The Flesch-Kincaid Grade Level Score is applied to assess ease of reading in the wording used; the National Quality Forum guideline statements are applied to determine whether the prototyping design process is meeting performance expectations; and then Nielsen’s heuristics are applied to evaluate ease of use of the latest prototype.

Findings – The page wordings started at a high reading grade level to be technically correct, with a strategy to progressively reduce levels without losing meaning. Reading level was reduced to an average of two and as much as six grades through editing between the third and fourth-generation prototypes. None of the National Quality Forum principles were found missing from the development process. The prototype web site was ranked at the middle compared to official public web sites of seven other States’ healthcare-associated infection programs, some of which had been open to the public for more than a year. Many of the heuristic violations that weighed against the prototype were described as being minor and easily fixed. Collaboration between a State health department and a university to advance this

evaluation-refinement process was valuable to both parties, enhancing the ability to produce a new public information web site that is more likely to meet the needs of its intended audience.

Practical implications – In response to increasing expectations of transparency and accountability, a growing number of public web sites are displaying hospital performance data. Washington State’s mandatory public reporting of healthcare-associated infection rates is a recent example of this trend. The Department of Health is required by law to launch a public information web site by December 2009. The research was based on an evidence-based approach to understand and meet the information needs of the public.

Originality/value – Although few studies have evaluated the usage and impact of hospital comparison web sites, these studies uniformly show relatively low usage and disappointing impact. Using the research literature, issues thought to account for poor usage and low impact, and developed design principles that address this poor past performance were identified. Throughout 2008 and 2009, successive prototypes were developed for the web site structure guided by those principles and refined each generation of prototype through focus group evaluations. This paper explains the approach, and summarizes results from the evaluations, leading to improvements before the final design first opens to the general public.

Keywords :Customer satisfaction, Hospitals, Performance management, Worldwide web, Information systems, United States of America

Paper type :Research paper

The current issue and full text archive of this journal is available at

www.emeraldinsight.com/1477-7274.htm

Clinical Governance: An International Journal

Vol. 15 No. 4, 2010

pp. 272-278

q Emerald Group Publishing Limited

1477-7274

DOI 10.1108/14777271011084037

Introduction

Starting in the late 1990s, few States had posted public information about patient satisfaction and hospital performance (Barr et al., 2002). In 2005 the Centers for Medicare and Medicaid Services (CMS) launched its Hospital Compare web site (WSHA, 2005). This event was recognized internationally as an enormous step forward in meeting the need for objective information to inform consumer choices (Canhealth.com, 2005). Since 2005 the number of States mandating public reporting of healthcare associated infection rates as a measure of hospital performance has grown quickly and steadily. The Washington State Department of Health is required by law to launch a healthcare-associated infections public information web site by December 2009.

            The impacts of public reporting, and reliability of measurements included in those reports, are being assessed in a body of literature that has grown less quickly. Thus far, evaluation results for the longest established public web sites uniformly show low usage (Harris and Buntin, 2008; Kaiser Family Foundation, 2008; California Healthcare Foundation, 2008) and disappointing impact (Fung et al., 2008). To give our new web site a greater chance for success, we identified underlying issues thought to explain past poor performance of other sites. We then established design principles based on research evidence informing those underlying issues. Finally, we developed prototypes for our web site consistent with these principles and are refining prototype generations by successive evaluation periods. In a pilot study at the third-generation prototype stage, our transition from showing single-page mock-ups to showing a fully functional web site, we explore use of an on-line evaluation approach to determine whether our design process is meeting performance expectations. In a subsequent fourth-generation stage, we engage a formal usability engineering assessment method to determine how well our evolving product conforms to established heuristics that have been applied to a wide range of information systems.

Methods

Third-generation prototype evaluation

In 2008 the National Quality Forum (NQF) issued guidelines for optimal design of consumer-focused public reporting (NQF, 2008a). We restated each of the seven NQF guideline statements as questions, each with response options in the form of a Likert scale with additional space for comments. We then invited each member of the Healthcare Associated Infections Program’s Advisory Committee to spend a month examining our third-generation prototype web site and complete a web-based evaluation. Both the prototype and evaluation form were hosted on Plone open-source content-management system software. Our Advisory Committee members had been introduced to the web site design process at earlier committee meetings and had seen two prior generations of our prototypes. Instructions on how to access the prototype evaluation site were sent to each member by e-mail, followed by one reminder message midway through the month-long evaluation period.

            The total number of evaluations received and tallies for each question’s five Likert scale response ranks were counted, and typical responses in open-text commentary areas were grouped into themes. We also used an assessment tool available within Microsoftw Wordw (the Flesch-Kincaid Grade Level Score) to evaluate ease of reading for our paragraphs on all prototype pages.

Fourth-generation prototype evaluation

While the third-generation evaluation was underway, we started editing wording for all web pages in our fourth-generation prototype to improve clarity, reduce sentence length and reduce average syllable length where possible. After compiling results from the third-generation evaluation, we then initiated a formal usability assessment of the resulting fourth-generation prototype. A total of 33 students in a graduate-level course on web site usability engineering were assigned to create a user-task matrix based on whom each student thought our web site users might be and what those users’ two most important tasks might be. The students were then instructed to conduct a heuristic evaluation of the Washington State prototype site (which is not yet a final design open to the public) and the actual public HAI web site of another State, applying at least Nielsen’s heuristics plus any other standard they felt applicable (Nielsen, 1993; Kushniruk and Patel, 2004). This involved the students systematically stepping through the sites (in order to carry out selected user tasks from their user-task matrices) and noting any violations to the usability heuristics in doing so.

            Students submitted reports independently. Their assessment conclusions were aggregated and their relative ranking of the Washington prototype versus another State’s actual public web site tabulated. The Sign Test was used to test significance of differences in the distribution of rankings.

Results

Third-generation prototype evaluation

Evaluation results were returned by 10 of 25 individuals invited to participate. Their responses to the seven NQF criteria questions are shown in the table. On each question, several of the respondents expressed no opinion (Table I).

Their open-response comments align with the following themes:

1)      Theme 1: Reading grade level of page text is too high (Typical comments:“. . . better broken down into simpler statements . . . definitions for central lines and ventilators are simple and easy to understand but many of the other pages use very complex language . . . great information but box plots are way too complex for the general public”):

Our design approach starts with phrasing that gives a technically complete and precise message, then edit it to simplify. “Plain talk” assessment of page text in our third-generation prototype pages ranges from grade level 9.8 to 19.5 (average 13.3); our goal is reading grade level 8.We improved this in our fourth-generation prototype (reducing those pages to a range of 8.4-13.8, average 11.1), and will attempt further improvements in our fifth-generation. We also will show all rate data several ways to help different audiences with different interests or literacy levels.

2)      Theme 2: Not enough self-help information given (Typical comments: “... know what to do to lessen risk . . . to talk to a health care provider about doing what they should to prevent infection without fear . . . ”):

Our legislative mandate is to report infection rates, not prevention practices. However, the line drawings used in defining central lines, ventilators and surgery show points where germs can enter so also could show best practices that everyone should expect to see in practice.

3)      Theme 3: Continue refining ease of use (Typical comments: “navigation from page to page is easy . . . feels cumbersome to move about in the web site . . . be nice to have back buttons to main page options”):

We’ll continue to refine navigation in our next two prototype evaluations.

Fourth-generation prototype evaluation

All 33 students applied Nielsen’s ten heuristic criteria (Nielsen, 1993); some applied two to nine additional criteria attributed to other sources (Kushniruk and Patel, 2004). In addition to their own assessment, each student proposed a way we could engage lay public members in future evaluations and pilot tested their proposed method with at least one volunteer. Many of the students had backgrounds in health professions; fewer of their pilot test volunteers had previous experience with hospital practices or interest in healthcare associated infections. After performing one or two information search tasks presumed to be important for typical web site users, ten students considered Washington’s prototype web site inferior to the official web site of a comparison State, eleven considered Washington’s superior to a comparison State’s, three judged both to be of equivalent quality and nine didn’t state a clear preference for either. Of the seven States against which Washington was compared, in no case was Washington found inferior by all of the students. Most of the heuristic violations noted for Washington’s prototype

related to limitations of display on the Plone platform or other style issues we already intended to address in the next generation, and most were noted to be of minor severity. Insightful suggestions gave us new ideas to improve navigation, help, and user-control on extent of explanatory features in our web site. Several commented that many of the violations would be easy to fix, resulting in superior heuristic scores if the comparisons were then repeated; very few expressed frank dislike for fundamental design features and that number was balanced by those expressing favorably on the same features.

Question: Did we . . .	Number of times ranked as:
	1	2	3	4	5
	absent		Srongly present
Identify the purpose & audience of the web-based report? Use a transparent process that involves stakeholders? Set the stage by communicating information about quality? Use measures that are transparent and meet widely accepted, rigorous criteria? Present and explain the data? Ensure that the report design and navigation enhance usability? Evaluate and improve the report?		2 1 1 2 1	3 2 2 3 2 1 2	1 2 2 1 1 1	2 3 2 3 2 3 2

Analysis and discussion

The Plone platform generated cryptic initial instruction messages that confused several recipients, and at least one found the on-line response format awkward (“would be nice to move between survey questions and the web site”). The evaluation period also coincided with an influenza pandemic, which kept many busy with higher-priority tasks. We may consider other approaches to conduct evaluations of our next prototypes.

            Selecting quality metrics that can be measured with sufficient precision, accuracy and reliability is fundamental to creating information for any audience (McKibben et al., 2005; Joint Public Policy Committee, 2007; NQF, 2008b) This raises concerns about current practices in public reporting of healthcare-associated infection rates (Birnbaum, 2008; Edmond, 2007). Two respondents expressed related concern (“Doing this with VAP is tough!”, “I am extremely uncomfortable to say this data is accurate. It is not validated like other data sets in the industry . . . ”). It also is important to distinguish between patient satisfaction versus quality of care measurement tools, and recognize that few of those many metrics have been validated (Gill and White, 2009). Therefore, we are attempting to explain context and limits to interpretation

instead of just publishing event rates on our evolving web site. Understanding the intended audience is fundamental to designing an effective product. We appear to be the first State program to develop its healthcare-associated infections public web site by refining prototypes through successive focus group evaluations. Our initial audience has been the program’s advisory committee. This group includes representatives of: the public; community organizations devoted to  transparency and effectiveness in quality and safety of patient care; societies that represent the health professions; the healthcare industry and health plan insurers; and experts in epidemiology and infection surveillance, control, and prevention. We will continue evaluation-refinement cycles as our prototypes evolve and expand the range of participants in every cycle.

            We chose this approach because there is no ideal web site we could identify as a model to follow. The search for an ideal model is complicated by the fact that “There are many, many instruments for assessing quality of health information (web sites), most of them haven’t been properly validated” (National Prostate Cancer Web site, 2005). Our goal is to create the most effective web site possible, through a continuous quality improvement process, while adding to knowledge about the most effective ways to communicate in this manner (Mazor et al., 2009; Cleveland, 1993, 1994; Wheildon, 2005; Krug, 2006; Tufte, 1983). Evaluation results, to date, suggest that the prototyping process and its resulting product are well along in meeting performance expectations.

            We completed a third-generation prototype evaluation over the month of May 2009, and a fourth-generation prototype evaluation cycle over the month of June. The results from these evaluation cycles are being iteratively fed back into refinement of the site. An even wider circle of people will be recruited for a fifth cycle, including as many infection prevention and control professionals and healthcare executives, as well as members of the public throughout the State of Washington, as possible. Evaluation and refinement will continue after public launch of our web site in December 2009, seeking even broader public participation. In this manner, we are actively seeking the voice of the customer in order to produce a more effective public information web site.

Acknowledgements

The authors have no conflicts of interest to disclose.

            The authors thank Pamela Lovinger, Michael Davisson, Laura Blaske and Robert Clark for advice and encouragement during the project; and the members of our Healthcare Associated Infections Advisory Committee as well as the graduate students in the University of Victoria’s Health Informatics 591 course on usability engineering for their participation in evaluating our evolving prototype designs. We also thank Roxie Zarate, MPH, Council of State and Territorial Epidemiologists Applied Epidemiology Fellow, for assistance with parts of the data analysis.

            This paper was special guest edited by Madhav Sinha, President and CEO of the Total Quality Research Foundation Canada and Founder and Chair of the Canadian Quality Congress, Winnipeg, Manitoba, Canada.

            This paper comes from the “first” annual Canadian Quality Congress presentations held last August 2009 in the campus of the University of British Columbia, Vancouver, Canada, sponsored and organized by Total Quality Research Foundation (TQRF) Canada.

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About the authors

David Birnbaum, M. Jeanne Cummings, Kara M. Guyton and James W. Schlotter are all based in the Washington State Department of Health, Olympia, WA, USA.

Andre´ Kushniruk is a faculty member at the School of Health Information Science at the University of Victoria in British Columbia, Canada.

David Birnbaum is the corresponding author and can be contacted at: david.birnbaum@ doh.wa.gov

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