Our project team used health failure mode and effect analysis, a proactive model for system risk assessment, 8
to understand VA primary care workflow and identify process steps to complete medication reconciliation. We observed sixteen providers and medical assistants (MA) to map out clinic throughput, common tasks, and existing reconciliation processes. The project team then generated a workflow diagram to highlight weak processes and outlined a “best practice” strategy using APHID technology (). Finally, the team helped implement the new process by working with staff to define roles and responsibilities.
Process steps were delegated to several members of the care team to distribute workload, foster collaboration, and increase the understanding of a common goal towards medication reconciliation. Check-in staff were instructed to proctor workstations and encourage patient use of APHID. Medical assistants were required to generate the templated health record note using CPRS workstations in the examination room. Providers could review the note before entering the examination room or during the patient interview. Although consideration was given to interacting directly with the medication list, this would have required development of more complicated logic and an information model to interpret patient-entered data. We also wanted the provider to critically review patient responses before addressing discrepancies.
We observed patients using early versions of APHID and we collected field notes which informed subsequent designs. Next, we assembled patient focus groups to refine the software. The final product reflects the intersection of patient comments, task specifics, and technology limitations.
A product roll-in phase was conducted over a 1-month interval using a convenience sample of 16 providers. Initially, several large-group training sessions were conducted with primary care staff and educational handouts were distributed. Throughout the roll-in phase, the APHID project team proctored workstations and assisted staff with clinical charting tasks. During weeks 1 and 2, feedback sessions focusing on information clarity and process design were held with providers using predefined structured questions. During weeks 3 and 4, a 6-item paper questionnaire adapted from a previously published software usability tool was handed to 75 consecutive patients immediately after using APHID 9
(see Appendix ). The purpose of the questionnaire was to assess interface ease of use. Patients were asked to complete and return the form to a Proctor before leaving the clinic. We excluded patients with cognitive, sensory, or motor impairment. Patients with multiple appointments were surveyed only once.
APHID use statistics in the Portland primary care clinics.
Following the 1 month roll-in phase, kiosks were left in production for an additional six months to assess sustainability of the model. We recorded the number of patients checked-in by the program in comparison to the total number of patients with primary care appointments at the Portland Campus.