"Designing for Health" is a monthly, web-exclusive series from healthcare interior design leaders at Perkins+Will that focuses on the issues, trends, challenges, and research involved in crafting today's healing environments. This month's topic:

A Prescription to go Paperless: Environments in support of the electronic health record

By Tama Duffy Day and Carrie Rich

Despite corporate evolution toward a "paperless" office, queues at copy machines have grown longer and Kinko copy centers exist in every city center.  Employees are reminded in email by-lines to "think before you print." With the growth of Electronic Health Records (EHRs), the healthcare industry is advancing quickly toward a "paperless" chart and maybe, just maybe, healthcare might precede Corporate America in achieving a "paperless" environment.

Existing research demonstrates that when EHR systems are designed and used effectively, benefits may include decreased need for repeat tests, timely access to medical information, avoidance of medication errors, and improved communication between a patient's healthcare team, leading to lower readmission rates and shorter lengths of stay.  Thus, a "paperless" healthcare system might literally be good for your health.

Achieving complete integration of EHRs, however, poses significant challenges.  To start, a major shortfall of successful EHR integration is lack of universal adoption.  Even when newly built healthcare facilities have the physical capacity to incorporate wireless technology, inconsistent communication systems hinder smooth information transfer between healthcare providers and organizations, disrupting delivery of effective healthcare services.  A less examined aspect of EHR integration is the design of supportive EHR hardware: the built environment.  This aspect of healthcare design must be at the forefront if the built environment is to keep pace with modern process changes that are rapidly influencing the world of evidence-based design.

Unlike many patients and professionals who prefer leaving healthcare technology to health information technology professionals, design practitioners must interpret the potential of EHRs and their changing impact on the efficient delivery of healthcare.  Merging evidence-based healthcare facility design with EHRs requires forward-thinking collaboration between patients, clinicians, administrators, strategic planners, health information technologists, ergonomists, architects, and interior designers to strategize on how the healthcare environment is changing and will continue to change as it accommodates new paradigms of care.  

Clinicians and administrators both expect increased EHR implementation.  Among physician respondents who participated in a 2008 survey conducted at Massachusetts General Hospital, 16 percent of those who did not use EHRs reported that their practices purchased EHR systems, but had not yet implemented them.  Additionally, 26 percent of physician respondents said their practice intended to purchase EHR systems within the next two years.  In a survey of more than 300 healthcare executives and upper-level managers conducted in 2006, financial support for EHRs implementation was an investment priority and main component of organizational budgets over the next two years; at least one-third of survey participants expected to be actively involved in the upcoming year.  As of 2006, more than two-thirds of hospitals (68 percent) had either fully or partially implemented EHRs.  In 2007, 72 percent of healthcare facilities reported being at least partially wireless, while 5 percent were entirely wireless.  Furthermore, EHR-related technologies are expected to dominate roughly half of upcoming health information technology projects over the next 12 months.  The take-away point, then, is that healthcare organizations consider data collection, maintenance and accessibility a top priority and require a physical infrastructure to support these needs—in addition to organizational culture and behavioral programs.  

Although new construction eases the facilitation in creating spaces for EHR integration, the accommodation will also be required in numerous existing facilities.  The most user-friendly examples of EHR workstations incorporate ergonomic benefits that not only support physical usability, but provide shared space for provider-patient communication centered around the computer.

Many hospitals struggle to reconcile mobile technology with the physical design of facilities, realizing that staff still needs some forms of paper for efficient communication and delivery of care. Architects should be aware of the need to reconcile these sometimes conflicting demands.
 
Manny Halpern, PhD, Certified Professional Ergonomist with the NYU School of Medicine points out that many of the guidelines for computer workstation setup are applicable to EHR stations:

•  Computer monitors should be easily adjustable so that patients and providers alike can read the screen without leaning the head, neck, or trunk forward or backward.

•  Reduce glare by locating the computer monitor at a right angle to windows with neither the computer monitor nor the user facing a window.  

•  Task lighting should be filtered and sources should be fully adjustable

•  Computer screens should be large enough for adequate visibility.  Usually 15 in. to 20 in. is sufficient for sharing information, though geriatric patients may require larger screens or the ability to accommodate larger letters and images on the screen

•  If a paper document holder is required to transfer medical information from paper to electronic form, it should be stable and large enough to hold the documents, and placed about the same height and distance as the monitor screen.
       
•  Adjustable keyboards, separate from the computer screen, allows the user to adjust the keyboard to provide straight angles of the arm and wrist while typing, limiting the effects of carpal tunnel syndrome.

•  Chairs should have height-adjustable seats as well as height and width adjustable armrest and seat slides, allowing each user to adjust to their individual body size and shape.

•  Extra chairs designed for flexibility should be available for patients to sit alongside the provider while EHR data entry occurs.  The furniture used in the observation space can be adjusted and rearranged so as to be ergonomically beneficial for staff while maximizing space efficiency in an ever-changing healthcare environment.  

A few illustrations of the integration of ergonomics into the built envioronment are included.  Within the Emergency Department at the Maimonides Medical Center in Brooklyn, NY, the central hub includes workstations for both seated and standing positions.  Workstations were created in this extremely busy department through the use of millwork and furniture systems.  The millwork was utilized in creating a central design element and circular hub, while furniture systems ring the staff work zones.

Two varied solutions for charting exist at MidState Medical Center in Meriden, Conn., and at the Bellevue Critical Care Pavilion in New York, NY.  Decentralized charting alcoves between the ICU rooms at MidState Medical Center incorporate a furniture element with ergonomic components; an adjustable keyboards and an adjustable monitor arm.  At Bellevue workstations were also created with furniture elements, providing a monitor on an adjustable arm, an adjustable keyboard tray, as well as space for another staff member or a family member to pull up a chair and dialogue.   All solutions incorporate chairs with adjustable seat height, adjustable back height and casters appropriate for the flooring conditions.
 
Through healthcare facility design targeted at flexible EHR documentation and evaluation processes, design practitioners can simultaneously help improve the efficiency, ergonomics, and sustainability of the work environment for clinicians and healthcare professions and, improve your health in the process.

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Tama Duffy Day, FASID, IIDA, LEED AP, is a principal at Perkins+Will, an international architectural and interior design firm. She is the national interior design healthcare practice leader, formulating research and design initiatives throughout the firm's 19 offices. She can be reached at Tama.DuffyDay@perkinswill.com.

Carrie Rich is a graduate student of Health Systems Administration at Georgetown University and a healthcare research analyst at Perkins+Will.  She can be reached at DCResearch@perkinswill.com


Citations
Cornell University's Human Factors and Ergonomics Research Group.  1 August 2008.  http://ergo.human.cornell.edu/

Designing the 21st Century Hospital: Environmental Leadership for Healthier Patients & Facilities.  Robert Wood Johnson Foundation.  2008.  

DesRoches, Catherine M.; Campbell, Eric G.; Rao, Sowmya R.; Donelan, Karen; Ferris, Timothy G.; Jha, Ashish; Kaushal, Rainu; Levy, Douglas E.; Rosenbaum, Sara; Shields, Alexandra E.; & Blumenthal, David.  Electronic Health Records in Ambulatory Care – A National Survey of Physicians.  The New England Journal of Medicine.  3 July 2008, 359(1), 50-60.    

Trends in Mobile Computing.  Healthcare Informatics. 23 June 2008, Webinar.  

Unlocking the Potential of Nursing IT.  The Advisory Board.  July 2007.  

U.S. Department of Occupational Safety and Health Administration (OSHA).  1 August 2008.  http://www.osha.gov/SLTC/ergonomics/index.html



Past installments of "Designing for Health" are available here:

• "Shifting Culture, Shifting Service Lines: Is Tiger Woods the New "Grandmother"?"

• "Research Informing Design"

• "Peace and Quiet"