The VISUAL case studies form the basis for assessing and developing the VISUAL language through practical application. This case study was hosted by DIPS ASA, the leading supplier of eHealth systems to Norwegian hospitals, with more than 80,000 daily users.
In 2015, DIPS was in the midst of re-developing the operation planning module in their system. Operation planning is a complex process that involves many actors: a patient, general practitioners, specialists, nurses, administrative personnel, and more. Critical and sensitive information is exchanged over time between the actors electronically through the DIPS system, but also face-to-face, and through letters and SMS.
The purpose of the study was to map the operation planning process, and evaluate the usefulness of the diagrams for training and knowledge sharing during rollout of the new module at hospitals in Norway.
The process of operation planning depends on many factors such as the clinical case, hospital size, and health region. Together with medical experts in DIPS, SINTEF and Halogen developed two patient stories: one emergency case and one planned operation. The patient stories were translated into detailed steps and visualized with the VISUAL swimlane diagram. References to relevant screen-shots in the DIPS system were indicated in each step.
The first scenario involved a patient pregnant with twins, in need of an immediate caesarean operation. The scenario started with the patient calling the midwife at the hospital after experiencing contractions and light bleeding. At the hospital, the patient is examined by the midwife and a, gynecologist, and they decide for a caesarean section. Planning and preparation for the emergency procedure involve also an anesthesiologist, operation coordinator, nurses and pediatricians. The DIPS module for operation planning is used by the personnel throughout the procedure.
The second scenario involved a patient that for a longer time had experienced persistent pain in his hip. The documentation of the journey starts with the patient visiting his general practitioner, which refers him to an x-ray clinic and an orthopedic outpatient clinic. The consultation with the specialist results in the need for a hip replacement. This process spans several months, and involves two visits at the hospital polyclinic and examination by orthopedist, anesthesiologist, and other specialists. Other hospital personnel are also involved, such as patient and operation coordinators.
The VISUAL diagrams of the two patient cases were presented to DIPS and evaluated in a workshop setting. None of the five participants had previous experience with the VISUAL language. First, they were introduced to the tools by constructing a diagram based on a simple training scenario. Then the users reconstructed the emergency story through the swimlane diagram. The planned operation case was reviewed in a plenary walk-through with a DIPS expert.
The VISUAL diagrams of the two operation planning scenarios were by DIPS consultants perceived as easy to understand and highly useful for understanding the journey process. “At a general level, it gives a good picture of who is doing what and how DIPS systems are used”, one consultant stated. Another said “the diagrams are useful in understanding the whole process and responsibilities”.
The direct reference between the diagram steps and system screen-shots was believed to make it easier for the various actors to understand their own work tasks, while at the same time keeping a holistic view of the total journey. “I think the diagrams might be useful for all actors involved in the process. One often acts without seeing how others are affected, and this is particularly problematic”, one of the DIPS consultants said, referring to the language being fit for providing a common understanding of activities and tasks involved in planning of an operation.
Another user stated: “The visualization of the process was clear. Simplification of activity in different swimlanes brings nuances and demonstrates complexity. The various actors often focus on their own tasks and the diagrams are useful to see the totality of all stakeholders, especially for understanding the patient’s experience”.
Currently, DIPS is considering how VISUAL can support their training and eLearning modules in a real setting, as the new module for operation planning is being implemented in Norwegian hospitals.