Copyright © IFAC Automated Systems Based on Human Skill,

Kranjska gora, Slovenia, 1997

THE NURSING INFORMATION SYSTEMS:

COLLABORATIVE DESIGN OF HEALTHCARE
INFORM ATION SYSTEMS

Frank Emspak* and Sharon Trimborn**

*Schoolfor Workers Continuing Education Extension

University of Wisconsin
610 Langdon St..
Madison WI 53703

**Executive Associate Director of Nursing

University of Wisconsin Hospital and Clinics
Wisconsin Hospital and Clinics Authority
Center for Clinical Sciences
600 Highland Ave.
Madison. Wl53792

Abstract: This paper will describe a participatory design process by which individuals
from many levels of hierarchy and diverse technical background envisioned and then
determined the design criteria for the software system to support the delivery of
high quality nursing services. Copyright © 1998 IFAC

Keywords: software design. participatory design, human centered design, user interfaces.

I . INTRODUCTION (RNs) only two members of the group from the

In October of 1995 the Federal Mediation and
Conciliation Service (FMCS) of the United States
awarded a grant to the University of Wisconsin
Hospitals and Clinics Nursing Administration and
the United Professionals for Quality Health Care,
local 1199W of the Service Employees Union
which represented nurses employed by the hospital.
The union and the Nursing administration asked the
FMCS to support the formation of a joint design
team to involve nurse clinicians in the development
of a clinical information system (Broad and
Robarts, 1995). The grant was the first of its kind
(and so far the only one) to support a collaborative
design project in the area of software or systems
design in a health care setting. The FMCS targeted
the healthcare industry a majority non union
industry with little history of labor-management
cooperation because of its importance to the
economy.
2. THE NURSING INFORMATION SYSTEMS
DESIGN GROUP
The Nursing Information Systems Design Group
(NISDG) had unique characteristics. Although all
the individuals involved were registered nurses
Nursing Ad'ministration staff had expertise in
software. (Note: Registered Nurses in the American
context are nurses who have completed at least four
years of training and are "registered" as having
done so). None of the clinical nurses had been
trained in system or software design. Nursing
Administration and the union leadership chose the
participants emphasize clinicians from a variety of
functional units. The majority of members were
nurse clinicians in their area of specialty as opposed
to nurses who happened to be Registered Nurses
and who really did system development. The group
comprised members from all levels of the
hierarchy. including senior nursing administration
(Trimborn) and the executive director of the union
(Robarts). A majority of the individuals were the
actual deliverers of nursing care on hospital wards,
in the operating room, in outpatient clinics and in
free standing geographically separate locations.
2.1 Testing the Participatory Design Process
The project tested several variables associated with
participatory design projects. First, could a group
without specific technical expertise envision a
system, make meaningful decision about it and
propose specific changes to it? Second, could the

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group find means to communicate within the body
bearing in mind wide disparities in technical
knowledge? Third, could the group overcome
hierarchical divisions enabling meaningful
consensus? Finally would other key stakeholders
accept the system and would the software house
employed by the University Hospital actually make
the changes suggested by the NISDG ?
Participation by the parties was voluntary.
Although a union and management initiated the
project and although it was supported by Federal
funding , there is nothing in American law or
practice to compel the parties to reach agreement
when discussing topics such as work
redesign.(Emspak, 1996).
2.2 The Problem Statement
The NISDG focused on the design and
development of a clinical information system
intended to benefit clinicians and patients. In the
view of the NISDG the system had to be designed
to ensure that it met the professional needs of the
clinician, while at the same time being more
efficient and improve the quality of patient care.
The ultimate goal for the NISDG is to formulate the
design structure for the information system. While
the technical challenges facing the group were clear
a related challenge was to learn the collaborative
design process and apply it.
2.3 The Design Process
The design process involved three distinct phases,
each of which required learning a set of skills. The
group learned the common group process skills,
with some emphasis on seeing a problem in a
dynamic fashion (flowcharts) as well as seeing a
problem as composed of several elements. At the
same time as these reasoning skills were developed
the group learned to work with each other and
actually hear what another person had to say. The
mutual listening is the heart of collaboration, and
the protected environment of the NISDG allowed
people to overcome the hierarchical divisions in the
group. Thirdly the NISDG learned how to envision
their reality and then the reality they wanted to
create. The visioning process, which was not taught
directly, is derived from the work of the Brazilian
educator Paulo Freire In this model visioning leads
to judgment which in turn can lead to
action.(Ferreira and Ferreira, 1997).
If we translate the above process to design
language, visioning leads to technical information,
that is the addition of technical knowledge to the
group. The knowledge is supplied by a variety of
consultants, as well as assessment tools designed by
the group. In turn as a consequence of decision
made by the NISDG that a new system would
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result, the group then translated their ideas into an
action plan .
3. THE DESIGN CRITERIA.
The NISDG determined the criteria by which they
would assess their system through a combination of
discussion amongst the NISDG, surveys, and
analysis of their departments. Nurses mapped the
flow of information within departments and
between departments and then determined how
effective the system was. Central to ascertaining the
effectiveness of the information system, the NISDG
also came to a mutually shared understanding of the
most important values regarding nursing and care
giving.
(Robarts and Trimborn, 1995).
3.1 Shared Values
Achieving consensus on the shared values drove the
process. The shared values included a commitment
to hands on nursing, that is the nurse as a care
giver, not as a manipulator of technology. The
consensus included the way in which nurses
delivered care, preferably in person and at the
bedside determined the initial concept of the
information system. The importance of the nurse as
care giver however was not simply based on an
idealistic view of health care. Studies of patient
outcomes indicated that patient outcomes improve
in direct proportion to the quality of nursing care.
(Aiken, 1994).
Over a period of 4 months the NISDG determined
their new system should be judged by the following
value statement. The value statement developed by
the NISDG read in part "We are committed to
nursing as a profession and believe that nursing is
and should remain an integral part of the health
care delivery system. Developing technology to
enhance our contributions to that system will
increase our efficiency and effectiveness, and
positively impact our ability to maintain our unique
role in the delivery system." The statement goes on
to say that the NISDG wants "to impact the
development of the information system so it is
designed to support an environment which
advances nursing practice, and the nursing process,
improves patient care without placing barriers
between the nurse and the patient." (Trimborn,
1997).
3.2 Functional Specifications
After having achieved consensus on the basic
criteria and values the NISDG then translated these
values into more specific functional specifications.
In the first place, the Nursing information system
had to be integratable with the existing SMS
Invision system and IBM mainframe platform. With
that in mind the NISDG defined two main criteria:
(l) Nursing's computerized patient record solution
must support multi-disciplinary documentation
across all care delivery settings; (2) The system
must integrate rules-based protocols, pathways and
clinical decision support.
Examples of key criteria embedded in the
specifications are:
1. Patient education-technology, case specific with
registered nurse responsible for evaluating learning
pre- and post-procedure; 2. Networking: with lab,
X-ray, physical therapy, Occupational therapy, unit-
to-unit, nurse-to-nurse, inpatient to outpatient and
to other caregivers; and other departments
(Trimborn, 1997).
3.3 Standards to Guide NIS Design
As the NISDG developed consensus regarding what
they wanted the system to do, the NISDG also set
standards to guide the NIS design. Two of the eight
such guides are:
1. Real-time entry and access to data from multiple
sites using
multiple methods; 2. Data entered one time through
anyone device had to be made available to all other
databases ; (Trimborn, 1997).
4. IMPLEMENTATION
Designing criteria are one thing, implementation is
another. Supporters of collaborative design and the
NISDG believe the process yielded more rapid
project implementation than other design systems.
NISDG experience tends to support this thesis.
The NISDG embarked on a three track
implementation process. First, the NISDG
undertook to talk to all the nurses affected by their
design ideas. NISDG members conducted sessions
throughout the hospital and clinics. The NISDG got
feed back from their colleagues and at the same
time validated their ideas. Secondly, the NISDG
sought support from other stakeholders. Through a
series of meetings, and one on one discussions the
NISDG gradually won support from significant
stake holders- e.g. physicians, other parts of the
administration and to an extent the management
information systems organization. In their efforts to
win support from others the NISDG consciously
arranged for clinicians, not just nursing
administration to make presentations. Thirdly the
group determined several "quick strike"
improvements which could be implemented
relatively quickly. Implementation of the "quick
strike" improvements demonstrated to a broader
audience the utility of their work as well as the
ability of the software provider to work with the
ideas of the NISDG.
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4.1 Quick Strikes
The NISDG recommended the following quick
strikes be accomplished through work with the
Information System Department staff. The Director
of IS committed to vigorously pursue 11 projects.
Included in them are 8 proposals to redesign the
current version of Action 2000, the system being
implemented now by the University of Wisconsin
Hospitals and Clinics. Two of the eleven projects
are described below.
Objectives include:
1. Redesign the system to ensure that data entered
once automatically populates to other screens
displaying the same data item. For example:
Advanced Directives checked as signed and
witnessed on pre-admission documentation screen
would also display on the patient Demographic
Summary screen.
2. Redefine security sign-on codes and standardize
by user class.
Additional functionality is needed across user
classes due to changes in clinical practice. Define
User Sign-on codes with pathway access needed by
clinicians to view patient data across the care
continuum. Nurses in in-patient units can access
clinic records, past lab values, visit encounter data.
The current in-patient versus out-patient dichotomy
built into screen pathways and access privileges is
eliminated through user code privileges and
common pathways.
For example: Case managers need access to both
clinical and financial information.
Two of the eight Quick Strike Ideas currently
completed or in process are:
1. Inclusion in the patient demographic element
screen a record for completion of Advanced
Medical Directives (AMD) and their location in the
patient record. The Admissions Department
participated with a sub-group of the NISDG and
others to build into the Demographic Screen the
AMD. In addition, one or two other elements were
identified for inclusion. Currently, Admissions' staff
are working with IS staff to bring about this change.
2. Capacity to access First Day Surgery patient
information prior to business hours of the
Admission Department. Several approaches to
resolve this objective have been discussed.
Essentially the problem is one relating to the
Admissions Department not with functionality of
the software program.
 5. CURRENT PROCESS USED BY NISDG
Once the NISDG completed its design work,
members were asked to serve on a variety of task
forces that grew out of the QUICK STRIKE section
of the NISDG software specifications document.
Members volunteered to work on task forces of
interest to them. There are three task forces:
Printer, First Day Surgery and Nurse Call System.
The progress of each task force is reported monthly
at each NISDG meeting. Subsequently, the NISDG
was asked whether or not they would agree to be
the work group for some of these and other future
projects. Instead of their participation sought for a
variety of task forces, other staff would join the
NISDG depending on the project work. NISDG
members agreed to this change in process believing
it to be more efficient and effective. (Trimborn
1997).
The NISDG is currently working on the many
aspects of changing practices related to the new
laser printer capability and to the ability to redesign
nursing screens. We believe that the expertise and
efforts of the NISDG will result in timely project
completion. In conclusion, designing the
information system specifications to support the
clinical practice of nurses was the first step in a
lengthy process of building and implementing the
system. We believe that the group will continue to
work on related projects for the next two years.
6. CONCLUSION
The NISDG started out with the objective of
designing and developing a clinical information
system broadly defined. The NISDG developed
criteria and a means to implement them and has
succeeded in implementing many of their ideas.
Thus the process of collaborative design, in this
case involving non specialists seems to be
validated.
specialists in the technical system which they wish
to design. The NISDG functioned without massive
professional or technical support. Therefore it
would suggest the utility of the collaborative design
process in countries which are resource poor.
REFERENCES
Aiken, L. (1994) A Study-Medical Care, University
of Pennsylvania.
Broad, ludith and Ruth Robarts (1995)
Application for Federal Assistance,
Proposal to the FMCS, submitted May 9,
1995.
Emspak, Frank (1996). Participatory Design:
Examples and Institutional Needs.
In PDC'96 Proceedings of the Participatory
Design Conference
(J.Blomberg,F. Kensing and E.A.
Dykstra-Ericson Eds.) pp.111-115. CPSR,
Palo Alto Ca.
Ferreira, Eleonora Castano and 10ao Castano
Ferreira. Making Sense of the Media,
A Handbook of Popular Education
Techniques; Monthly Review Press,
NYNY, USA.
Robarts, R., S.1. Trimborn (1995). Collaborative
Design of Healthcare Information
Systems: A Report on A Pilot Union
Management Project.; 5th IFAc
Symposium on Automated Systems Based on
Human Skill, Berlin, Germany 1995.
Trimborn, S.l . (1997). Notes of the NISDG,
Madison WI. 1997.

Grant driven projects suffer from discontinuity and

lack of institutionalization. Often organizations
involved do not institutionalize the collaborative
processes developed during the life of the grant.
However in this case, Nursing Administration
Information Systems staff and the nurses still active
in the NISDG see the NISDG continuing to play an
advisory role in information systems development
in the nursing area.

The NISDG project can also have an unintended

consequence. The actual mental processes
described in the processes of design were
recognized by Freire in his development of teaching
methods in Brazil in the 1960ies. Upon reflection it
appears the NISDG went through the same
processes- visioning, judgment and action. The
NISDG illustrates that collectives of users can
design a complex system, even if they are not

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