ABSTRACT
INTRODUCTION: As a result of COVID-19, several clinics have adopted telemedicine to safely deliver care. However, the introduction of a new technology into an already complex system creates new challenges that have the potential to negatively impact patient and provider experience. We aimed to use a human factors approach (the science concerned with understanding the interactions between humans and other elements in a complex system) to identify where systemic vulnerabilities may exist throughout the patient/provider experience with telemedicine. METHODS: A total of 23 patients scheduled for telemedicine consults were observed during visits with providers. A trained human factors observer documented disruptions to system efficiency (eg communication breakdowns, connectivity problems and interruptions) and invited patients and providers to take a survey investigating perceptions of telemedicine technology usability, satisfaction with the experience and opportunities to improve the process. RESULTS: Visits lasted an average of 17 minutes, 20 seconds and each visit had an average of 6 disruptions. Inefficiencies were categorized into 13 categories consisting mainly of interruptions (21, 15.22%), Internet connectivity issues (21, 15.22%), nonoptimal device setup (19, 13.77%) and repeat communication (18, 13.04%). Provider satisfaction with the system was 3.72/5.00 and perceived usability was 63.15 (68 is considered acceptable). Patient satisfaction was 4.80/5.00 and perceived usability was 85. CONCLUSIONS: These findings highlight opportunities for a multifaceted intervention, including the development of an informational sheet/video for patients, a telemedicine "best practices" guideline for physicians, a standardized training process and checklist for front office staff and an in-service training for the entire care team.
ABSTRACT
BACKGROUND: The integration of high technology into health care systems is intended to provide new treatment options and improve the quality, safety, and efficiency of care. Robotic-assisted surgery is an example of high technology integration in health care, which has become ubiquitous in many surgical disciplines. OBJECTIVE: This study aims to understand and measure current robotic-assisted surgery processes in a systematic, quantitative, and replicable manner to identify latent systemic threats and opportunities for improvement based on our observations and to implement and evaluate interventions. This 5-year study will follow a human factors engineering approach to improve the safety and efficiency of robotic-assisted surgery across 4 US hospitals. METHODS: The study uses a stepped wedge crossover design with 3 interventions, introduced in different sequences at each of the hospitals over four 8-month phases. Robotic-assisted surgery procedures will be observed in the following specialties: urogynecology, gynecology, urology, bariatrics, general, and colorectal. We will use the data collected from observations, surveys, and interviews to inform interventions focused on teamwork, task design, and workplace design. We intend to evaluate attitudes toward each intervention, safety culture, subjective workload for each case, effectiveness of each intervention (including through direct observation of a sample of surgeries in each observational phase), operating room duration, length of stay, and patient safety incident reports. Analytic methods will include statistical data analysis, point process analysis, and thematic content analysis. RESULTS: The study was funded in September 2018 and approved by the institutional review board of each institution in May and June of 2019 (CSMC and MDRH: Pro00056245; VCMC: STUDY 270; MUSC: Pro00088741). After refining the 3 interventions in phase 1, data collection for phase 2 (baseline data) began in November 2019 and was scheduled to continue through June 2020. However, data collection was suspended in March 2020 due to the COVID-19 pandemic. We collected a total of 65 observations across the 4 sites before the pandemic. Data collection for phase 2 was resumed in October 2020 at 2 of the 4 sites. CONCLUSIONS: This will be the largest direct observational study of surgery ever conducted with data collected on 680 robotic surgery procedures at 4 different institutions. The proposed interventions will be evaluated using individual-level (workload and attitude), process-level (perioperative duration and flow disruption), and organizational-level (safety culture and complications) measures. An implementation science framework is also used to investigate the causes of success or failure of each intervention at each site and understand the potential spread of the interventions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/25284.